GRAPEVINE, TX - Computerized physician order-entry (CPOE) technology isn't just for referring physicians anymore. CPOE software can be used by radiologists to efficiently order the scanner protocols that carry out imaging studies, according to a presentation on Saturday at the Society for Imaging Informatics in Medicine (SIIM) meeting.
At MD Anderson Cancer Center, a scanner protocol order-entry system for radiologists that is embedded in the institution's electronic medical record (EMR) has completely eliminated paper-based protocol ordering for MR and CT studies at five separate locations. In addition to yielding efficiency gains, the order-entry system elevates the radiologist's role in clinical management, according to presenter Dr. Kevin McEnery.
"CPOE provides radiologists with the opportunity for an integral role in the imaging process," McEnery said. "In my opinion, radiologist CPOE systems will contribute to redefining the radiologist value proposition."
Problems with paper
Imaging procedure protocols are a key step in translating the ordered imaging study into instructions for the technologist. These protocols usually reference preinstalled procedures on scanners, but specific scan parameters can also be sent directly to the scanner, McEnery said.
Typically, most radiology departments order imaging protocols via a paper-based process. This method, however, relies on manual retrieval of clinical information and offers no capability for decision support. It can also result in ambiguous and "boutique" protocols, he said.
Furthermore, paper-based systems involve complicated logistics such as faxing and delivery, with the potential for lost protocols. They are also not integrated into digital workflow and provide no data for process improvement efforts.
Generally speaking, incorporating clinical order sets in EMRs allows for standardization of care delivery processes. These order sets enable efficient clinician ordering of numerous care events. They can also contain multiple instructions for care, covering medications, required tests, nursing instructions, imaging procedures, and consults, McEnery said.
In CT and MRI, order sets would include descriptions and specifications of medications encompassing oral contrast, intravenous contrast, allergy mitigation, and anxiety relief. They would also include contrast administration guidelines and procedure details.
Radiologists using the system can select from a list of CT protocols with specific presets. They can also add options and medications. In MRI, radiologists can specify aspects such as areas of interest and the scanning sequences needed. The system will also estimate the total time expected for the protocol to be performed, he said.
Since it was implemented in 2012, the system has been used for approximately 110,000 CT protocols and 43,000 MRI protocols. All of the information is also available for data-mining purposes.
"It's been very gratifying seeing how quickly people transitioned over to the electronic system," he said. "There's really no pushback."
Standardization of imaging protocols is a necessary step to ensure consistency, especially if imaging services are distributed across multiple sites.
"Standardized protocols increase technologist efficiency and the consistency of imaging," McEnery said.
Radiologist as clinician
Research studies on the use of CPOE software in radiology have typically evaluated EMR order creation by clinicians, and decision-support studies have focused on clinicians ordering the correct exam. There hasn't been much exploration of radiologist use of CPOE and decision support for exam specifications, McEnery said.
What's more, existing software does not typically recognize radiologists as clinicians. The EMR is an order system, while the RIS is a protocol entry system. Protocols dictate the technical aspects of the examination, while medication order entry and integrated review of historical information focus on the clinical aspects of the radiologist's role.
Because the radiologist's role is to ensure that the patient's scan will be optimized for radiation, medication, and clinical outcome, he or she must be involved in both the technical and clinical imaging aspects, according to McEnery.
"We need to evolve these systems to the concept of radiologist CPOE: systems designed for the radiologist to do order entry in the context of the information flow of the patient," he said. "It will elevate the role of the radiologist in the clinical management process. Radiologists filling out protocols and order sets exactly like clinicians gives the perception -- and, actually, the reality -- that the radiologists are participating in the same caregiving process that the clinicians are."
Order-entry applications will need to be optimized for radiologists to accommodate imaging order sets. They will also need to be integrated into workflow and provide tracking metrics for process and outcome improvement, he said.
For its part, MD Anderson's system has yielded efficient operations. A recent Sunday evening worklist review showed 168 MRI protocols requiring orders from radiologists for Tuesday. There were 191 MRI protocol orders awaiting nurse processing for Monday and Tuesday.
"Every single exam that was scheduled on Monday had already been protocoled, and the radiologists were already working on Tuesday," McEnery said.
The institution's system demonstrates the potential for examination order sets, and it is efficient, safe, and operationally effective, according to McEnery.
"Future investigation of radiologist CPOE will be needed to optimize these systems, not just at our center but at other centers," he said.
