Study Questions Effectiveness of Computerized Clinical Decision Support Systems

An analysis of the use of computerized clinical decision support systems regarding orders for advanced diagnostic imaging found that the systems failed to identify relevant appropriateness criteria for the majority of orders, according to a study in the June 2 issue of JAMA.
Computerized clinical decision support (CDS) systems that match patient characteristics against appropriateness criteria to produce algorithmic treatment recommendations are a potential means of improving care. The Protecting Access to Medicare Act of 2014 mandates use of CDS systems for the ordering of advanced diagnostic imaging in the Medicare program starting in 2017, according to background information in the article.
Peter S. Hussey, Ph.D., of RAND, Boston, and colleagues used data from the Medicare Imaging Demonstration to evaluate the relationship of CDS system use with the appropriateness of ordered images. Between October 2011 and November 2013, clinicians used computerized radiology order entry systems and CDS systems for selected magnetic resonance imaging, computed tomography, and nuclear medicine procedures. During a 6-month baseline period, the CDS systems tracked whether orders were linked with appropriateness criteria but did not provide clinicians with feedback on appropriateness of orders.
During the 18-month intervention period, the CDS systems provided feedback indicating whether the order was linked to appropriateness criteria and, if so, the appropriateness rating, any recommendations for alternative orders, and a link to documentation supporting each rating. National medical specialty societies developed the appropriateness criteria using expert panels that reviewed evidence and completed a structured rating process.
The 3,340 participating clinicians placed 117,348 orders for advanced diagnostic imaging procedures. The CDS systems did not identify relevant appropriateness criteria for 63.3 percent of orders during the baseline period and for 66.5 percent during the intervention period. During the baseline period, 11.1 percent of final rated orders were inappropriate vs 6.4 percent during the intervention period. During the baseline period, 73.7 percent of final rated orders were appropriate vs 81.0 percent during the intervention period. Of orders initially rated as inappropriate, 4.8 percent were changed and 1.9 percent were canceled.
“Most orders were unable to be matched by the CDS systems to appropriateness criteria. Of those matched, there was a small increase in the percentage of orders rated appropriate between the baseline and intervention periods, although few inappropriate orders were changed or canceled immediately following feedback from the CDS systems. Therefore, improvements in appropriate imaging ordering do not appear related to immediate feedback and instead may be related to physician learning or secular changes,” the authors write.
“Implementing CDS systems in real-world settings has many challenges that must be addressed to meaningfully affect patient care.”