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RADIOLOGY ORDER ENTRY (ROE) WITH DECISION SUPPORT

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

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RADIOLOGY ORDER ENTRY (ROE) WITH DECISION SUPPORT

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  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” • 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 • 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

  7. 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

  8. Proceed on Red:Reasons

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

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

  11. 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

  12. 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

  13. Sample Analysis:Indications for Cardiac Imaging • Rory B WeinerM.D. cardiology • Faisal M MerchantM.D. cardiology • Jeffrey BWeilburgM.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

  14. Sample analysis: Rory B WeinerM.D. Faisal M MerchantM.D.Jeffrey BWeilburgM.D.

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

  16. 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

  17. Exam As % of Total Hospital Volume % Red by exam type % of Total Hospital Low Utility Exams 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% FACE OR SINUS CT 1% 14% 5% TOTAL 91% Low Utility Examinations

  18. % 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 Reasons for Proceeding on “Red”

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

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

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

  22. The EndFor more information, please contact:Daniel Rosenthal, MDDIRosenthal@partners.org617 726 8784

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