CLINICAL DECISION SUPPORT FOR EUROPEAN IMAGING REFERRAL GUIDELINES

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1 CLINICAL DECISION SUPPORT FOR EUROPEAN IMAGING REFERRAL GUIDELINES Prof. Guy Frija, Paris/France Chair, ESR EuroSafe Imaging Steering Committee Reykjavík/IS, 22 May 2015

2 DISCLOSURE No conflict of interest in relation with this presentation

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4 Hôpital Européen Georges Pompidou Paris Oncologic, Cardiovascular and Trauma center

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6 IMAGING SECTION Liver cancer (22 Million E),Consortium on heterogeneous data structuration

7 PURPOSES Reasons why CDS is becoming an important issue What is a CDS Evidence on the main benefits and limitations of CDS Present the ESR i Guide project and achievements

8 BACKGROUND BSS Directive EURATOM basic safety standards directive (passed in 2013 and applicable from February 2018) mandates guideline availability in all member states For safety reasons,ie avoid unnecessary exposure

9 OVERUTILISATION CT scans in the emergency department (ED) increased by 330% from 1996 to 2007, a time when the rate of ED visits increased by only 11%. Pre authorisation,radiology Benefit manager,medicare pressures in the USA

10 HETEROGENEITIES Dose Datamed 2

11 REFERAL GUIDELINES European survey by the ESR Availability of RG (~ 70%) Production : UK and France Adopted and adaptated : others

12 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

13 CHANGE IN PARADIGM Producing EBM Using EBM CDS

14 CDS FIVE RIGHTS CDS Five Rights framework,now recommended by the Centers for Medicare & Medicaid Services as a quality improvement best practice. The framework suggests that improving outcomes requires: the right information to the right person in the right intervention format through the right channel at the right time in the workflow.

15 CONCEPT OF CDS Answer to a clinical question Provide guidance based on appropriatness criteria Integrated in the physician workflow Ideally integrated into the EMR

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17 WHY CDS? CDS has led to improved compliance with immunizations Routine screening tests Awareness of critical laboratory values Medication interactions

18 WHY CDS? CDS has led to improved compliance with immunizations Routine screening tests Awareness of critical laboratory values Medication interactions WHY NOT IN IMAGING???

19 REASONS FOR IMAGING CDS Protection against radiation exposure Tailoring of imaging orders Access to guidelines Reminders for preventive care Alerts about potential dangers Better care for patients. Better quality in Radiology Bruce Hillman et al., JACR 2004

20 CDS IN IMAGING Proven efficiency in the literature Possibility to integrate into the CPOE and into the physician workflow Patient centric, i.e. «personalised» Adaptable to the practice setting: localisation Scalable : focused or comprehensive

21 CONCEPT OF CDS Content is an algorithmic format of pre existing textual guidelines Technical platform is a sophisticated software which operates according to pre- and post-test probabilities Provides feedback to the physician: «profile» of compliance

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

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29 Example of ROE form displayed after provider selects MR imaging of the lumbar spine by Radiological Society of North America Sistrom C L et al. Radiology 2009;251:

30 Screenshot of the DS feedback displayed after submitting a request for MR imaging of the lumbar spine with symptom of back pain improved with exercise and abnormal result at previous examination of abnormal x-ray DJD [degenerative joint disease]. PCP's... Sistrom C L et al. Radiology 2009;251: by Radiological Society of North America

31 VARIOUS OPTIONS Pop-up:just an alert Soft stop:possible to override Hard stop:override only after approval

32 Screen presented to users who wish to proceed to order and schedule an examination that had received a low decision support score (1 3 [red]). Vartanians V M et al. Radiology 2010;255: by Radiological Society of North America

33 Message displayed to support staff users of the order entry system who attempted a second request of an examination that has been locked. Vartanians V M et al. Radiology 2010;255: by Radiological Society of North America

34 CDS OUTLINES Guide physicians for well-founded decisions Imaging recommendations Integrating information Evidence-based predictions Accessible at the point of care Information on radiation exposure Adaptation to specific setting Continuous updating

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37 CDS BENEFITS Improve the appropriate use by a significant amount Decrease the use by a small amount

38 CDS BENEFITS Initial results at MGH demonstrated a decrease in low-utility examinations from 6% percent to 2 %

39 Massachusetts General Hospital High Cost Imaging Adjusted Annual Compound Growth Rate 1% Effects of CDS Adjusted Annual Compound Growth Rate 12% Quarters = Total exams = Ordered with ROE Sistrom C L et al. Radiology 2009;251:

40 Massachusetts General Hospital ACO Population Effects of CDS and Physician Feedback HCI / 1,000 Patients 2007 = = HCI/1,000 Pts 150 HCI/1,000 Pts Courtesy of K.Dreyer

41 MGH EXPERIENCE Lessons Learned Change Management CDS is just the tool Multidisciplinary Teams - Continual process for evaluation & reassessment CDS is as effective as RBMs for managing inappropriate utilization When implemented correctly, there is a higher physician acceptance Need physician feedback to reduce variability and utilization Courtesy of K.Dreyer

42 OTHER CDS EXPERIENCE Adoption by the physicians is a very critical step Finding success in implementing a CDS program lies in the organization as a whole. there has to be a will or a culture of wanting to do this type of quality project Advanced imaging use by specialists more closely followed the ACR AC guidelines compared with use by primary care providers

43 OTHER CDS EXPERIENCE Technical implementation and integration Business model Management of the changes Part of a total quality programm Part of a National policy

44 POLICIES OPTIONS IT tools Access Guidelines Incentives QUALITY DRIVEN Accreditation Audit USA EU RBM Self Referal Loss of Accreditation Penalties COST DRIVEN

45 QUALITY DRIVEN IT tools Access Guidelines INCENTIVES Accreditation Audit USA EU Must use Must have

46 QUALITY DRIVEN IT tools Access Guidelines INCENTIVES Accreditation Audit USA Must use AWARENESS EU Must have

47 QUALITY DRIVEN IT tools Access Guidelines INCENTIVES Accreditation Audit USA Must use PATIENTS HCP EU Must have

48 Patients ESR Patient Advisory Group Regulators Experts EC-HERCA Stakeholders Industry ESPR-CIRSE-EFOMP-EFRS COCIR

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50 RAND Analysis MID Data Analysis (n=117,670 exams) 34% 66% Rated by AUC Unrated by AUC Courtesy K.Dreyer *MID Evaluation Report, RAND Corp, 2014

51 RAND Analysis MID Data Analysis (n=117,670 exams) RAND Analysis Results 66% 34% Inappropriate Equivocal Appropriate Unrated by AUC *MID Evaluation Report, RAND Corp, 2014 Courtesy K.Dreyer

52 RAND Analysis 100% 80% 60% 40% 20% Inappropriate Equivocal Appropriate Unrated 0% Pre-MID MID *MID Evaluation Report, RAND Corp, 2014 Courtesy K.Dreyer

53 RAND Analysis inhibits drawing definitive conclusions Lewin Report p5 100% 80% 60% 40% 20% Inappropriate Equivocal Appropriate Unrated 0% Pre-MID MID *MID Evaluation Report, RAND Corp, 2014 Courtesy K.Dreyer

54 RAND Analysis These increases in appropriateness are indicative of a successful intervention * p % 10,9 6,7 80% 60% 40% 20% 0% 73,7 80,7 Inappropriate Equivocal Appropriate Pre-MID MID *MID Evaluation Report, RAND Corp, 2014 Courtesy K.Dreyer

55 We found no evidence that the intervention led to anything beyond a small reduction if any reduction at all in advanced imaging volume These increases in appropriateness are indicative of a successful intervention to the extent that advanced imaging orders can be successfully rated for appropriateness.

56 While the MID evaluation provides support for changes in appropriateness in association with clinician exposure to guidelines, the conceptual model for changing behavior should be expanded to further attend to the needs of clinicians who serve as the vector for change CDS IS JUST A TOOL!!!

57 ESR PILOT PHASE Discussions with the EC ( ) on the opportunity to establish European guidelines:vision and funding discrepancies ESR initiated pilot project (2013) to create European imaging referral guidelines for use in CDS Merger of national European guidelines revealed significant discrepancies:national approach deemed unfeasible No significant industry forces in Europe ESR decided to develop generic, evidence-based guidelines for use in a CDS system with flexibility for localisation

58 TRANSATLANTIC PARTNERSHIP American College of Radiology (ACR),ie the content and NDSC ie the platform,introduced ACR Select in the United States in 2012

59 TRANSATLANTIC PARTNERSHIP Pre authorisation,radiology benefit managers,over utilisation of cross sectional imaging,self referral,federal policy of cost containment of health care services Protecting Access to Medicare Act of 2014 Health care providers will be required to consult appropriate use criteria using a qualified decision support mechanism when ordering advanced imaging for Medicare patients, beginning in April 2016

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61 EUROPEANISATION Scientific review of ACR Select content by ESR experts started in November scenarios and 551 indications Overseen by dedicated methodologist - Ensures review meets scientific criteria and that guidelines conform to latest available evidence and European standards of practice - Adaptation of ACR AC to European standards of practice; incorporating evidence from the latest European studies

62 DISCREPANCIES:9% Breast:2% Urinary:0% Brain:7% Cardiac:28% Chest:1% MSK:4% Vascular:7% Women s:0%

63 LOCALISATION A crucial step for adoption by the physicians Possible to add a new indication which would be reviewed by the ACR/ESR experts -either remain local -or incorporated to the general stock Possible to change the rating of the tests -Ultrasound for example probably more used in some EU countries than in the USA

64 POTENTIAL SITES Austria Belgium Croatia Denmark France Germany Hungary Ireland Italy Netherlands Norway Poland Spain Sweden Switzerland United Kingdom

65 BARCELONA PILOT PHASE Independent pilot phase Translation and coding adaptation (PWC) without any difficulty Firstly targeted at GPs : very well received Next expansion to emergency physicians

66 INDICATORS OF SUCESS(1) Short term: can be measured Higher yield of diagnostic imaging tests Reduced health care resource utilization Improved short-term patient outcomes Reduced health care costs related to imaging Reduced radiation exposure Physician profile Adapted fromm.hunink

67 INDICATORS OF SUCCESS (2) Long-term: can be estimated Improved long-term patient outcomes Reduced health care costs Reduced radiation-induced cancers Courtesy M.Hunink

68 KEY MESSAGES 1/3 Based on clinical guidelines evidence-based to the greatest extent possible, supplemented as needed by clinical expert opinion, transparent and readily reviewable, and regularly updated Accessible at the point of care,real-time "clinical Interface Diagnostic advice must be given in a probabilistic form

69 KEY MESSAGES 2/3 Explanation and Justification accessible Must not attempt to replace the Doctor Ability to override CDS guidance Explicit CDS criteria of revision and localisation Benchmarking,accreditation A tool in a global policy of Safety and Quality

70 KEY MESSAGES 3/3 Localisation is a critical step for adoption It is not just a project of the imaging Dept!!! Deployment should be supported by an institutional policy Management of the changes should be carefully prepared

71 From AHRQ

72 THANK YOU!