A Systematic Review: EHR-based Interventions for Reducing Inappropriate Imaging in the Clinical Setting
BACKGROUND:
Dramatic increases in use of radiology imaging procedures – particularly advanced imaging techniques such as computed tomography (CT) scanning, magnetic resonance imaging (MRI), and CT angiography – and subsequent increases in overall healthcare costs have resulted in increased scrutiny regarding the clinical value of these imaging studies. This has led to the development of interventions to encourage more appropriate radiology utilization. Some of these interventions have made use of the computerized clinical decision support (CCDS) capabilities of electronic health records (EHRs). Given that adoption of EHRs is expanding, investigators conducted a systematic review and meta-analysis of EHR-based interventions to improve the appropriateness of diagnostic imaging. A search of the literature from 1995 to September 2014 produced 23 studies, including 3 randomized trials, 7 time-series studies, and 13 pre-post studies that assessed the effect of CCDS on diagnostic radiologic test ordering in adults. Three of these studies were performed in integrated care delivery settings, and only one study was performed in VA.
FINDINGS:
- Computerized clinical decision support that is integrated into the physician order entry system of an electronic health record can help improve the appropriate ordering of diagnostic imaging studies. Of the 23 studies in this review, 21 studies provided moderate-quality evidence that EHR-based interventions can change appropriate test ordering by a moderate amount – and can reduce overall use by a small amount.
- Interventions that include a "hard stop" to prevent clinicians from ordering imaging tests classified as inappropriate, and implementation in an integrated care delivery setting may improve effectiveness.
- Potential harms of computerized clinical decision-support interventions have been rarely studied.
IMPLICATIONS:
- VA's EHR does not currently contain a computerized clinical decision support tool specifically for imaging orders. However, VISNs can pilot their own systems if they can get OIT (Office of Information & Technology) permission for use of the vendor's interface.
LIMITATIONS:
- There is a limited body of literature in this area and there are likely additional CCDS interventions to increase imaging appropriateness that were never formally evaluated or published.
- Key information on context and implementation, and on potential harms, were not reported in published studies.
AUTHOR/FUNDING INFORMATION:
The study was funded through VA HSR&D's Quality Enhancement Research Initiative (QUERI) and the Evidence Synthesis Program. Drs. Goldzweig and Shekelle and Mss. Miake-Lye and Beroes are part of HSR&D's Center for the Study of Healthcare Innovation and Implementation and the VA Greater Los Angeles Healthcare System.
Goldzweig C, Orshansky G, Paige N, Miake-Lye I, Beroes J, Ewing B, and Shekelle P. Electronic Health Record-Based Interventions for Improving Appropriate Diagnostic Imaging. Annals of Internal Medicine. April 21, 2015;162(8):557-64.
