FROM CLINICAL GUIDELINES TO CLINICAL DECISION SUPPORT

Guy Frija, ESR Past-PresidenteHealth Forum, Athens, 12-14 May 2014

NEED FOR GUIDELINES IN IMAGING

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

Dose Datamed 2,2013

CLINICAL GUIDELINES

European survey by the ESR

Availability of RG (~ 70%)

Production: UK and France

Adapted and adopted: others

OTHER REFERAL GUIDELINES

USA : ACR appropriatness

Australia : flow chart approach

“ 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 ”…

CHANGE IN PARADIGM

Producing EB data

Increase EB practices

CDS

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

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

ACR SELECT

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)

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

Decision support system

Konwledge Base DataBase

Inference Engine

Timely

CDS/CPOE

Point of Care DS

Clinical GuidelinesEHR/HIS/RIS

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

Select reason for examSearch enabled

Select body area

Select reason for exam

Select requested exam

Appropriateness information displayed

Summary of exam selected

ACRSelect – ACR Appropriateness CriteriaAC Scoring Table (>600 Original Documents)

Dr. Smith

ACRSelect – ACR Appropriateness CriteriaACR evidence scoring of all reviewed literature (>5,000)

Dr. Smith

ACRSelect – ACR Appropriateness CriteriaReferences to all reviewed literature (>5,000)

Dr. Smith

ACRSelect – ACR Appropriateness CriteriaSummaries of Literature Review (>600 Original Documents)

Dr. Smith

EUROPEAN CDS AND THE EC

DG’s: TRANSPORT,CONNECT,SANCO,RESEARCH

After 2 meetings:no funding available

Other organisations (IAEA,HERCA)

Proceed independently

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

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

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

CLINICAL DECISION SUPPORT

Common Terminology

Clinical Decision Support

Structured Reporting

Data Mining

Continuous ImprovementPhysician Feedback: profiling

CDS as an educational tool

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),

62000 members,and 52 affiliate national Societies of radiology