PC 9 - Implementing and evaluating clinical decision support (CDS) for imaging referral guidelines
on Mar 3rd
08:30 - 10:00
1. To understand the challenges to implementing CDS.
2. To learn from practical experiences of CDS implementation.
3. To understand how a CDS implementation can be evaluated and impact measured.
4. To understand the perspective of CDS users: referring physicians.
Clinical decision support systems (CDS) represent computer application systems to enhance decision-making in the clinical workflow. These tools include clinical recommended guidelines, condition-specific order sets, computerized alerts and relevant reference information. Among the benefits of the use of CDS, we can include increase of quality and safety of care, avoidance of errors and improved efficiency. Implementation strategies and outcomes in the hospitals depend on their culture and resources. The introduction of a CDS includes a number of steps, such as identifying the needs and functional requirements, designing or configuring the system for use in the local environment, planning the implementation process and determining how to assess the needs identified. Most research has evaluated the effects of CDS, it has been focused primarily on clinician decision-making, but little has been published on how those decisions affect patient’s outcomes. It is important to involve clinicians to avoid misconceptions about the use of CDS. Finally, an application of the CDS includes its application in medical schools to train students on the appropriateness of the imaging techniques in the clinical setting.
1. To learn about challenges in the implementation of CDS.
2. To understand the opportunities of advanced functions of CDS.
3. To appreciate the contribution of CDS to value-centred radiology.
Radiologists are participating in the transition from the volume-centred pay-for-service to the value-centred pay-for-performance. Thus, clinical and economic outcomes are driving the reimbursement. However, the definition of metrics to measure performance, quality and outcome within the complex web of the healthcare system is challenging. Overall, the goal-directed behaviour of patients, ordering physicians, radiologists and specialists has to be aligned. As workflow is critical, incentives for improvements in collaborative care are pivotal. CDS will play an important role in improving quality and efficacy of the workflow and the radiology service in value-centred medicine. Basic CDS will check the appropriateness of CT or MRI for a given clinical scenario, mainly based on evidence and guidelines. Major challenges of CDS are 1) the deep integration into an existing multi-vendor environment of HIS and RIS as well as image acquisition devices and PACS; 2) data security and patient privacy issues between different health care providers and the integration of a cloud-based service into the system; 3) the adaptation of the basic “guidelines” of the CDS provider to the specific requirements of the institution and its imaging department(s). This in particular relates to the level of healthcare (in- or outside, prevalence of disease), complexity of cases, comorbidities, local, regional and national standard of care and operating procedures. Advanced CDS should also check for already available imaging studies and reports as well as whether intravenous contrast should be given. If yes, contraindications (allergies, renal insufficiency, etc.) should automatically be checked from the electric patient record.
1. To understand the difficulties in evaluating the impact of CDS and guideline use.
2. To learn about what can be measured and how.
3. To understand how comparisons between different hospitals can be drawn and lessons learned.
Background: guidelines and appropriateness criteria have been published to help physicians choose the right test for the right patient at the right time. These are typically implemented through computerized decision support systems (CDSSs) so that the advice is presented at the point-of-care. ACR select and ESR iGuide are such systems. The results of implementation of CDSSs for guiding imaging referrals is, however, not (yet) convincing: are CDSSs really cost-effective in guiding the justified use of imaging procedures? Study designs to evaluate CDSSs: to evaluate interventions, ideally a parallel group double-blinded RCT is performed but this is not feasible in this context given the nature of the intervention. A pragmatic parallel group RCT may be feasible but contamination effects between care-givers could easily occur invalidating such a study and this study design would be logistically difficult to perform. More realistic is a stepped-wedge cluster RCT or a matched pair cluster RCT. So far single-centre before-after studies have been published with their limitations. Outcome measures to evaluate CDSSs: ideally mortality, morbidity, quality of life and costs are evaluated to determine the cost-effectiveness of implementing CDSSs, requiring large studies with long follow-up. More realistic is to measure short-term quality of life, complications of testing and costs of the diagnostic workup. So far studies have focused on diagnostic yield and the number of exams ordered which provides only a very limited picture.
1. To understand how referrers view and what they expect from imaging referral guidelines.
2. To learn how CDS can best be integrated into referral workflows and what to avoid.
3. To learn how general practitioners can best be involved in the process of introducing CDS.
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1. To understand how guidelines and CDS can be used for education.
2. To understand how test cases are developed and hear about user experiences.
3. To learn about the ESR eGuide project and how to participate.
Imaging referral guidelines are not only a legally recognised concept to ensure imaging is used appropriately or an evidence-based tool to improve clinical practice, but also a vital educational tool. Over the past years, the ESR has worked to create CDS-compatible guidelines based on the American College of Radiology Appropriateness Criteria which are now available at the point of care through ESR iGuide. Building on this effort, the ESR eGuide project aims to reap the educational benefits of referral guidelines and clinical decision support. An ESR Education Committee Taskforce is creating case studies on appropriate imaging to be solved with decision support using the ESR’s referral guidelines. Taking a long-term approach to improving appropriateness in medical imaging, the overall purpose of this project is to educate doctors-in-training about appropriate imaging using evidence-based referral guidelines, while introducing the concept of clinical decision support and familiarising them with a technology they will encounter in their professional careers. The ESR eGuide project is part of the implementation of the EuroSafe Imaging Call for Action with regard to Action 1 on Clinical Decision Support and Action 6 focusing on educational activities including the development of e-learning tools. The objectives of ESR eGuide are: improving the quality of medical education with regard to diagnostic imaging, educating medical students about the appropriateness of different imaging modalities for given clinical indications, familiarising medical students with CDS technology, demonstrating the efficacy and utility of CDS, reinforcing the concept of evidence-based medicine.