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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

RADIOLOGY ORDER ENTRY(ROE)WITH DECISION SUPPORT

Daniel I. Rosenthal MD

Massachusetts General Hospital

Boston, MA

ABR Practice performance Summit

August 19, 2006

background
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
FEATURES
  • MD and support staff functions
  • Appointment selection
  • Insurance Preauthorization
  • Patient information
  • “Important Findings Alert”
  • Duplicate examination warning
  • Special billing circumstances
the ordering page
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

indications
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
“Appropriateness” Values

1-3

Low Utility

4-6

Intermediate

7-9

High Utility

utilization management
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
from recommendations to roe ds
From Recommendationsto ROE-DS

Pre-Test Probability of CAD

J Am Coll Cardiol 2005; 46:1602.

From information system

from recommendations to roe ds13
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
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

from recommendations to roe ds combined indications
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

sample analysis indications for cardiac imaging
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
sample analysis rory b weiner m d faisal m merchant m d jeffrey b weilburg m d
Sample analysis: Rory B WeinerM.D. Faisal M MerchantM.D.Jeffrey BWeilburgM.D.
growth of roe
Growth of ROE
  • 3500-4000 examinations per week
    • 200,000 per year

Decision support added

current status
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

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
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

Reasons for Proceeding on “Red”
why is the red rate falling
Why is the “Red Rate” falling?
  • More appropriate ordering
  • Same appropriate orders, additional justification
  • False histories (gaming)
what has worked
What Has Worked
  • Support from clinical leadership
  • Close collaboration with administrative leads
slide25
The EndFor more information, please contact:Daniel Rosenthal, MDDIRosenthal@partners.org617 726 8784