It's All in the Evidence: Decision Support in Radiology

In 2002, Brigham and Women's Hospital in Boston undertook a massive project. The hospital sought to replace the old physician imaging study order paradigm with an evidence-based medicine system. The plan is to implement a filmless, paperless, errorless system to enable the deployment of evidence-based imaging. Ramin Khorasani, MD, is vice chairman of the Department of Radiology and director of the Center for Evidence-Based Imaging at Brigham and Women's Hospital. Health Imaging & IT spoke with Khorasani about this ambitious decision support effort.

Q: Why did Brigham and Women's Hospital establish The Center for Evidence-Based imaging? What issues does the hospital plan to address via decision support?

The Institute of Medicine outlines the basic premises for decision support in its 2001 "Crossing the Quality Chasm" report. Uninformed decisions impact quality and efficiency at every level in medicine, and these issues are notorious in radiology. It takes five to 10 years from the time published studies establish a specific imaging exam protocol for it to be adopted in clinical practice. We find tremendous variation in how physicians use imaging to address clinical issues. There is also tremendous variation in follow-up examinations recommended by radiologists. These variations aren't based on evidence - they are based on physicians' own experiences. The result is a lack of standardization of knowledge to consistently practice medicine. The answer is not working harder and smarter to make better decisions. We need systems change.

Q: What is decision support and how can it address these issues?

There are two elements to consider. Generically speaking in medicine, we need more evidence than what we have; so one component of decision support is gathering and housing that evidence. The second component is delivery. We need the tools to deliver evidence to someone in real-time to facilitate an informed decision. This evidence needs to be context-specific. That is, if a clinician wants to order a head MRI because his patient reports recurrent headaches, he needs the two sentences of a five-page study that addresses this particular case - not a five-page study on multiple indications for head MRI. Finally, decision support must be evidence-based or educational. This could be anything from site-based guidelines to scientific recommendations.

Q: What is the focus of The Center for Evidence-Based Imaging?

We set out with two focuses. First, the center plans to develop evidence, deliver it to decision-makers and measure the results in terms of patient outcomes. Second, we plan to measure the impact of IT tools in imaging. We're analyzing patient care and ROI - not just in terms of finances, but also in terms of efficiency and quality of care.

Q: What tools are needed to implement decision support?

The tools to accomplish these tasks are IT-based. The building block of decision support is computerized physician order entry (CPOE). CPOE provides means to deliver information to the physician. On the radiology side, tools can be embedded in the PACS workstation or the report generation tool.

Q: Can you provide an example of decision support?

Suppose a radiologist is interpreting an abdominal CT and finds a 2 cm cystic structure and notes 'cystic structure' in his report. The computer will pop up with a specific recommendation such as 'ultrasound indicated.' The key point is that the information is provided at the time of the decision. Decision support does not assume that the physician will go to a book to look for the information. The computer remembers what the physician needs to know.

Q: This is clearly an ambitious program. Do you have partners to help you accomplish this vision? How does it all fit together?

The Center for Evidence-Based Imaging is a joint effort of Brigham and Women's Hospital, Faulkner Hospitals and Dana Farber Cancer Institute. These three systems complete more than 600,000 imaging exams annually. Clearly, we could not undertake this effort on our own. We have three partners: GE Healthcare, EMC and Medicalis.

We are using GE Centricity PACS to deliver electronic images to the enterprise. EMC's Clarion enterprise storage systems and software and Centera content-addressed storage systems and software provide storage for the two terabytes of imaging data generated each month. Medicalis, a company grown out of Brigham and Women's, provides the CPOE piece-Percipio, a paperless enterprise online scheduling tool. Percipio and Centricity are integrated into the radiology portal to facilitate the paperless and filmless model from ordering to scheduling and image and report delivery. The Center also uses GE' Six Sigma resources for process re-engineering and change management.

Q: What results have you measured so far?

Our results can be divided into three categories: filmless, paperless and errorless. We went live with PACS in August 2003 and have shut off 60 percent of film so far. We'll shut off another 20 to 25 percent in 2004. Our use of Centricity is doubling every two months. Last month, 380,000 images on 28,000 patients were viewed on the system.

The paperless CPOE has been well implemented on the inpatient side for several years. On the outpatient side, the Center supports 40 clinics and 1,700 users generating 3,700 to 4,000 exams a week. Our computerized order capture rate is 97 percent in the ER, 88 percent for outpatient exams and 63 percent for specialty care practices. And on the errorless component, we measured the first intervention: online education and preapproval for outpatient CT and MRI. With very liberal rules, we are able to reduce outpatient CT and MRI studies for one of our payors by 6 percent. These were exams that were clearly inappropriate.

Q: Are there other impacts in terms of revenue?

We've found that for every outpatient CT exam, we are leaving more than $4 on the table by not including appropriate information on the bill. The CPOE allows us to capture the appropriate information at the time of order to improve billing and generate a successful application to the payor.

Q: What does the future hold for The Center for Evidence-Based Imaging?

Over the next 18 months, we plan to finish deploying the CPOE. Right now, we're about 71 percent paperless. We plan to be 80 to 85 percent paperless by the end of FY 2005. We'll continue to shut off film to reach 90 to 95 percent filmless across the enterprise. On the errorless side, we'll complete detailed measurements of the benefits, errors and revenue captured. Over the next 18 months, we'll turn on more evidence-based decision support tools. These embedded medical management tools will preauthorize imaging exams. And, of course, we will measure and publish results.

Decision Support by the Numbers

10% -30%
Potentially inappropriate imaging studies ordered in the United States

Annual imaging exams at Brigham and Women's Hospital (BWH)

2 Terabytes
Monthly imaging data generated at BWH

Image acquisition devices at BWH

Reduction in outpatient CT and MRI for one BWH payor after liberal evidence-based preauthorization adopted

$2 million
Potential annual savings from improved paperless billing at BWH

$3 million
Annual BWH cost for analog film and film handling

Evidence-Based Medicine in Action

The Center for Evidence-Based Imaging is a work-in-progress. When all phases of the project are complete, the center will reinvent the traditional physician imaging study order paradigm. How will it work?

A patient visits a clinician and reports certain symptoms. The physician enters the symptoms in a Web-based application using a desktop computer or wireless PC.

The system goes to work analyzing the symptoms and comparing them to patient records of similar symptoms, relevant published reports and best practice guidelines.

Next, it crosschecks for potential problems including contraindications.

After analyzing all of the data, the system suggests a protocol and summarizes the rationale for that course of action. The physician can follow the suggestion and paperlessly order the exam through a secure Internet site. (Alternately, the physician can override the suggestion.)

After the imaging exam is complete, digital images are routed to the radiologist and stored on the secure network.

The radiologist interprets the exam and completes a multimedia report, which is made available to the physician.

The data also are integrated back into the growing evidence-based system for use with other patients.