RADIOLOGY ORDER ENTRY (ROE) WITH DECISION SUPPORT Daniel I. Rosenthal MD Massachusetts General Hospital Boston, MA ABR Practice performance Summit August 19, 2006

BACKGROUND Order Entry system created 2001-2002 Information required by Radiology Convenience of clinicians Decision Support added 11/2004 Perceived need for clinical guidance Insurance issues Increasing pre-authorization requirements “Pay for performance” contracts

FEATURES MD and support staff functions Appointment selection Insurance Preauthorization Patient information “Important Findings Alert” Duplicate examination warning Special billing circumstances

The Ordering “page” “Special Considerations” Indications: Free text Communications “Protocols” Indications: Signs and symptoms Known diagnoses (not r/o) Abnormal previous tests Free text optional At least one is mandatory optional

INDICATIONS Derivation Maintenance Requirements: Expert opinion Common medical language Minimize duplication Requirements: ICD9 Appropriateness value Maintenance Additions, deletions Clinical review: CPM groups including specialists and primary care doctors

“Appropriateness” Values 1-3 Low Utility 4-6 Intermediate 7-9 High Utility

Utilization Management NOT a gatekeeper “Scores” and all changes to orders are recorded Regular analyses are done Senior clinicians (not Radiologists) counsel individuals with low scores

Proceed on Red: Reasons

From Recommendations to ROE-DS Pre-Test Probability of CAD J Am Coll Cardiol 2005; 46:1602. From information system

From Recommendations to ROE-DS Pre-Test Probability of CAD J Am Coll Cardiol 2005; 46:1602. Not indications for imaging

Example: ATYPICAL, POSSIBLY ANGINAL PAIN Not Radiology Demographics Modalities NON-IMAGING STRESS Start age X Ray MR PET NUC PERF End age CT MRA ANGIO ECHO CTA Sex Different utility depending upon age and sex

From Recommendations to ROE-DS: Combined indications When two or more indications with different appropriateness scores are listed: 1) the HIGHER appropriateness table is shown 2) UNLESS they combine to give a specific appropriateness value

Sample Analysis: Indications for Cardiac Imaging Rory B Weiner M.D. cardiology Faisal M Merchant M.D. cardiology Jeffrey B Weilburg M.D. physicians org admin 30 consecutive out-patient studies Fall 2005 Indications for MIBI imaging as entered by providers into ROE verified by review of the medical record

Sample analysis: Rory B Weiner M. D. Faisal M Merchant M. D Sample analysis: Rory B Weiner M.D. Faisal M Merchant M.D. Jeffrey B Weilburg M.D. ROE Indication for MIBI Indication verified by chart review Indication specifically refuted by chart review Unable to verify indication based on chart review Chest pain 5 7 4 Dyspnea 8 2 Presyncope/ syncope 1 Lightheaded/dizzy 3 h/o CAD, PTCA, CABG 6 Abnormal baseline ECG Hyperlipidemia 21 Hypertension 19 Diabetes Family history

Growth of ROE 3500-4000 examinations per week 200,000 per year Decision support added

Current Status ROE handles 90% of all pre-scheduled outpatient exams 95% of PCPs either use ROE directly or have their clinical staff do it for them 80% of general Internal Medicine orders come directly from physicians

Low Utility Examinations   Low Utility Examinations   Exam As % of Total Hospital Volume % Red by exam type % of Total Hospital Low Utility Exams FACE OR SINUS CT 1% 14% 5% SPINE MRI 10% 15% 43% SPINE CT 2% 27% EXTREMITY MRI 7% 6% HEAD CT 4% 8% 9% Nuclear Cardiology 3% TOTAL   91%  

Reasons for Proceeding on “Red”   % Disagree with guidelines 25 Other imaging was tried and unhelpful 6 Other imaging would take too long to obtain 5 Recommended by a specialist 55 Patient Demand 9 TOTAL 100

“Red” rate over time vs. Physician Log-on

Why is the “Red Rate” falling? More appropriate ordering Same appropriate orders, additional justification False histories (gaming)

What Has Worked Support from clinical leadership Close collaboration with administrative leads

The End For more information, please contact: Daniel Rosenthal, MD DIRosenthal@partners.org 617 726 8784