Implementation and Evaluation of Imaging Decision Support Incorporating CER

描述(由申请人提供)：拟议的研究将实施实时放射学决策支持，并研究其对传播和采用与成像相关的比较有效性研究(CER)结果的影响。包括计算机断层扫描(CT)、磁共振成像(MRI)、单光子发射计算机断层扫描(SPECT)和正电子发射断层扫描(PET)在内的先进成像技术的发展和广泛应用极大地改变了医学实践。然而，这些进步并非没有成本：诊断成像在美国医疗总支出中占很大比例，而且还在不断增长，人们担心，订购和执行的成像中有很大一部分可能是不必要的。也有证据表明，患者的偏好可能至少对成像的一些增长负责。不适当的成像不仅增加了医疗系统的成本，还可能通过辐射暴露或过度诊断而造成伤害，导致治疗无法改善患者的结果。计算机医生订单录入(CPOE)包括强大的决策支持(DS)，通过提高订购检查的适当性和减少不必要的成像，具有提高医疗质量和降低成本的巨大潜力。使用CPOE-DS支持临床实践是CMS确定的“有意义地使用”电子健康记录技术的目标之一。麻省理工学院放射科是首批开发和实施具有实时DS成像功能的CPOE之一。我们的放射学订单录入(ROE)系统自2004年开始使用，现在几乎所有的先进成像都是使用该系统订购的。ROE的使用减缓了成像使用率的增长，并增加了所执行研究的适当性。1由于ROE是在内部开发的，因此很容易进行修改，以纳入关于在特定临床场景中最适当使用成像的不断发展的证据库。最近的更新纳入了与成像相关的CER结果，并扩大了涵盖的测试和条件。我们将在合作伙伴医疗系统(PHS)内的一家大型社区医院实施ROE。牛顿-韦尔斯利医院(NWH)是一家提供全方位服务的内科、外科和专科医院，它完全集成到PHS信息技术系统中，但没有用于成像的DS。NWH和PHS领导层迫切希望实施放射学DS，并完全支持当前的提议。通过共同努力，我们将修改ROE，以纳入与成像相关的CER新发现，创建新的以患者为中心的界面，并在西北医院实施该系统。我们将对使用该系统的提供者和患者进行广泛的调查，以评估其可接受性，并研究ROE实施对影像利用率和适宜性的影响。这项研究将提供关于临床决策支持的可行性、可接受性和有效性的迫切需要的数据，作为传播和采用与成像相关的CER结果的一种手段，重点是一家大型社区医院和几种优先情况。 公共卫生相关性：该研究将在波士顿地区的一家大型社区医院为放射学检查订购实施实时临床决策支持，并研究该系统对影像相关比较有效性研究(CER)结果的传播和采用的影响。放射学的临床决策支持允许有关成像研究的潜在用处的相关信息实时呈现给订购医生和患者。这项研究将为在大型社区医院使用这种系统的可行性提供重要信息，并有助于了解临床决策支持对影像研究的利用率和适当性的影响。

DESCRIPTION (provided by applicant): The proposed research will implement real-time radiology decision support and study its effects on the dissemination and adoption of imaging-related comparative effectiveness research (CER) findings. The development and broad adoption of advanced imaging techniques, including computed tomography (CT), magnetic resonance imaging (MRI), single photon emission computed tomography (SPECT) and positron emission tomography (PET) has dramatically changed the practice of medicine. However, these advances are not without costs: diagnostic imaging represents a large and growing portion of total health care spending in the U.S., and there is concern that a substantial portion of the imaging ordered and performed may be unnecessary. There is also evidence that patient preference may be responsible for at least some growth in imaging. Inappropriate imaging not only adds cost to the healthcare system, it can also cause harm via radiation exposure or over diagnosis, leading to treatments that do not improve patient outcomes. Computer physician order entry (CPOE) that includes robust decision support (DS) has great potential to improve healthcare quality and reduce cost by improving the appropriateness of tests ordered and reducing unnecessary imaging. Use of CPOE-DS to support clinical practice is one of the goals identified for "meaningful use" of electronic health record technology by CMS. The Department of Radiology at MGH was one of the first to develop and implement CPOE with real-time DS for imaging. Our Radiology Order Entry (ROE) system has been in place since 2004 and virtually all advanced imaging is now ordered using the system. ROE use has slowed the growth of imaging utilization and increased appropriateness of studies performed.1 Because ROE was developed in house, it is easily modified to incorporate an ever-evolving evidence base regarding the most appropriate use of imaging in specific clinical scenarios. Recent updates have incorporated imaging-related CER findings and expanded the tests and conditions covered. We will implement ROE at a large community hospital within Partners HealthCare System (PHS). Newton- Wellesley Hospital (NWH) is a full-service medical, surgical and specialty hospital that is fully integrated into the PHS Information Technology system but does not have DS for imaging. NWH and PHS leadership are eager to implement radiology DS, and fully support the current proposal. Working together, we will modify ROE to incorporate new imaging-related CER findings, create a new patient-focused interface and implement the system at NWH. We will conduct extensive surveys of providers and patients using the system to evaluate its acceptability, and we will study the effects of ROE implementation on imaging utilization and appropriateness. The research will contribute much needed data concerning the feasibility, acceptability and effectiveness of clinical decision support as a means to disseminate and adopt imaging-related CER findings, focusing on a large community hospital and several priority conditions. PUBLIC HEALTH RELEVANCE: The research will implement real-time clinical decision support for radiology test ordering at a large community hospital in the Boston area, and study the system's effects on the dissemination and adoption of imaging-related comparative effectiveness research (CER) findings. Clinical decision support for radiology allows relevant information concerning the potential usefulness of an imaging study to be presented to ordering physicians - and patients - in real time. The research will provide important information concerning the feasibility of using such a system at a large community hospital, and also help to understand the impact of clinical decision support on the utilization and appropriateness of imaging studies.