Decision support decreases inappropriate exam ordering

Massachusetts General Hospital cites a steady decline in the number of inappropriate imaging exams ordered by physicians, thanks to the addition of decision support and appropriateness criteria to its outpatient order entry system, according to a paper presented Tuesday at the RSNA meeting.

Through use of the system, physicians may be learning how to order more appropriate exams or may simply be providing additional justification for the exams ordered, said Dr. Daniel Rosenthal, associate radiologist-in-chief at MGH.

The system was created in 2001 to capture all information required by radiology, and was not intended to guide physicians in using diagnostic imaging, he said. However, with more insurance companies requiring preauthorization for examinations, and the emergence of pay-for-performance contracts, overutilization is now associated with stiffer financial penalties.

To order an exam using the system, physicians complete a page that includes special considerations, indications, and free text notes. The types of imaging exams indicated for a specific application are labeled with an appropriateness number: a score of 1 to 3 indicates low utility, 4 to 6 is intermediate, and 7 to 9 indicates high utility. For multiple indications, the higher appropriateness table is shown.

Physicians can select an exam rated as low utility, but must answer a series of questions as to why the more appropriate exam was not used, Rosenthal said.

The system has been in place for about one year. The highest number of low utility exams ordered tend to be related to the spine, with spine MR and spine CT accounting for nearly 60% of inappropriate imaging studies, according to Rosenthal.

Surprisingly, the number one reason that physicians gave for disregarding a suggested appropriate exam was that the exam ordered was recommended by a specialist, he said. Additionally, a significant number of physicians listed disagreement with the guidelines as a reason for choosing a different exam.

The appropriateness guidelines used by the MGH system differs enormously from the ACR guidelines, Rosenthal said, but that is because creation of the guidelines is a dynamic and ongoing process.

MGH is already seeing a steady increase in the rate at which physicians log onto the system, he said.