The Night Decision Support Came to Visit

May 20, 2013

They ordered a CT without contrast and missed my daughter’s peri-tonsillar abscess. We must leverage decision support to ensure the right test is done the first time.

It was a Saturday night not long ago. I was sitting far from my grown baby when the electronic umbilical cord began to tug. The texts began during dinner out, interrupted, ruined by worry, and they kept coming until 2 a.m. By then my daughter had undergone her second drainage in ten days, for the same thing: a peri-tonsillar abscess.

It was weeks in the brewing, seen by a parade of ENT docs, providers at student health, and entailed three trips for me. At a distance, I was helpless in the face of the medical machine, even when it was my daughter. My first trip, I went home reassured after her endoscopy was negative. Time passed, her course worsened, and the imaging began. When in doubt, get an X-ray.

Her first CT was negative, and her doctor told her she did not have an abscess, but two days later the abscess that never was was being drained in the hospital. That was my second trip. Negative CT - really? Really?

Soon enough again she could not swallow, not even saliva, and went alone on a Saturday night to Emergency, afraid and quite ill. No more Dr. Nice Mom. My email to her attending laid out a reasonable medical approach, which I suggested he follow - or deal with me.

First, I suggested, if you want to see what is going on in her neck, a CT with contrast is imperative.  Repeating a CT without contrast, his previous test of choice, would only compound the mistake of ever having ordered it in the first place.

Of course, there was a large peri-tonsillar abscess present, easily seen, and well described in the report.  What was not said in the report was that it looked the same as the other CT scan, but the abscess was just easier to see with contrast, and had been missed by the first radiologist. 

Why is this our collective fault? When will we lend support to better decision making? According to the ACR, the test of choice in a patient with fever and a neck mass is a CT scan with contrast. 

No surprise, right? We all know that, but not everyone else knows that.  Not even really smart sub-specialists with great training and good hearts.

How many times a day do you come across a patient in whom the wrong study is ordered? Sometimes it is brought to our attention before the test is done, and then we take a deep breath and try to fix it.  Insulting our referring docs by telling them they ordered the wrong test is never fun. That is if you can even reach them. Where is the incentive to be scolded for bothering them? And of course then the insurance pre-certs may no longer apply. And the hospital loses money, and we don’t get paid… And once the wrong test is done, it is too late.

How can we do this better? Because we must do better. We have no choice.

It is an imperative that we leverage technology to help our profession ensure the right test is done the first time.  Decision support is key. 

The ACR has been working on this for some time, by establishing criteria to rank suggested imaging exams for given diagnoses. The current tables are crude, and their impact across patient populations has not been tried and tested. 

As the EMR becomes universal and we implement computer aided decision support at the point of physician order entry, we will begin to change ordering patterns established for decades. This will not be without difficulties and many doctors will figure out how to order what they want, by working around the system. 

Yet we will gain the power to circle back and see, for each doctor and for each population studied, what makes an effective and sensible ordering practice and learn from this. Big data and data analytics will be brought to bear on what test to order when, analyzing what works and what doesn’t. This will allow refined suggestions for imaging, based on an individual doctor’s track record, based on the population considered, and based on things like seasonal prevalence of illness. What is suggested in flu season may not be appropriate in summertime.

Data analytics in concert with computer aided decision support will help ensure that the right test is ordered the first time. It will allow us to take a second look at studies where the imaging findings are unexpected, given the clinical situation.

So next time a patient comes to a specialist’s office with a suspected peri-tonsillar abscess, a CT with contrast will automatically be ordered, and if it is “negative” despite a high clinical suspicion, we look one more time to make sure we did not miss the diagnosis.

What do you think?