JACR: Professional guidelines not cut out for decision support

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Radiology professional society guidelines, in and of themselves, do not comprise effective decision support for reducing inappropriate use of medical imaging, opined Ramin Khorasani, MD, MPH, vice chair of radiology at Brigham and Women’s Hospital in Boston, in the September issue of the Journal of the American College of Radiology.

Effective decision support promises to enable quality improvement and reduce waste, and it must be integrated into the referring physician workflow to qualify for meaningful use incentives beyond 2012 and avoid penalties beyond 2014.

As the radiology community searches for the best source of decision support and decision support to quell inappropriate use, the question of tapping into professional guidelines such as American College of Radiology (ACR) Appropriateness Criteria inevitably arises.

“These guidelines serve many critical functions … but there is little evidence that the traditional methods of guideline dissemination lead to substantial improvement in the test-ordering behavior of referring physicians,” wrote Khorasani. That is, guidelines have not helped stem the tide of inappropriate use. “Guidelines alone are unlikely to result in measurable sustainable improvement in the appropriate use of imaging,” he continued.

One of radiology’s top decision support experts, Khorasani identified five drawbacks to converting professional guidelines into decision support:

  1. Guidelines are not actionable. Most describe the relative merits of one approach over another rather than prescribe an appropriate course of action.
  2. Effective decision support must be delivered real-time in the daily workflow via the EMR, but the professional societies that develop and disseminate guidelines fall short on EMR and health IT know-how.
  3. Many existing guidelines lack the strength of evidence necessary to spur widespread adoption by clinicians. They are better suited to broad educational purposes rather than actionable decision support rules.
  4. Effective decision support must be up-to-date and frequently updated, explained Khorasani. These ongoing tasks may be beyond the scope of professional societies.
  5. Decision support, including tools based on professional guidelines, must incorporate consequences for ignoring rules in order to insure maximum impact.

Relevant peer-reviewed publications and professional guidelines from various professional societies provide rich sources of evidence to be mined in the development of decision support and “will have the most credibility with colleagues in other specialties,” noted Khorasani. In cases of scant evidence, Khorasani recommended implementation of extensive health IT infrastructure followed by the collection and mining of data to create the next generation of decision support.

Guidelines should play a supportive--not starring--role in the decision support, summed Khorasani. “Specific guidelines that can be converted into effective decision support will likely have the most impact, but not all guidelines are well-suited for this purpose,” he concluded.