Transforming Decision Support into Clinical Practice

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 The concept of clinical decision support is simple. It delivers context-specific education material in real time to a physician trying to make a patient-care decision. Tools can be divided into several basic types. Some help clinicians select the appropriate imaging study, and others help physicians make the appropriate clinical decision. But implementing decision support in clinical practice? That’s a bit more complicated. But like many things that truly matter, where there’s a will, there’s a way.

The need for clinical decision support is clear. “It’s very hard for physicians ordering imaging tests to keep [all of the required] information in their head,” points out Katherine Gray, president of Sage Health Management Systems, Inc. For example, the Ottawa Ankle Rule, which determines ankle sprain patients who require an x-ray, is too specific and detailed for non-specialists to remember. While clinicians deal with thousands of complex rules and guidelines, radiologists contend with other challenges. The number of cases and images continues to skyrocket, and studies are growing in complexity as well. What’s more, the base of clinical knowledge is not a constant. Guidelines change as researchers uncover new findings and publish new studies and physician associations release new guidelines, but it can take five years or longer to incorporate new clinical guidelines into practice.

Medical errors, waste and the increasing adoption of imaging utilization management programs by payors also are driving the market. Nevertheless, current decision support adoption rates hover in the single-digit range, says long-time advocate Ramin Khorasani, MD, MPH, who is director, Center for Evidence-Based Imaging at Brigham and Women’s Hospital in Boston.

The challenge, says Khorasani, is three-fold. First, the tools that enable delivery of decision support — computerized physician order entry (CPOE) and structured reporting — must be more widely adopted. The next challenge is knowledge delivery; developers must engineer multiple programs to deliver content through CPOE or the structured report. Finally, the system must incorporate knowledge management, which comprises mechanisms to track and update content.

Despite the hurdles, decision support is being implemented at facilities across the country. Some sites opt for solutions developed by vendors, while others use CPOE or the electronic medical record (EMR) as a foundation and develop their own solution. This month, Health Imaging & IT visits a handful of these sites to learn about decision-support options and the benefits of the technology.

Decision support & imaging utilization

This graph shows variability in primary care physician use of outpatient radiology at Brigham & Women’s Hospital . The X axis depicts each physician with an identifier and bars of same color denote physicians practicing in the same office location. The Y axis represents the number of imaging tests requested per patient per year.

Imaging utilization is heterogeneous and represents both over- and under-utilization of imaging tests. For example, studies indicate an increasing reliance on appendiceal ultrasound to diagnose acute appendicitis despite its lack of effectiveness. At the same time, mammography is underutilized with only a fraction of the target population receiving appropriate screening exams. (Based on recent government health surveys, the percentage of women 40 and older who reported getting a mammogram in the last one to two years dropped to 74.6 percent in 2005 from 76.4 percent in 2000, according to the Centers for Disease Control.)

Decision support transforms the picture by alerting the physician to patient needs and the most appropriate imaging study. During the electronic order process, a pop-up can inform the ordering physician if the ordered study is inappropriate or contraindicated or if the patient is due for a regular screening exam.

Brigham and Women’s Hospital has taken a leading role in decision support. More than 90 percent of physicians have adopted CPOE, enabling delivery of critical information about imaging studies.

One key to effective decision support is embedding tools in daily clinical workflow. That is, decision support cannot require additional steps; it must integrate both with existing technology and workflow, says Khorasani. In addition, decision support must be actionable and current. It must reinforce or contradict behavior. For example, it might refer to recent studies