FROM CLINICAL GUIDELINES TO CLINICAL DECISION SUPPORT. Guy Frija, ESR Past-President ehealth Forum, Athens, May 2014

Transcription

1 FROM CLINICAL GUIDELINES TO CLINICAL DECISION SUPPORT Guy Frija, ESR Past-President ehealth Forum, Athens, May 2014

2 NEED FOR GUIDELINES IN IMAGING

3 WHY? EUROPE: Euratom Directives and BSS Mandatory establishment of clinical and technical guidelines Umbrella of patient safety Umbrella of EU citizens rights: quality of care, patient mobility (cross-border healthcare directive) USA: economic pressure Explosion of the use of cross-sectional imaging 20 to 30% inappropriate tests Side effects of incidental findings Patient concerns about the risks of ionising radiation

4 Dose Datamed 2,2013

5 CLINICAL GUIDELINES European survey by the ESR Availability of RG (~ 70%) Production: UK and France Adapted and adopted: others

6 OTHER REFERAL GUIDELINES USA : ACR appropriatness Australia : flow chart approach

7 In Belgium we have referral guidelines; in fact, nobody really takes them into account Referral guidelines for diagnostic imaging in general are not in use in Hungary They are not used in the Netherlands Although we have several official referral guidelines published (in Spain), they are not used generally speaking In Italy the referral guidelines were published in 2004 by the Ministry of Health. Unfortunately they are not always followed in clinical practice There is no official guide line enforcement in the State service in Ireland In Germany, the guidelines are note routinely used In France, there are guidelines, but they are not used

8 CHANGE IN PARADIGM Producing EB data Increase EB practices CDS

9 WHY CDS? Proven efficiency in the literature Possibility to integrate into CPOE,in the physician workflow,and with the EHR Patient centric, i.e. «personalised» Adaptable to the practice setting Scalable: focused or comprehensive

10

11 CLINICAL GUIDELINES Proven efficiency in the literature:no! Possibility to integrate into CPOE,in the physician workflow,and with the EHR:No! Patient centric, i.e. «personalised»:no! Adaptable to the practice setting:no! Scalable: focused or comprehensive:yes

12 NEW LEGAL REQUIREMENT IN THE USA US House of Representatives passed the Protecting Access to Medicare Act, signed into law 1 April 2014 Includes requirement for ordering physicians to consult appropriateness criteria before prescribing advanced imaging procedures for Medicare patients (from 1 January 2017) Applies to CT, MRI, NM and PET (not US and x-ray) ACR SELECT

13 WHAT IS A CDS? Decision support systems are a set computer-based tools that assist in some decision-making activity Designed to help resolve complicated problems and/or questions by supporting the decision-making process Especially valuable in situations where the amount of available information is prohibitive for the intuition of a human decision maker and where precision and optimal performance are of importance

14 Clinical Guidelines Konwledge Base DataBase EHR/HIS/RIS Inference Engine CDS/CPOE Decision support system Point of Care DS Timely

15 Recommendations Based on clinical guidelines evidence-based and are regularly updated Accessible at the point of care. Real-time "clinical Interface Diagnostic advice must be given in a probabilistic form Explanation and Justification accessible Must not attempt to replace the Doctor Ability to override CDS guidance

16 Select reason for exam Search enabled

17 Select body area

18 Select reason for exam Select requested exam Appropriateness information displayed

19 Summary of exam selected

20 ACRSelect ACR Appropriateness Criteria AC Scoring Table (>600 Original Documents) Dr. Smith

21 ACRSelect ACR Appropriateness Criteria ACR evidence scoring of all reviewed literature (>5,000) Dr. Smith

22 ACRSelect ACR Appropriateness Criteria References to all reviewed literature (>5,000) Dr. Smith

23 ACRSelect ACR Appropriateness Criteria Summaries of Literature Review (>600 Original Documents) Dr. Smith

24 EUROPEAN CDS AND THE EC DG s: TRANSPORT,CONNECT,SANCO,RESEARCH After 2 meetings:no funding available Other organisations (IAEA,HERCA) Proceed independently

25 EUROPEAN CDS Phase 1: merging RCR and SFR guidelines failed Phase 2: open call for CDS tools only 2 appropriate submissions NDSC was considered most adequate Phase 3: MOU with ACR for using Appropriateness Criteria Phase 4: Europeanisation of ACR AC Phase 5: ESR product («iguide») with NDSC Phase 6: ACR-ESR common set of guidelines

26 BARCELONA PILOT PHASE Independent pilot phase Translation and coding adaptation (PWC) without any difficulty Initially targeted to GPs: very welcome Next expansion to emergency physicians

27 MORE THAN A CDS Common terminology:clinical indication and examens -useful for benchmarking Physician feedback: profiling -useful for continuous improvement Potentially integrable with structured reporting -useful for increasing quality and reliability -useful for datamining Educational tool - are you appropriate? For residents training

28 CLINICAL DECISION SUPPORT CDS as an educational tool Continuous Improvement Physician Feedback: profiling Data Mining Structured Reporting Clinical Decision Support Common Terminology

29 ESR CDS:SUMMARY Expected outcomes:decrease radiation exposure,increase health quality and disparities,health economics,interoperability Private-Private partnership :ESR-NDSC-ACR ESR:not for profit scientific association-315 volunteers (pro bono), members,and 52 affiliate national Societies of radiology