Clinical decision support (CDS) systems can help reduce the number of orders for unnecessary imaging, but practical challenges remain when it comes to putting the tools to work in clinical settings, according to a study by the RAND Corp. published in of the Journal of the American Medical Association.
Too often the CDS systems don't have or can't find appropriateness criteria for a particular test on which to make recommendations.
The Medicare Imaging Demonstration was sponsored by the Centers for Medicare & Medicaid Services. The RAND Corp. independently evaluated the demonstration, testing whether exposing physicians to appropriateness guidelines for advanced imaging would reduce or eliminate unnecessary tests. National medical specialty societies developed the appropriateness criteria that were loaded into the CDS tools for all participating clinicians.
By 2017, CMS will require the use of CDS to inform the ordering of any advanced diagnostic imaging study paid for by Medicare.
The study involved a six-month baseline period in which CDS systems tracked whether orders for selected magnetic resonance imaging, computed tomography and nuclear medicine procedures were linked with appropriateness criteria, but did not provide clinicians with feedback on appropriateness of orders. During the 18-month intervention period, the CDS systems did provide feedback about any appropriateness criteria, recommendations for alternative orders and a link to documentation supporting each rating.
The CDS systems did not identify relevant appropriateness criteria for 63.3 percent of orders during the baseline period and for 66.5 percent during the intervention period. During the baseline period, 11.1 percent of final rated orders were inappropriate and 6.4 percent were inappropriate during the intervention period. During the baseline period, 73.7 percent of final rated orders were appropriate compared with 81.0 percent that were appropriate during the intervention period.
"We need a more comprehensive set of evidence-based guidelines that cover a greater proportion of advanced imaging orders for Medicare patients, and provide better methods for communicating feedback to clinicians," Katherine Kahn, M.D., principal investigator on the study, said in an announcement.
A review of 23 studies on the effect of CDS on diagnostic radiology test ordering that was funded in part by the Department of Veterans Affairs found a reduction in orders, but also included a warning:
"This lack of reporting of context and implementation, which is common to many studies of health IT, limits readers' ability to draw conclusions about effectiveness and may perpetuate the belief that these kinds of interventions can be developed separate from the workflow of practicing clinicians and then simply 'turned on' with the expectation that clinicians will know how to use the intervention and use it correctly."