How (and Why) to Get Your Colleagues on Board with CDS

Practical Steps to Leverage Clinical Decision Support Tools and Enhance Collaboration Between Ordering Physicians and RadiologistsCDS pic

In the drive to reduce inappropriate imaging and deliver better care at lower costs, it is imperative for physicians who order imaging and for radiologists to forge a strong, collaborative partnership. Avoiding unnecessary care begins by following evidence-based recommendations for which tests and procedures are most appropriate for each patient’s clinical situation.

Such recommendations can be found in published guidelines or embedded in clinical decision support (CDS) tools. Avoiding unnecessary care continues with a consultative partnership with radiologists who can help us determine the right test for our patients at the right time. As members of the multi-disciplinary care team, radiologists are integral to the appropriate imaging decision-making process.

What is the importance of a collaborative approach to care?

According to numerous studies and the well-publicized Choosing Wisely initiative, overutilization of imaging can have hazardous consequences — both for the patient and for the health care system as a whole. From the patient's perspective, inappropriate imaging can lead to increased costs, intensified anxiety, incidental findings, and possibly unnecessary workup or even surgery. For the health care system, inappropriate imaging contributes to driving up costs and adversely impacts our goal of providing high-value care to patients.

Clearly, there is strong motivation to ensure that imaging is done appropriately. A crucial part of that effort is to foster good communication between ordering providers and radiologists. Radiologists have a tremendous amount of expertise and can help guide appropriate ordering practices.

How can providers form a collaborative relationship with radiologists and enable better communication at the point of care?

Hospital systems work best when they strive for team-based care and providers feel comfortable freely interacting with colleagues from other disciplines. Toward that end, it is invaluable to have radiologists and referring providers meet face to face, even if briefly, so we all know who is on the other end of the phone and can discuss goals and insights. We should invite radiologists to participate in multi-disciplinary, quality improvement meetings as valued members of the care team. In that way, we can foster a collegial, collaborative environment and recognize that our goals are shared. We all want to provide the best care possible for patients — utilizing imaging’s tremendous value in appropriately selected cases while minimizing the costs, incidental findings, and potential radiation exposure of unnecessary tests. There are also collaborative programs like R-SCAN that provide a pathway and resources that radiologists and ordering clinicians can use to work together to reduce inappropriate imaging.

What role do CDS tools play in achieving the goal of appropriate imaging?

Well-designed CDS tools that are embedded in electronic medical record (EMR) systems can certainly play a valuable role in decision-making at the point of care. Several studies have already demonstrated their value in reducing inappropriate imaging.

While CDS and EMR systems are instrumental to patient care, they can’t always replace direct communication (either on the phone or in person) between a referring provider and a radiologist. Every patient situation is unique, and there are many subtleties. As referring providers, we see a wide spectrum of cases. Some are more clear-cut than others, and we may want to utilize evidence-based CDS tools for more routine cases and consult directly with our radiology colleagues on the more difficult cases. Radiologists have invaluable expertise, and leveraging that knowledge for the benefit of our patients can help us provide optimal patient care, in the same way that consulting with infectious disease doctors, nephrologists, gastroenterologists, and other specialists provides optimal care as well. There’s also an educational opportunity for radiologists to share their expertise with providers in a way that creates lasting value beyond a specific patient encounter.

Steps to Take

To effectively improve collaboration and communication, it is critical to take advantage of all the tools and resources available. Here are four steps that will help ordering clinicians and radiologists fine-tune their working relationships.

Step 1. If evidence-based CDS tools for imaging are well designed and available at the point of care, utilize them first, if needed. CDS can provide the initial layer of expertise for appropriate imaging decisions and may obviate the need for an interaction between ordering providers and radiologists. For more challenging but non-urgent cases, you can often use the EMR system to send a secure, instant message to the radiologist, who can also use the system to access relevant patient records and notes. In select cases, if you need guidance even sooner, you can also call the radiologist and get preliminary recommendations over the phone regarding whether imaging is warranted, and if so, what imaging modality is ideal. This is where it helps to have previously met your radiology colleagues.

Step 2. Look into collaborative programs such as R-SCAN to build strong relationships, establish processes to improve appropriate imaging, and start getting some immediate results. R-SCAN offers tremendous value — both as an educational intervention and as an initiative that fosters buy-in from both referring physicians and radiologists. It also serves as a resource to keep track of how we're doing in terms of minimizing unnecessary imaging.

Step 3. Recognize that we're all part of the same team and have the same goals — providing high-value care to our patients.

By Jason L. Hom, MD, Hospitalist, Stanford Healthcare, Stanford University, Calif.

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