Radiologists at Massachusetts General Hospital (MGH) in Boston have elected the enlightenment approach -- with barriers established for nonconformance.
MGH pioneered the concept of using informatics to advise its physicians of the appropriateness of the diagnostic imaging exams they were ordering. In 2004, a system providing real-time feedback about order appropriateness was added to the hospital's Web-based radiology order entry system. In addition to advising the ordering physician of the level of appropriateness of the procedure being requested using a simple utility score of 1-9, the system also recommends procedure(s) that would be more appropriate based on clinical indications of the patient.
The system had a very positive impact, as reported at previous RSNA annual meetings. But low-utility exams were still being ordered, frequently by nonclinical support staff working for the referring physician.
So in 2007, a simple change was implemented that restricted support staff from ordering exams that received scores indicating low utility -- these could only be authorized by the referring physician. As a result, the number of low-utility exams ordered decreased by half, to less than 2% of the total. In addition, the proportion of exam requests ordered by clinicians themselves more than doubled.
"Doctors need to use the decision-support system for it to be effective, but getting them to do so can be difficult. A minimally disruptive alteration in the radiology order entry system can encourage this behavior, enhancing the effectiveness of decision support and decreasing the overall use of low-yield examinations," said Dr. Vartan Vartanians, a radiology clinical research associate and the session presenter.
