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

2. 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

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

4. 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

5. 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

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

9. 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

11. Proceed on Red: Reasons

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

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

14. 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

15. 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

16. 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

17. 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

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

19. 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

20. 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%

21. 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

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

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

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

25. The End For more information, please contact: Daniel Rosenthal, MD