Abstract
Despite its considerable contributions to patient care, utilization of medical imaging is a cost driver in health care [1]. In diagnostic imaging increasing utilization is related to rapid technological change allowing clinicians to achieve rapid, accurate diagnosis [2]. This rapid expansion has also led to some inappropriate utilization, as referring physicians find it progressively challenging to keep up with complex, new imaging technologies. Physicians' decisions directly and indirectly account for approximately 80% of overall healthcare expenditures [3]. Inappropriate or excess use results in unnecessary increase in health care expenditures and may expose patients to unnecessary stress and potential harm including radiation dose from computed tomography. There is a growing body of literature that suggests that there is some clinically ineffective use of radiology in Canada [4],[5]. Extensive geographic variation [6] suggests that imaging is probably overused in some populations and underused in others, modulated by both resource distribution and clinical demand. Resource stewardship is the “appropriate” allocation of resources that results in high-value, effective care.
Everyone involved in health care strives to achieve the best outcomes for patients; however, there are factors that may interfere with these best intentions. It takes considerable volunteer effort to optimize and maintain imaging referral guidelines. There are important challenges: imaging technologies evolve rapidly and the lengthy algorithm needed to develop evidence-based guidelines can render specific recommendations nearly obsolete by the time of publication. Working collaboratively, with a dedicated team of radiologists, institutions such as the Canadian Association of Radiologists and American College of Radiology have demonstrated that it can be done. Given such guidelines, it can be very difficult for a generalist or specialist to remain current with the complete list of guidelines.
Most referral guidelines are available in booklet, PDF, and compact disc formats and on physician websites; however, these are time consuming to use. To maximize efficiency and cost savings, guidelines must be made seamlessly available within a clinician's regular workflow. Clinical decision support (CDS) systems in computerized provider order entry (CPOE) for imaging will provide real-time guidance to ordering physicians. Access through CPOE systems or via electronic health records will enable decision support to be used as part of normal everyday workflow. CDS software maps a patient's clinical scenario to accepted guidelines and ranks the appropriateness of a physician's order for a specific diagnostic imaging test. In the United States, the use of CDS for imaging referrals has been mandated by Medicare effective 2017. The European Society of Radiology has also adopted the use of CDS and is in the implementation phase.
As health care needs continue to grow, physicians are squeezed for time. Imaging tests are often ordered with incomplete clinical history, thus limiting the ability of the radiologist to appropriately triage the request. A CDS system will require relevant clinical history before a test can be ordered, allowing for effective clinical decision support. Data generated from the use of CDS systems will be able to provide system feedback and will help to improve the decision tree accordingly.
CDS implementation can raise concerns such as “I don't want to be told how to practice medicine,” or that the real purpose is to ration imaging testing. The CDS software will not replace skilled clinicians but will help guide them to efficient and excellent patient care. CDS is designed not to ration care, but rather to guide physicians to order the right imaging examination at the right time.
There is a cost to the implementation of CDS; however, it should be noted that in the United States, implementation has already helped hospitals meet appropriate use criteria, which in turn helped reduce healthcare costs [7],[8]. The health care system in Canada may be somewhat more amenable to the implementation of CDS systems, given a less litigious environment than in the United States. This will theoretically permit the implementation of appropriateness guidelines with less concern for the threat of medical malpractice suits from patients who “demand” a test. Furthermore, Canadian physicians are concerned about lengthy wait lists, and may be willing to embrace CDS in order optimize the administration of health care in an environment of limited resources. CDS systems have been successfully implemented on a small scale in Canada [4],[9]. To date, the most commonly used CDS tools use the comprehensive ACR appropriateness criteria to link patient data with an electronic knowledge base to improve decision making. These systems may also combine guidelines from other sources into the same system. The appropriateness criteria can be supplemented by guidelines from additional medical societies, such as the CAR. If properly implemented and maintained, such a CDS will effectively implement the use of imaging referral guidelines and will help clinicians stay up to date with current appropriateness criteria.
Now that CPOE has been or being adopted in many Canadian hospitals, there is an opportunity to implement clinical decision support systems into the regular workflow for imaging requests. Most CDS software is able to integrate into commonly used Radiology Information Systems, electronic medical record (EMR), and electronic patient records (EPR) software. The success or failure of healthcare IT depends on usability, implementation, and how software fits with clinical workflow. Active engagement with the clinicians during implementation will be critical to the successful acceptance of this essential tool in Canadian healthcare systems.
We can improve the current state of imaging in Canada. The adoption of established appropriateness criteria delivered through a CDS structure integrated into CPOE (available at the time of request for imaging) is a fundamental and necessary step to improve efficiency and appropriateness. Wide implementation of CDS in CPOE will advance the practice of health care in Canada.