RADIOLOGY ORDER ENTRY (ROE) WITH DECISION SUPPORT

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
(No Transcript)
8
(No Transcript)
9
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

10
(No Transcript)
11
Proceed on RedReasons
12
From Recommendationsto ROE-DS
Pre-Test Probability of CAD J Am Coll Cardiol
2005 461602.
From information system
13
From Recommendationsto ROE-DS
Pre-Test Probability of CAD J Am Coll Cardiol
2005 461602.
Not indications for imaging
14
ExampleATYPICAL, 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
15
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

16
Sample AnalysisIndications for Cardiac Imaging
Rory B Weiner M.D. cardiology Faisal M Merchant
M.D. cardiology Jeffrey B Weilburg M.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

17
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
18
Growth of ROE
3500-4000 examinations per week 200,000 per year
Decision support added
19
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

20
Low Utility Examinations
 
 
 
21
Reasons for Proceeding on Red
22
Red rate over time vs. Physician Log-on
23
Why is the Red Rate falling?

• More appropriate ordering
• Same appropriate orders, additional justification
• False histories (gaming)

24
What Has Worked

• Support from clinical leadership
• Close collaboration with administrative leads

25
The EndFor more information, please
contactDaniel Rosenthal, MDDIRosenthal_at_partner
s.org617 726 8784