radiology order entry (roe) with decision support daniel i. rosenthal md massachusetts general...
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RADIOLOGY ORDER ENTRY(ROE)
WITH DECISION SUPPORTDaniel I. Rosenthal MD
Massachusetts General HospitalBoston, MA
ABR Practice performance SummitAugust 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” – Communications– “Protocols”
• Indications:– Signs and symptoms– Known diagnoses (not r/o)– Abnormal previous tests
• Free text
optional
optional
At least one is mandatory
INDICATIONS
• Derivation– 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
4-6Intermediate
1-3Low Utility
7-9High 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 Recommendationsto ROE-DS
Pre-Test Probability of CAD J Am Coll Cardiol 2005; 46:1602.
From information system
From Recommendationsto ROE-DS
Pre-Test Probability of CAD J Am Coll Cardiol 2005; 46:1602.
Not indications for imaging
Example:ATYPICAL, POSSIBLY ANGINAL
PAIN
Start age
End age
Sex
X Ray
CT
CTA
MR
MRA
ANGIO
PET
NUC PERF
ECHO
0 50 F 9 6 6 6 6 2 4 5 8 851 100 F 9 6 6 6 6 2 4 8 8 50 40 M 7 5 7 7 5 9 7 5 8 841 100 M 7 5 7 7 5 9 7 9 8 5
NON-IMAGINGSTRESS
Demographics Modalities
Different utility depending upon ageand sex
Not Radiology
From Recommendationsto 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
LIVER/PANCREAS/SPLEEN Jaundice 0 0 3 8 3 2 0
LIVER/PANCREAS/SPLEEN 4 6 5 8LIVER/PANCREAS/SPLEEN JaundiceLIVER/PANCREAS/SPLEEN Pain
Exam Indication Start_age End_age Sex X_Ray CT CTA MR MRA ANGIO PET NUC_PERF US
Sample Analysis:Indications for Cardiac
Imaging
• 30 consecutive out-patient studies Fall 2005
• Indications for MIBI imaging as entered by providers into ROE verified by review of the medical record
Rory B Weiner M.D. cardiologyFaisal M Merchant M.D. cardiologyJeffrey B Weilburg M.D. physicians org admin
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 7 8 2
Presyncope/ syncope 1 2
Lightheaded/dizzy 2 3 1
h/o CAD, PTCA, CABG
6
Abnormal baseline ECG
1 4
Hyperlipidemia 21 1 1
Hypertension 19 1 1
Diabetes 7
Family history 4 3 2
Growth of ROE
0
500
1000
1500
2000
2500
3000
3500
4000
4500
12/2
1/01
2/8/
02
3/22
/02
5/3/
02
6/14
/02
7/26
/02
9/7/
02
10/1
9/02
11/3
0/02
1/4/
03
2/15
/03
3/29
/03
5/10
/03
6/21
/03
8/2/
03
9/13
/03
10/2
5/03
12/6
/03
1/10
/04
2/21
/04
4/3/
04
5/15
/04
6/26
/04
8/7/
04
9/18
/04
10/3
0/04
12/1
1/04
1/15
/05
2/26
/05
4/9/
05
5/21
/05
7/2/
05
8/13
/05
9/24
/05
11/5
/05
Series1
3500-4000 examinations per week3500-4000 examinations per week
200,000 per year200,000 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
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% 14%
EXTREMITY MRI 7% 6% 14%
HEAD CT 4% 8% 9%
Nuclear Cardiology 3% 7% 6%
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
