HIE, Imaging & Appropriate Use: Rads Need to Lead the Charge

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Radiologists and other imaging professionals in the U.S. are getting involved in efforts to improve healthcare quality using health information systems—by increasing the amount and quality of information, including patients’ histories and imaging exams, available to members of the care team at the point of care. Health information exchange (HIE) may be crucial to meeting this goal.

Nowhere is good information more important than in the evaluation of acute illness in the emergency department (ED). Radiologists know many imaging studies in this setting are unnecessary, but they typically lack the information needed to help care teams make sure that all imaging obtained is appropriate. Most agree that we should cut down on unnecessary imaging, but many questions remain unanswered.

  • How do we differentiate unnecessary images from those that are medically warranted?
  • How can we get physicians to follow evidence-based guidelines and rely on their clinical judgment more often in the face of diagnostic uncertainty, liability concerns and pressure to meet patients’ expectations?  
  • Can improved health information systems help radiologists contribute to better patient care?

HIE has been widely advocated as an essential approach to improve healthcare quality, safety and efficiency. HIE has the potential to reduce unnecessary testing and improve quality of care in the ED by making prior visit and test results from other hospitals readily available at the time of the current visit. Based on these potential benefits, the American College of Emergency Physicians (ACEP) encourages hospital participation in HIE initiatives.

But is there credible evidence that HIE can reduce unnecessary imaging and improve care? Furthermore, can providers be encouraged to access HIE? Even in communities with well-developed HIE systems, radiologists and other members of the care team may not have time or inclination to use these systems.

Our research team at the University of Tennessee Health Science Center in Memphis decided to investigate the utility of HIE in reducing unnecessary neuroimaging and improving quality of headache care in the ED. Since 2007, the greater Memphis area has been served by an HIE that shares health information among the major hospitals in the MidSouth region.

We chose to assess the effect of the HIE system on headache care because headaches are frequently seen in the ED but rarely require neuroimaging for diagnosis. Evidence-based guidelines have been established to promote more judicious, appropriate use of neuroimaging, but physicians are often not comfortable relying on these guidelines alone. Neuroimaging in the ED has dramatically increased over the last 10 years. Broder et al found that head CTs in the ED increased 51 percent from 2000 to 2005 and 13 percent of all ED encounters received a head CT (Emerg Radiol 2006;13:25–30).

However, the evidence-based guidelines issued by ACEP and the U.S. Headache Consortium suggest that many neuroimaging exams ordered for headache patients are unnecessary. Studies have clearly demonstrated that CT and MRI neuroimaging are very low yield and costly in chronic headache patients with no other neurological findings on exam. Furthermore, many of these are repeat images. Friedman showed that while only 1 percent of severe headache patients were frequent users of the ED, these frequent users accounted for 51 percent of all ED visits by severe headache patients (Headache 2009;49:21–30). Our recent study showed similar results—15 percent of all ED patient-visits for headache were by repeat visitors (J Gen Intern Med 2012 May 31).

We found that 70 percent of patients in our region with repeat ED visits for headache received neuroimaging upon return to an area ED. When members of the ED care team used HIE, the odds of unnecessary neuroimaging decreased by 62 percent and the odds of adherence with evidence-based neuroimaging guidelines increased by 33 percent. Although imaging is common in the ED and hospital setting, it does not come without risks, which are substantially increased in patients who receive multiple repeat CTs.  

Our study is among the first to examine the effect of HIE on patient care in the ED, and it shows that HIE can save many patients from unnecessary repeat neuroimaging and radiation exposure. Other studies by our group and Vanderbilt University researchers suggest that HIE can improve care only when physicians and other members of the care team use it routinely. While more hospital systems and clinics are implementing EHRs, most independent systems do not share information with one another, limiting their capability to help physicians avoid unnecessary testing.

In our community, we found that the HIE was accessed 22 percent of the time for repeat ED patient-visits for headache. Simple changes in practice, such as having an assistant or processor include the HIE record on the chart at check-in or radiologist review and reporting of outside results to the treating physician prior to repeat scans, may be able to improve HIE use.

Despite low HIE utilization rates in our community, we estimate that HIE use resulted in the avoidance of at least 163 head CTs in a two-year period. With aggressive implementation and incentives for HIE utilization on a larger scale, HIE has the potential to eliminate hundreds of thousands of unnecessary CT scans in U.S. EDs every year.

Reliance on radiological imaging for diagnosis and monitoring is likely to increase. However, as clinicians, we need to continue to implement ways to facilitate appropriate evidence-based use of radiological imaging. Insurance companies will not continue to reimburse for unnecessary repeat images and patient encounters. Effective accountable care organizations are likely to incentivize radiologists to help reduce unnecessary testing and assist in the provision of evidence-based care. We need to continue to explore ways to reduce unnecessary imaging not only to reduce cost to the system but also to avoid unnecessary harm to our patients.

HIE has been proven to reduce unnecessary neuroimaging in repeat headache patients in the ED, but we must encourage implementation of HIE systems as well as their appropriate utilization to maximize their impact. HIE has the potential to improve healthcare quality when applied to many other patient diagnoses and areas of testing and radiologists can help to lead the charge.

Lisa M. Mabry, MD, is a resident physician in radiology at the University of Alabama at Birmingham. James E. Bailey, MD, MPH, is a professor of medicine and directs the Center for Health Systems Improvement at the University of Tennessee Health Science Center in Memphis.