JACR® July Highlights
Impact of a Commercially-Available Clinical Decision Support Program on Provider Ordering Habits
In 2014, the authors’ institution embedded ACR Select® clinical decision support into the EMR to provide feedback and support to clinicians when ordering imaging exams. The first six months after implementation, ACR Select operated in “silent” mode, without displaying appropriateness scores for ordered exams. On retrospective review, the system scored a total of 6,754 studies. Of these, 11 percent were low utility, 24.5 percent were marginal utility, and 64.5 percent were indicated. Following this sic-month period, appropriateness criteria scores were displayed for ordered studies. Over the next 24 months, 16,909 studies were scored. Of these, 5.4 percent were low utility, 12.6 percent were marginal utility, and 82 percent were indicated. The decrease in low-utility exams was found to be statistically significant, and the improvement was most pronounced for trainee physicians.
Good Relationships Mean Good Reimbursement
While clinical excellence is always paramount to effective radiology, the most important aspect of daily practice might be the relationships cultivated with referring clinicians, hospital administrators, and patients. “Quality” and “value” are concepts with different meanings for each of those groups. Developing relationships through effective communication is essential to establish the trust needed to fulfill those different versions of value. As reimbursement moves away from fee-for-service and toward value-based alternative payment models, maintaining the trust of patients, clinicians, and administrators will become more necessary to maintain a healthy and sustainable practice.
Tailoring Radiology Resident Education Using Aggregated Missed-Cases Data
Since 2003, the authors’ home institution has used an automated system to log and categorize discrepancies between residents’ preliminary and finalized reports. The program uses a 12-point scoring system and classifies reports as having “no discrepancy,” “questionable discrepancy,” “minor discrepancy,” or “major discrepancy.” A retrospective review of 13,604 cardiothoracic CT cases since 2003 demonstrated 46 (0.3 percent) studies with a major discrepancy in their interpretation, and 504 (3.7 percent) studies with a minor discrepancy. Discrepancies were further separated into one of 12 common categories, which were then presented at resident quality improvement educational conferences. Conferences were led by a fourth-year resident and received positive feedback from trainees within the program. Although there is commonly reluctance within radiology practices and training programs to hold “missed” or “discrepant” case conferences, they were well-received at this program and will continue to play a role in quality improvement efforts.
Few efforts are more challenging than changing the culture of a practice or training program in which feedback is not valued and problems are brushed aside. A transparent, positive, quality-focused culture is necessary to provide excellent patient care, but also creates a more rewarding environment in which to work and learn. Radiology leaders from around the country share their insights on the process of culture change. Common themes which emerge include the need for accurate self-diagnosis of the problem and constant, open two-way communication. A collaborative approach is needed to change a culture within an organization — top-down initiatives rarely have staying power. All members of a practice or program must have the ability to affect change in areas they view as problematic. If participants feel disempowered, efforts are likely to be unsuccessful.