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Electronic ordering system could reduce imaging costs, radiation exposure

by Brendon Nafziger, DOTmed News Associate Editor | May 26, 2010
Workflow systems may
impact ordering decisions
A computerized ordering system that prevents office staff from ordering advanced imaging studies with little likely benefit could cut imaging costs and protect patients from exposure to unnecessary medical radiation, a new study finds.

An electronic system that prevents nurses or office assistants from ordering CT, MR or nuclear medicine scans deemed "low yield" made it three and a half times more likely for such studies to be dropped, according to a paper out this week in Radiology.

It also nearly doubled direct clinician involvement in ordering tests.

"A modification of the order entry work flow that affects only a small percentage of cases can change physician behavior, encouraging greater interaction with the decision support system, and result in fewer low-yield orders," write the authors, led by Dr. Vartan M. Vartanians, a clinical researcher in radiology at Massachusetts General Hospital, where the investigation took place.

In the study, the researchers installed a so-called hard stop on red, or HSOR, electronic ordering system that required on-call physicians to authorize advanced imaging studies that only scored 1-3 points on the American College of Radiology's nine-point appropriateness criteria scale. The ACR scale ranks imaging exams for how useful they are in diagnosing conditions.

The researchers then compared around 76,000 orders taken from April 2007 to December 2007 with the new system in place against around 43,000 orders from the same period the year before.

While always small, the fraction of low-yield exams fell by more than half, dropping from 5.4 percent to only 1.9 percent of all exams in the HSOR period. Imaging studies deemed "high yield" were unaffected by the change, according to the study.

"We feel that's a better way to approach the issue of potential overutilization," Shawn Farley, a spokesman for the American College of Radiology, told DOTmed News. "Unlike radiation benefit managers or preauthorization, it doesn't take the decision-making out of physician hands and put it in the hands of a third-party [administrator]."

The electronic ordering system could be especially helpful in curbing medical radiation exposure, Farley said. When given a choice between two diagnostically equivalent exams, physicians could pick the one that delivers a smaller dose.

"If MR and CT are ranked equal, and if it's non-emergent, the doctor can choose MRI because it doesn't use [ionizing] radiation," Farley said.

The study authors acknowledged objections that the system adds to physicians' already towering workload, but countered that it eliminates other burdens such as telephone preauthorization requests.

"Physicians are asked to complete the order; they need not schedule the patient; this can be done by non-clinician support staff," the authors write. "In this way, the order entry system replaces the creation of a paper form."

Medicare plans to kick off a pilot project investigating these systems later this year, Farley said.