Computerized clinical decision support may improve appropriate use of diagnostic radiology
1. From a systematic review and meta-analysis, use of computerized clinical decision support (CCDS) tools integrated into electronic health records (EHRs) was associated with moderate improvement in appropriate use and decreased overall use of diagnostic imaging.
2. However, the potential harms of integrating CCDS into EHRs, such as under-use of appropriate imaging tests, were underreported.
Evidence Rating Level: 2 (Good)
Study Rundown: The use of diagnostic imaging tests has increased over the last two decades, but inappropriate use of these tests can be expensive and harmful to patients. To better inform their use, computerized clinical decision-support (CCDS) tools have been developed to help guide providers in ordering common imaging tests. This study reviewed and analyzed data from several investigations, each of which evaluated CCDS embedded in electronic health records (EHRs) to determine if CCDS improved appropriate use of imaging tests. Overall, CCDS tools were associated with a moderate improvement in the appropriate use of diagnostic radiology. Use of CCDS tools was also associated with a slight decrease in the overall use of diagnostic imaging. Notably, potential harms from integrating CCDS into EHRs, such as underuse of appropriate tests, were rarely reported. This study was limited by substantial differences in study design and results between the studies evaluated. Additionally, it is unknown whether many health centers have deployed CCDS as part of EHRs but not reported their experiences in academic literature. Together, the moderate improvement in appropriate use of imaging tests with CCDS, combined with the dearth of data on potential harms, highlight the need for further research on this potentially risk- and cost-saving tool.
Click to read the study, published today in the Annals of Internal Medicine
Relevant Reading: The Impact of Computerized Provider Order Entry Systems on Medical-Imaging Services: A Systematic Review
In-Depth [systematic review]: This systematic review and meta-analysis included 23 studies (3 randomized trials, 7 time-series studies, and 13 pre-post studies) that evaluated integration of CCDS into EHRs. Appropriateness of radiographic tests was specified by each included study, on the basis of clinical guidelines or locally developed guidelines. Pooling data from 21 of the included studies, use of EHR-based CCDS was associated with moderate increase in appropriateness (effect size -0.49; 95%CI -0.71 to -0.26) and moderate reduction in use (effect size -0.13; 95%CI -0.23 to -0.04) of imaging tests. Notably, there was marked heterogeneity in evaluation of appropriateness (I2 = 99.5%) and reduction in use (I2 = 100%). Although there was not sufficient data to thoroughly analyze characteristics of CCDS tools or study settings, there was some suggestion of improved effectiveness from CCDS tools that involved “hard stops” (i.e. a provider could not order a test without outside consultation if CCDS appropriateness criteria were not met), and tools that were incorporated into EHRs in integrated care settings.
Image: PD
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