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?
A: 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?
A: 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?
A: 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?
A: 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?
A: 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?
A: 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