RADIOLOGY ORDER ENTRY (ROE) WITH DECISION SUPPORT Daniel I. Rosenthal MD Massachusetts General...

RADIOLOGY ORDER ENTRY(ROE)

WITH DECISION SUPPORTDaniel I. Rosenthal MD

Massachusetts General HospitalBoston, MA

ABR Practice performance SummitAugust 19, 2006

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

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

The Ordering “page”

• “Special Considerations” – Communications– “Protocols”

• Indications:– Signs and symptoms– Known diagnoses (not r/o)– Abnormal previous tests

• Free text

optional

optional

At least one is mandatory

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

4-6Intermediate

1-3Low Utility

7-9High Utility

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

Proceed on Red:Reasons

From Recommendationsto ROE-DS

Pre-Test Probability of CAD J Am Coll Cardiol 2005; 46:1602.

From information system

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

Start age

End age

Sex

X Ray

CT

CTA

MR

MRA

ANGIO

PET

NUC PERF

ECHO

0 50 F 9 6 6 6 6 2 4 5 8 851 100 F 9 6 6 6 6 2 4 8 8 50 40 M 7 5 7 7 5 9 7 5 8 841 100 M 7 5 7 7 5 9 7 9 8 5

NON-IMAGINGSTRESS

Demographics Modalities

Different utility depending upon ageand sex

Not Radiology

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

LIVER/PANCREAS/SPLEEN Jaundice 0 0 3 8 3 2 0

LIVER/PANCREAS/SPLEEN 4 6 5 8LIVER/PANCREAS/SPLEEN JaundiceLIVER/PANCREAS/SPLEEN Pain

Exam Indication Start_age End_age Sex X_Ray CT CTA MR MRA ANGIO PET NUC_PERF US

Sample Analysis:Indications for Cardiac

Imaging

• 30 consecutive out-patient studies Fall 2005

• Indications for MIBI imaging as entered by providers into ROE verified by review of the medical record

Rory B Weiner M.D. cardiologyFaisal M Merchant M.D. cardiologyJeffrey B Weilburg M.D. physicians org admin

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

Growth of ROE

0

500

1000

1500

2000

2500

3000

3500

4000

4500

12/2

1/01

2/8/

02

3/22

/02

5/3/

02

6/14

/02

7/26

/02

9/7/

02

10/1

9/02

11/3

0/02

1/4/

03

2/15

/03

3/29

/03

5/10

/03

6/21

/03

8/2/

03

9/13

/03

10/2

5/03

12/6

/03

1/10

/04

2/21

/04

4/3/

04

5/15

/04

6/26

/04

8/7/

04

9/18

/04

10/3

0/04

12/1

1/04

1/15

/05

2/26

/05

4/9/

05

5/21

/05

7/2/

05

8/13

/05

9/24

/05

11/5

/05

Series1

3500-4000 examinations per week3500-4000 examinations per week

200,000 per year200,000 per year

Decision support added

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

FACE OR SINUS CT 1% 14% 5%

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%

TOTAL     91%

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

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

Why is the “Red Rate” falling?

• More appropriate ordering• Same appropriate orders,

additional justification• False histories (gaming)

What Has Worked

• Support from clinical leadership• Close collaboration with

administrative leads

The End

For more information, please contact:

Daniel Rosenthal, MDDIRosenthal@partners.org

617 726 8784