Clinical Decision Support Systems: Implications for Advancing Optimal Medical Imaging Use in Canada
DISCLOSURE • Relationship with Commercial Interest: • Grant/Research Support: • Speaker Bureau/Honoraria: • Consulting fees: • Memberships on advisory committees, boards: • Other Affiliations:
Clinical Decision Support Systems: Implications for Advancing Optimal Medical Imaging Use in Canada
A Perspective From A Frontline CDS User Brian H. Rowe, MD, MSc Emergency Physician, University of Alberta Hospital Co-Chair, Choosing Wisely Working Group, Canadian Association of Emergency Physicians (CAEP) Professor, Department of Emergency Medicine University of Alberta
DISCLOSURE: B Rowe • Relationship with Commercial Interest: None . • Employment: University of Alberta/CIHR • Grant/Research Support: CIHR, AHS, AIHS • Speaker Bureau/Honoraria: None . • Consulting fees: None. • Memberships on advisory committees, boards: CIHR. • Other Affiliations: will be passing the hat at the end of the session!
Emergency Department • Clinicians working in emergency departments face pressure to reduce delays; • Practice variation is well documented; • Most EDs are paper-based (although this is changing); • CDS are well developed. 5
CDS in Emergencies • Pneumonia severity: CURB-65, PSI; • Pulmonary embolism: PERC, Well’s, more; • DVT: Well’s criteria; • C-spine: Canadian C-Spine rule; • Concussion: Canadian CT Head Rule; • Ankle/foot: Ottawa Ankle Rule; • Evidence no longer the issue; • So many rules, so little time!. 6
Emergency Department Reality • ED overcrowding and long waits are common in Canada. • Crowding related to: • Input factors; • Throughput factors; • Output factors; and • System factors. • One more reason for unnecessary testing, procedures and treatment . 7
Example: CT Scans for mTBI • Reasonably easy to acquire at most large hospitals. • Risks: • Radiation exposure; • Time in ED; • Costs. • Does everyone need one?
Canadian CT Head Rules • Well-validated, sensitive decision rule for use of CT head in mTBI. • Canadian CT head rule (CCTHR) for minor head injuries. • CCTHR performance: • Sn = 100%: if you have no criteria, the risk of a serious head injury is ~0% (1: 10,000). • Decreases need for CT and time in ED; • Still need to provide concussion F/U. Stiell I, et al. JAMA. 2005;294(12):1511-1518.
…but its hard to change practice • 12 Canadian Centres • Controls (n = 6): standard practice; • Intervention sites (n = 6): • Strategies to implement CCT to reduce CT ordering; • Paper-based to computer-based; • Each strategy required ED MDs to complete a CCT sheet regarding CT ordering
Physicians: Common reasons for tests, procedures and therapies. Demand: Patterns: I’ve always The patient “wants” it done it this way Innovation: New tests are Income: good Financial incentives Fear: Patterns: I don’t want to Better to do get sued something than nothing Peer Pressure: Referring doctor wants it
CAEP Approach • Initiated CWC WG and surveyed members. • Developed CWC/CAEP lists: • Top-5: 2015; Top-10: 2017 . • • Dissemination: passive (websites + local). • Evaluation: limited. • Some regions: evaluation grants (PRIHS). • Debate: continues. 12
Solutions • Valid and reliable utilization data. • Evidence-based solutions. • CDS incorporated into electronic medical record; • Computerized physician order entry; • Audit and feedback strategies (but not too much). 13
National Approaches 14
Thank you! Questions/Comments? 15
Diagnostic Imaging Referral Guidelines Martin H. Reed MD FRCPC FACR FCAR Chair, Referral Guidelines Working Group Canadian Association of Radiologists
DISCLOSURE • Relationship with Commercial Interest: no • Grant/Research Support: no • Speaker Bureau/Honoraria: no • Consulting fees: CADTH • Memberships on advisory committees, boards: no • Other Affiliations: Canadian Association of Radiologists
Diagnostic Imaging Referral Guidelines • iRefer - The Royal College of Radiologists (1989) • Appropriateness Criteria – The American College of Radiology (1993) Guide du bon usage des examens d’ imagarie médicale - La Société Française de Radiologie • Diagnostic Imaging Pathways • Diagnostic Imaging Referral Guidelines – Canadian Association of Radiologists
Diagnostic Imaging Referral Guidelines CAR Diagnostic Imaging Referral Guidelines
Diagnostic Imaging Referral Guidelines ACR Appropriateness Criteria
Diagnostic Imaging Referral Guidelines Diagnostic Imaging Pathways
Computerized Decision Support • Canadian Association of Radiologists • J Am Coll Radiol. 2011;8:251-8. The effect of incorporating guidelines into a computerized order entry system for diagnostic imaging. Bowen S 1 , Johnson K, Reed MH, et al. • J Am Med Inform Assoc. 2011;18;267-70. Electronic decision support for diagnostic imaging in a primary care setting. Curry L 1 , Reed MH. • American College of Radiology • ACR Select • European Society of Radiology • iGuide • The Royal College of Radiologists
Thank You 23
Clinical Decision Support Systems: Mark MacMillan Director, Clinical Decision Support, Diagnostic Imaging, AHS
DISCLOSURE • Relationship with Commercial Interest: None • Grant/Research Support: None • Speaker Bureau/Honoraria: None • Consulting fees: None • Memberships on advisory committees, boards: None • Other Affiliations: Alberta Health Service Employee
Utilization vs Appropriateness 26
Alberta’s Opportunity • the right information, • AHS Diagnostic Imaging • to the right person, • Connect Care Initiative • in the right intervention • Clinical Decision Support format, Framework • through the right channel, • 2019 Alberta CDS • at the right time in workflow Integration 27
Clinician Engagement • De- implementation • Physician Learning • Audit and Feedback • Learn from the past 28
Thank You 29
References CT Utilization by Population CADTH Medical Imaging Inventory 5 rights of clinical decision support: “Improving Outcomes with CDS: An Implementer’s Guide (second edition),” written by by Jerome Osheroff, MD, in 2012 CDS Cube “CIS Frameworks – Clinical Decision Support,” Alberta Health Services, concept Dr. Allen Ausford, Dr. Rob Hayward, Dr. Doug Campbell
Clinical Decision Support Systems: Lynne Zucker Executive Vice President, ACCESS Health Canada Health Infoway
DISCLOSURE • Relationship with Commercial Interest: • Grant/Research Support: • Speaker Bureau/Honoraria: • Consulting fees: • Memberships on advisory committees, boards: • Other Affiliations:
Canada Health Infoway Clinical Decision Support in the pan Canadian Digital Health Landscape • Established in 2001 as an independent, not-for-profit corporation • Equally accountable to 14 federal, provincial and territorial governments, through the Members (f/p/t 2017-2022: $300M Deputy Ministers of Health) who appoint the independent Board of Directors • Since inception, $2.45 billion in capitalization from the federal government through Health Canada: 2016-2018: $50M 2001: $500M Electronic health records (EHRs) E-Prescribing & Telehomecare 2007: $400M 2003: $600M EHRs & Wait Time Systems 2017-2022: $300M EHRs, Standards & Telehealth 2010: $500M E-Prescribing, Virtual Care, Patient Access 2004: $100M Electronic Medical Records (EMRs) to Health Information, Linking EHR Systems Public Health Surveillance Systems Foundational Mandate - Completed Current Mandate 33
Evolution of Infoway’s Activities 2017-2022: $300M 34
Opportunity for Clinical Decision Support “Used appropriately and based on quality EMR data, CDS tools have a great potential to improve the efficiency and quality of care provided within a family practice.” • Standardized guidelines available at time of referral or ordering have made little progress integrating with primary care EMRs - while it is acknowledged as a best practice • A pan-Canadian CDS framework and business case for integration into community based clinical systems is required. This will require co-ordination between the various “guideline owners” and possibly shared infrastructure 35
Thank You 36
Clinical Decision Support Systems: What is the evidence? Harindra Wijeysundera Vice President, Medical Devices & Clinical Interventions CADTH
DISCLOSURE • Relationship with Commercial Interest: none • Grant/Research Support: Edwards Lifesciences and Medtronic Inc • Speaker Bureau/Honoraria: none • Consulting fees: none • Memberships on advisory committees, boards: CorHealth Cardiac Funding Reform • Other Affiliations: CADTH exec
What is the evidence? Rapid Response Report Clinical Decision Support Systems for Appropriate Medical Imaging: Clinical Evidence and Cost-Effectiveness January 2019
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