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Management Brief No. 91

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Management eBriefs
Issue 91February 2015

A Systematic Review: Electronic Health Record-Based Interventions for Reducing Inappropriate Imaging in the Clinical Setting

Dramatic increases in use of radiology imaging procedures — particularly advanced imaging techniques such as computed tomography (CT) scanning, magnetic resonance imaging (MRI), and CT angiography — and subsequent increases in overall healthcare costs have led to increased scrutiny regarding the clinical value of these imaging studies. In some cases, strong evidence exists that the imaging studies provide no value to, or even harm, patients.

The recognition that more appropriate use of imaging could improve quality and reduce costs has led to the development of interventions to encourage more appropriate radiology utilization. Some of these interventions have made use of the clinical decision support (CDS) capabilities of electronic health records. VA has been a leader in the use of electronic health records and clinical decision support, and VA leadership therefore requested a review of published studies assessing the effect of electronic health record (EHR)-based interventions to improve the appropriateness of imaging.

This synthesis, conducted by the Evidence-based Synthesis Program (ESP) Center at the West Los Angeles VA Medical Center, concluded that computerized decision support integrated with EHR can reduce inappropriate use of diagnostic radiology testing by a moderate amount. Characteristics of the intervention, the implementation, or the setting may increase effectiveness. There are few data on the potential harms of CDS to reduce inappropriate radiology test ordering.

Twenty-one studies provide moderate-quality evidence that EHR-based interventions can reduce inappropriate test ordering by a moderate amount, and reduce overall utilization by a small amount (summarized in Table 1, below). Low-quality evidence suggests that interventions that include a "hard stop" — preventing ordering clinicians from overriding a CDS determination — and implementation in an integrated care delivery setting are associated with greater effectiveness. Audit-and-feedback (a review of test ordering provided to the clinician along with comparison with other providers, for example) may be a useful implementation tool, but data are too sparse to draw conclusions.

Change in imaging orders after EHR-based intervension

Only 3 studies were performed in integrated care delivery settings, and only one study was performed in VA. However, there is evidence suggesting that interventions implemented in integrated care delivery settings may be more effective than in other settings, indicating VA may realize benefits equal to or greater than the average benefit reported here.

Before widespread adoption can be advocated, more research is needed on possible harms, such as unintentional reductions in clinically appropriate imaging. Harms of a CDS system intervention with a "hard stop" have been reported in other clinical situations. An explicit assessment of harms should be incorporated into every study of interventions.

This report was developed based on a nomination from the VHA Choosing Wisely Workgroup.

Given these findings, the VHA Radiology Program Office of Patient Care Services (PCS) offers the following guidance:

1. While computerized clinical decision support is not the only way to ensure that the use of imaging is appropriate, it can contribute to good practice, especially if it is employed in a targeted manner to high-cost or high-volume procedures that have been shown to be inappropriate. VA does not currently own a computerized clinical decision support tool for imaging. VISNs can pilot their own systems, if they can get OIT permission for use of the vendor's interface.

2. As part of the "Protecting Access to Medicare Act of 2014" (H.R. 4302), referring clinicians must use appropriateness criteria when ordering advanced imaging for Medicare patients. This Act goes into effect in January of 2017. The Secretary of Health and Human Services is charged with identifying clinical decision support tools by November 2015 to help clinicians select these criteria. It is likely that VA will conform to the tools that HHS selects, and if so, VA will need to implement computerized clinical decision support within the next few years.

3. The Choosing Wisely campaign was established by the American Board of Internal Medicine (ABIM) Foundation and Consumer Reports to promote conversations between patients and doctors about effective, evidence-based healthcare practices. Numerous organizations have compiled lists of tests, procedures and treatments that doctors and patients should question. The Veterans Health Administration (VHA) supports this campaign and has identified a select few of these initiatives to be promoted within our system. A large percentage of the Choosing Wisely recommendations are related to diagnostic imaging. These initiatives cite clinical evidence that imaging has no clinical benefit for certain conditions, such as MRI for uncomplicated low back pain, or CT or MRI for headaches absent specific risk factors. Participation in the Choosing Wisely campaign is voluntary in VHA. Since radiology decision support tools are not widely available in VA, sites that participate in Choosing Wisely should focus on providing a toolkit of educational resources and alternative treatments for both the ordering provider and the patient. Patient information should explain both the alternative treatment and why the imaging exam would not benefit them.

4. VHA Directive 1117 — Utilization Management Program delineates VA policies and procedures for utilization review. The most recent update of the policy recommends that hospitals undertake review of high-cost imaging procedures.

Goldzweig C L, Orshansky G, Paige N M, Ewing B A, Miake-Lye I M, Beroes J M, Shekelle P G. Electronic Health Record-Based Interventions for Reducing Inappropriate Imaging in the Clinical Setting: A Systematic Review of the Evidence. VA ESP Project #05-226; 2014.

A Cyberseminar session on this ESP Report will be held on Monday, May 18, 2015 at 2:00pm (ET). To register, go to the HSR&D Cyberseminar web page.

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Read past HSR&D Management e-Briefs on the HSR&D website.

This Management eBrief is a product of the HSR&D Evidence Synthesis Program (ESP). ESP is currently soliciting review topics from the broader VA community. Nominations will be accepted electronically using the online Topic Submission Form. If your topic is selected for a synthesis, you will be contacted by an ESP Center to refine the questions and determine a timeline for the report.

This Management e-Brief is provided to inform you about recent HSR&D findings that may be of interest. The views expressed in this article are those of the authors and do not necessarily reflect the position or policy of the Department of Veterans Affairs. If you have any questions or comments about this Brief, please email CIDER. The Center for Information Dissemination and Education Resources (CIDER) is a VA HSR&D Resource Center charged with disseminating important HSR&D findings and information to policy makers, managers, clinicians, and researchers working to improve the health and care of Veterans.


This report is a product of VA/HSR&D's Quality Enhancement Research Initiative's (QUERI) Evidence-Based Synthesis Program (ESP), which was established to provide timely and accurate synthesis of targeted healthcare topics of particular importance to VA managers and policymakers – and to disseminate these reports throughout VA.

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