LIVE FROM RSNA: Can Clinical Decision Support Change Radiology Practice?

Dec. 4, 2014
A new medical specialty society-hospital-vendor initiative offers the potential to support fundamental change in radiology practice

Are all the planets aligning to help facilitate a fundamental change in the way radiologists will work? Talking to Lincoln L. Berland, M.D., and Keith Dreyer, D.O., Ph.D., it is quite possible to believe so. And they’re not the only ones bullish on a future of radiological practice that is more evidence-based, collaborative, and better enabled by clinical decision support (CDS) tools. That’s because both radiologists are heavily involved in helping to spearhead change in their specialty.

Dreyer, the vice-chairman of radiology at Massachusetts General Hospital in Boston, a professor of radiology at Harvard Medical School, and chairman of the Informatics Commission of the American College of Radiology, and Berland, vice-chairman for quality improvement and the patient safety chief in the Department of Radiology at the University of Alabama-Birmingham, are two radiologists who believe the future of the specialty lies with enhanced support for better clinical decision-making. Thus, both are involved in a range of efforts to help bring that future about.

It is in that context that executives from the Burlington, Mass.-based Nuance Communications, Inc. announced Dec. 1 from the RSNA Conference, being held at the McCormick Place Convention Center in Chicago, that their company is working with the American College of Radiology (ACR) and Massachusetts General Hospital (MGH) to “leverage the Nuance PowerShare Network, the industry’s largest cloud-based medical imaging exchange to bring clinical guidelines to the radiologist’s workflow and automate the process of collecting and reporting quality measures to meet industry regulations and guidelines.”

A collaborative association-provider-vendor initiative

What’s happening is that Mass General, in partnership with the ACR and Nuance, will deliver an initial set of radiology clinical decision support guidelines to the broader radiology community by integrating them into the PowerScribe workflow, so that radiologists will be able to access those evidence-based guidelines at the point of interpretation. As the guidelines are updated and expanded, Nuance will share them digitally to radiologists nationwide through its PowerShare Network.

The Dec. 1 press release quoted James A. Brink, M.D., radiologist-in-chief at Mass General, as saying, “Our goal is to provide the highest-quality patient care that is consistent with recognized national guidelines and standards. Mass General has long been committed to developing, adopting, and leveraging innovative systems and technology to achieve this goal.”

The press release noted that Nuance will use its PowerShare Network to connect more than 2,000 provider organizations sharing 3 billion medical images, to produce diagnostic reports, with radiologists leveraging the network’s capabilities to access clinical decision support at the point of interpretation.

The struggles behind the change

The newly announced initiative reflects the fact that for years, radiologists have struggled to try to use clinical guidelines to support their decision-making, Dr. Berland notes. “This provides us the ability to access CDS electronically and within our natural workflow, and not to have to pull out a paper or look it up on a screen,” he says. “When it finds a key word like adrenal nodule, it will pop up an alert saying there’s a guideline for that and you get prompted to provide the characteristics, and then that helps you follow the guideline.” The reality, he says, is that, “Someday, almost everyone will have to use CDS. And right now, people are winging it. Even if they’re familiar with the criteria, they may not be able to apply them, because things are too complex. There’s just too much information in medicine. They’ve been taping cheat-sheets to their computers. So I’m very excited about the capabilities.”

As for the involvement of radiologists at Mass General in spearheading the initiative, Berland says, “They’re farther along at Massachusetts General,” so their leadership in the initiative is natural. Meanwhile he says, “Part of the problem is that you can’t specify every condition a patient might have, the algorithm gets too complicated. And you can’t oversimplify it, either. But the thing I keep harping on is that these are not laws. These are guides.” And actually, he says, “I think radiologists are probably more attuned to [the use of guidelines] than some other specialists. We’re very technically oriented; we understand responding to and interacting with technology. People understand that systems can help them, because they do it on an ongoing basis. I’m not saying it won’t be hard; it will be hard. But I really think it will happen. I think we’ll see modest adoption for the next couple of years. But if we can get the assistance on the clinical decision support side, and if we can get a critical mass of guidelines in various areas, it will become obvious.”

New federal mandate cited

Says Mass General’s Dryer, “We want to build this step by step. The ACR will find a recommendation—body part, exam type, modality, date, conditions, something related to clinical history or prior exam. Start with that structured object. We can do that quickly, in a matter of a few months, and companies like Nuance can structure and implement that quickly. And then have the EHR pre-load an order of a CT of the head, and in fact, the system could pre-order the exam, following best-practice guidelines, and then notifying the patient to trigger the scheduling of that exam.”

Importantly, Dreyer notes, according to the terms of the legislation passed  by Congress and signed by President Obama in April 2014 to extend the “SGR patch”—the extension of a hold on physician payment cuts under the Medicare sustainable growth rate formula—one clause in that legislation—Section 218 of H.R. 4302—is requiring the use of clinical decision support-based ordering criteria on the part of the referring/ordering physician, beginning in January 2017. “By January 2017, for the radiologist to get paid, you the ordering physician will have to refer to appropriate ordering criteria,” he notes. “That means all these physicians ordering these diagnostic tests are going to have to go to decision support, and get an appropriate score based on formal criteria, before ordering. With regard to pre-ordering future follow-up exams, clinical decision support will really help the radiologists themselves,” he notes.

Dryer believes that all physicians will ultimately benefit from clinical decision support, including the CDS mandated by the new federal law. Indeed, he and several other physicians spoke about the subject in a briefing before members of Congress in late October. Of course, such acceptance and adoption will only come over time. “People are still living in the high-volume, fee-for-service world,” he observes. “And they say, how am I going to add quality elements to what I’m doing every day? But when you tell them the wheel they’re on is just going to spin faster and faster and faster, and that quality will change that, they begin to listen. They will still say, well, when I go back to work tomorrow, I have 200 CT studies to read. So this has to be provided by the vendors so seamlessly that it doesn’t slow people down; it has to be embedded into the workflow so they don’t have extra tasks. And don’t tell them at the end of the month all the things they have to do, just tell them there’s a quality issue to look at. And that’s where natural language processing fits in as well. And I think it will be up to the organizations—the department of radiology, CMO, chief quality officer—to police that.”

The role of healthcare IT leaders in leading change

Asked what the role of healthcare IT leaders will be in creating change, Dreyer immediately exclaims, “Oh, it will be big! For example,” he says, shifting the subject towards a slightly different topic, “I was involved in Nuance’s clinical advisory board meeting for their medical practice customers, and I was asking CMIOs and CIOs questions about radiology. And we asked them, if we could collectively create systems that would allow a clinician who read a radiologist report to rate the quality of that report based on a point system, would be valuable? And they said, absolutely. And chairs of radiology would love to be able to see that. ‘Did this [performance by a radiologist] affect the clinical outcome?’ might be one of the queries posted of referring physicians, using such a point system. That resonated very well with the CMIOs. So now it’s the task of the College to define a set of objects that goes out to those clinicians from a reporting system like Nuance into an EHR system like Epic or Cerner. Then that would come back to radiologists to tell them whether their reports were helpful, confusing, changed patient care, etc. There could be great value in that as well.”

In short, clinical decision support has the potential to transform radiological practice, Berland and Dreyer agree. And the new initiative is one element in a bigger picture, as the practice of radiology evolves forward into something unprecedented in the coming years.

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