Ramin Khorasani

Ten Commandments for Effective Clinical Decision Support: Making the Practice of Evidence-based Medicine a Reality

While evidence-based medicine has increasingly broad-based support in health care, it remains difficult to get physicians to actually practice it. Across most domains in medicine, practice has lagged behind knowledge by at least several years. The authors believe that the key tools for closing this gap will be information systems that provide decision support to users at the time they make decisions, which should result in improved quality of care. Furthermore, providers make many errors, and clinical decision support can be useful for finding and preventing such errors. Over the last eight years the authors have implemented and studied the impact of decision support across a broad array of domains and have found a number of common elements important to success. The goal of this report is to discuss these lessons learned in the interest of informing the efforts of others working to make the practice of evidence-based medicine a reality.

Recurrent CT, Cumulative Radiation Exposure, and Associated Radiation-induced Cancer Risks from CT of Adults

PURPOSE To estimate cumulative radiation exposure and lifetime attributable risk (LAR) of radiation-induced cancer from computed tomographic (CT) scanning of adult patients at a tertiary care academic medical center. MATERIALS AND METHODS This HIPAA-compliant study was approved by the institutional review board with waiver of informed consent. The cohort comprised 31,462 patients who underwent diagnostic CT in 2007 and had undergone 190,712 CT examinations over the prior 22 years. Each patients cumulative CT radiation exposure was estimated by summing typical CT effective doses, and the Biological Effects of Ionizing Radiation (BEIR) VII methodology was used to estimate LAR on the basis of sex and age at each exposure. Billing ICD9 codes and electronic order entry information were used to stratify patients with LAR greater than 1%. RESULTS Thirty-three percent of patients underwent five or more lifetime CT examinations, and 5% underwent between 22 and 132 examinations. Fifteen percent received estimated cumulative effective doses of more than 100 mSv, and 4% received between 250 and 1375 mSv. Associated LAR had mean and maximum values of 0.3% and 12% for cancer incidence and 0.2% and 6.8% for cancer mortality, respectively. CT exposures were estimated to produce 0.7% of total expected baseline cancer incidence and 1% of total cancer mortality. Seven percent of the cohort had estimated LAR greater than 1%, of which 40% had either no malignancy history or a cancer history without evidence of residual disease. CONCLUSION Cumulative CT radiation exposure added incrementally to baseline cancer risk in the cohort. While most patients accrue low radiation-induced cancer risks, a subgroup is potentially at higher risk due to recurrent CT imaging.

Lung volumes and emphysema in smokers with interstitial lung abnormalities.

BACKGROUND Cigarette smoking is associated with emphysema and radiographic interstitial lung abnormalities. The degree to which interstitial lung abnormalities are associated with reduced total lung capacity and the extent of emphysema is not known. METHODS We looked for interstitial lung abnormalities in 2416 (96%) of 2508 high-resolution computed tomographic (HRCT) scans of the lung obtained from a cohort of smokers. We used linear and logistic regression to evaluate the associations between interstitial lung abnormalities and HRCT measurements of total lung capacity and emphysema. RESULTS Interstitial lung abnormalities were present in 194 (8%) of the 2416 HRCT scans evaluated. In statistical models adjusting for relevant covariates, interstitial lung abnormalities were associated with reduced total lung capacity (-0.444 liters; 95% confidence interval [CI], -0.596 to -0.292; P<0.001) and a lower percentage of emphysema defined by lung-attenuation thresholds of -950 Hounsfield units (-3%; 95% CI, -4 to -2; P<0.001) and -910 Hounsfield units (-10%; 95% CI, -12 to -8; P<0.001). As compared with participants without interstitial lung abnormalities, those with abnormalities were more likely to have a restrictive lung deficit (total lung capacity <80% of the predicted value; odds ratio, 2.3; 95% CI, 1.4 to 3.7; P<0.001) and were less likely to meet the diagnostic criteria for chronic obstructive pulmonary disease (COPD) (odds ratio, 0.53; 95% CI, 0.37 to 0.76; P<0.001). The effect of interstitial lung abnormalities on total lung capacity and emphysema was dependent on COPD status (P<0.02 for the interactions). Interstitial lung abnormalities were positively associated with both greater exposure to tobacco smoke and current smoking. CONCLUSIONS In smokers, interstitial lung abnormalities--which were present on about 1 of every 12 HRCT scans--were associated with reduced total lung capacity and a lesser amount of emphysema. (Funded by the National Institutes of Health and the Parker B. Francis Foundation; ClinicalTrials.gov number, NCT00608764.).

Return on Investment for a Computerized Physician Order Entry System

OBJECTIVE Although computerized physician order entry (CPOE) may decrease errors and improve quality, hospital adoption has been slow. The high costs and limited data on financial benefits of CPOE systems are a major barrier to adoption. The authors assessed the costs and financial benefits of the CPOE system at Brigham and Womens Hospital over ten years. DESIGN Cost and benefit estimates of a hospital CPOE system at Brigham and Womens Hospital (BWH), a 720-adult bed, tertiary care, academic hospital in Boston. MEASUREMENTS Institutional experts provided data about the costs of the CPOE system. Benefits were determined from published studies of the BWH CPOE system, interviews with hospital experts, and relevant internal documents. Net overall savings to the institution and operating budget savings were determined. All data are presented as value figures represented in 2002 dollars. RESULTS Between 1993 and 2002, the BWH spent

Effect of Computerized Clinical Decision Support on the Use and Yield of CT Pulmonary Angiography in the Emergency Department

11.8 million to develop, implement, and operate CPOE. Over ten years, the system saved BWH

Automated Evidence-based Critiquing of Orders for Abdominal Radiographs: Impact on Utilization and Appropriateness

28.5 million for cumulative net savings of

Is Terminology Used Effectively to Convey Diagnostic Certainty in Radiology Reports

16.7 million and net operating budget savings of

Variation in Use of Head Computed Tomography by Emergency Physicians

9.5 million given the institutional 80% prospective reimbursement rate. The CPOE system elements that resulted in the greatest cumulative savings were renal dosing guidance, nursing time utilization, specific drug guidance, and adverse drug event prevention. The CPOE system at BWH has resulted in substantial savings, including operating budget savings, to the institution over ten years. CONCLUSION Other hospitals may be able to save money and improve patient safety by investing in CPOE systems.

Impact of a 4-year Quality Improvement Initiative to Improve Communication of Critical Imaging Test Results

PURPOSE To determine the effect of evidence-based clinical decision support (CDS) on the use and yield of computed tomographic (CT) pulmonary angiography for acute pulmonary embolism (PE) in the emergency department (ED). MATERIALS AND METHODS Institutional review board approval was obtained for this HIPAA-compliant study, which was performed between October 1, 2003, and September 30, 2009, at a 793-bed quaternary care institution with 60,000 annual ED visits. Use (number of examinations per 1000 ED visits) and yield (percentage of examinations positive for acute PE) of CT pulmonary angiography were compared before and after CDS implementation in August 2007. The authors included all adult patients presenting to the ED and developed and validated a natural language processing tool to identify acute PE diagnoses. Linear trend analysis was used to assess for variation in CT pulmonary angiography use. Logistic regression was used to determine variation in yield after controlling for patient demographic and clinical characteristics. RESULTS Of 338,230 patients presenting to the ED, 6838 (2.0%) underwent CT pulmonary angiography. Quarterly CT pulmonary angiography use increased 82.1% before CDS implementation, from 14.5 to 26.4 examinations per 1000 patients (P<.0001) between October 10, 2003, and July 31, 2007. After CDS implementation, quarterly use decreased 20.1%, from 26.4 to 21.1 examinations per 1000 patients between August 1, 2007, and September 30, 2009 (P=.0379). Overall, 686 (10.0%) of the CT pulmonary angiographic examinations performed during the 6-year period were positive for PE; subsequent to CDS implementation, yield by quarter increased 69.0%, from 5.8% to 9.8% (P=.0323). CONCLUSION Implementation of evidence-based CDS in the ED was associated with a significant decrease in use, and increase in yield, of CT pulmonary angiography for the evaluation of acute PE.

Inpatient Radiology Utilization: Trends over the Past Decade

OBJECTIVE Inappropriate utilization of diagnostic testing has been well documented. The purpose of this study was to measure the impact of presenting real time, evidence-based critiques about the appropriateness of abdominal radiograph (KUB) orders on physician decision making. DESIGN Prospective trial where evidence-based critiques were presented to ordering clinicians in two kinds of situations: (1) a KUB was likely to have a low probability of providing useful information, or (2) an alternative view(s) was more appropriate given the clinical circumstance. There were two phases of the trial: Phase 1 was a 9-week period where evidence-based critiques were presented at the time of ordering a KUB, followed by Phase 2, a 19-week period in which orderers were randomized to receive critiques either amended to include both institutional data regarding the utility of the critiques and stronger messages about the lack of utility of the study, or the same critiques as presented in Phase 1, depending upon indication. Based upon the radiologists report of their interpretation of the exams, the results of the examinations were scored as positive, equivocal, or negative using structured criteria. RESULTS 299 KUBs in Phase 1 and 385 KUBs in Phase 2 received at least one critique. Cancellation rates of low yield films were low, and were similar in Phase 1 and 2, 8/258 (3%) vs. 10/283 (4%). Compliance with the recommendation for alternative view(s) was higher: 19/104 (38%) in Phase 1 vs. 96/176 (55%) in Phase 2 (p = 0.006). The results differentiated low-yield from non-low-yield films: 5% of low-yield films vs. 20% of non-low-yield films were positive in Phase 2 (p < 0.0001). Surgical physicians were less likely to cancel (p = 0.07) or to change to the suggested view(s) (p < 0.0001) than medical physicians or nurses. CONCLUSIONS The intervention identified clinical situations in which KUBs appeared to have a low clinical yield. In response to evidence-based critiques, providers were reluctant to cancel their order, but were more willing to change to different views. To reduce the number of inappropriate radiographic films, stronger incentives or interventions may be required.