1. health and fitness

2015 Academic Emergency Medicine Consensus Conference. Group 5 Manuscript. Draft 2.
Title: Knowledge Translation and Barriers to Imaging Optimization in the Emergency
Department: A Research Agenda
Abstract
Researchers have attempted to optimize imaging utilization by describing which clinical
variables are more predictive of acute disease and, conversely, what combination of variables
can obviate the end for imaging. These results can then be used to develop evidence-based
clinical pathways, clinical decision instruments, and clinical practice guidelines. Despite the
validation of these results in subsequent studies, with some demonstrating improved
outcomes, their actual use is often limited. This document outlines a research agenda to
promote the dissemination and implementation (also known as Knowledge Translation) of
evidence-based interventions (EBIs) for ED imaging (i.e. clinical pathways, clinical decision
instruments and clinical practice guidelines). We convened a multidisciplinary group of
stakeholders and held online and telephone discussions over a 12-month period culminating in
an in-person meeting at the 2015 Academic Emergency Medicine Consensus Conference. We
identified the following four key research questions: 1) What determinants (barriers and
facilitators) influence emergency physicians’ use of EBIs when ordering imaging in the ED? 2)
What implementation strategies at the institutional level can improve the use of EBIs for ED
imaging? 3) What interventions at the healthcare policy level can facilitate the adoption of EBIs
for ED imaging? 4) How can health information technology, including electronic health records,
clinical decision support, and health-information exchanges, be used to increase awareness, use
and adherence to EBIs for ED imaging? Advancing research that addresses these questions will
provide valuable information as to how we can use evidence-based interventions to optimize
imaging utilization and ultimately improve patient care.
Word Count: 246
Keywords: Diagnostic imaging, Emergency Department, dissemination and implementation,
knowledge translation.
Glossary of terms.
Dissemination and Implementation: (D&I)
Dissemination is the targeted distribution of information and intervention materials to a specific clinical
practice audience.
Implementation is the use of strategies to adopt and integrate evidence-based health interventions and
change practice patterns within specific clinical settings.
Knowledge Translation: (KT)
Knowledge translation describes any activity or process that facilitates the transfer of high-quality
evidence from research into effective changes in health policy, clinical practice, or products.
Clinical Decision Instrument: (CDI)
Clinical decision instruments are tools designed to help clinicians make diagnostic and therapeutic
decisions at the bedside. Also known as clinical decision rules, clinical decision aids or clinical prediction
rules.
Clinical Practice Guideline: (CPG)
Clinical practice guidelines are statements that include recommendations intended to optimize patient
care, which are informed by a systematic review of evidence and an assessment of the benefits and
harms of alternative care options.
Evidence-Based Guidance: (EBG)?
Evidence-based guidance is an umbrella term that includes clinical practice guidelines and clinical
decision instruments.
Evidence-based Clinical Algorithms (EBCA)?
Evidence-based clinical algorithms refer to clinical pathways, clinical practice guidelines, and clinical
decision instruments which are based on sound medical evidence.
Evidence-Based Interventions (EBIs) ?
The objects of dissemination and implementation activities are interventions with proven
efficacy and effectiveness (i.e. evidence-based). Interventions are broadly defined and may
include programs, practices, policies, and guidelines.
Electronic Health Record: (EHR)
Electronic Health Records are real-time, patient-centered digital records that make information available
instantly and securely to authorized users.
Clinical Decision Support Systems: (CDSS)
Clinical decision support systems are software designed to directly assist in clinical decision-making, in
which the characteristics of an individual patient are matched to a computerized clinical knowledge base
and patient-specific assessments such as alerts, order-sets and templates or referrals to guidelines are
then presented to the clinician.
Health information exchange: (HIE)
Health information exchanges (HIEs) are entities that bring together health care stakeholders generally
within a defined geographic area and govern the electronic sharing of health information promoting
interoperability among them for the purpose of improving health and care in that community.
Health information Technology: (HIT)
Health information technology encompasses a wide range of products and services—including software,
hardware and infrastructure—designed to collect, store and exchange digital patient data throughout
the clinical practice of medicine.
Adaptation
Adaptation is defined as the degree to which an evidence-based intervention is changed or modified by
a user during adoption and implementation to suit the needs of the setting or to improve the fit to local
conditions.
Fidelity
Fidelity measures the degree to which an intervention is implemented as it is prescribed in the original
protocol.
Sustainability
Sustainability describes to what extent an evidence-based intervention can deliver its intended benefits
over an extended period of time after external support from the donor agency is terminated.
Adoption
Adoption is the decision of an organization or a community to commit to and initiate an evidence-based
intervention.
Acceptability
Acceptability is related to the ideas of complexity and relative advantage; it refers to a specific
intervention and describes whether the potential implementers, based on their knowledge of or direct
experience with the intervention, perceive it as agreeable, palatable, or satisfactory.
Introduction
There are currently many evidence-based interventions (EBIs) focused on improving ED
diagnostic imaging resource utilization, including several clinical pathways, clinical practice
guidelines (CPGs) and clinical decision instruments (CDIs) [Gaddis 2007, Agrawal 2009, Green
2014]. These are designed to assist clinicians with decision-making in specific clinical situations
(e.g. mild head injury); specifically, to safely reduce ED imaging while identifying clinically
important disease. Multiple CDIs have been shown to have high sensitivity and sufficient
specificity to safely decrease imaging rates without compromising patient outcomes [Hoffman
2000, Stiell 1993, Stiell 2001, Stiell 2005]. Various evidence-based emergency medicine CPGs
have also been developed to aid ED clinicians in certain diagnostic situations (e.g. syncope,
seizure, acute headache) to improve resource utilization with regards to ED imaging [Edlow
2008, Huff 2007]. Recently, the American College of Emergency Physicians released 10
recommendations as part of the “Choosing Wisely” campaign, five of which pertain to avoiding
unnecessary advanced imaging [Shuur Raja, JAMA IM. 2014]. If properly implemented and
used, these EBIs have the potential to optimize imaging utilization resulting in lower costs,
decreased radiation exposure, enhanced ED throughput and improved patient care. Yet, this
guidance is not commonly used in actual ED clinical practice (Cabana JAMA 1999). A recent
national survey on diagnostic imaging revealed that the vast majority of emergency physicians
believe that roughly 1 in 5 imaging studies ordered in the ED are medically unnecessary. Fear of
missing a diagnosis and medicolegal concerns were most often cited as contributing factors to
obtaining imaging while shared decision-making and tort reform were cited as potential
solutions (Kanzaria, Probst. AcaEM 2015 x 2)
Methods
This manuscript is a product of a 12-month process consisting of a substantial review of the
literature, creation of a 60-article annotated bibliography, monthly hour-long group conference
calls, and an in-person planning meeting, ultimately culminating in the 2015 Academic
Emergency Medicine consensus conference in San Diego in May 2015. Our group, consisting of
a multidisciplinary team of emergency physicians, emergency radiologists, and a psychologist
with expertise in implementation science, was tasked with creating a research agenda to guide
future efforts focusing on the dissemination and implementation (also known as knowledge
translation) of evidence-based interventions for diagnostic imaging in the ED. Through an
iterative process, a list of four overarching research questions was composed and developed in
parallel by four different sub-groups. The initial draft of the manuscript was discussed and then
revised during the consensus conference itself.
Research Question 1: What are the cultural, medico-legal, psychological, pragmatic,
institutional, or educational determinants of emergency physicians’ use of evidence-based
interventions (EBI) when deciding to order diagnostic imaging in the ED?
Background/Rationale
Identifying and addressing the gaps between evidence-based practice and actual clinical care is
the goal of dissemination and implementation (D&I) science, also known as knowledge
translation. One critical D&I step toward facilitating EBI use for imaging decisions in the ED is
identifying the determinants (barriers and facilitators) of evidence use in relevant clinical
situations.
There are a multitude of conceptual models/frameworks that have been developed to assess
the barriers and facilitators to evidence uptake and use [ref Straus 2013]. These conceptual
frameworks can help researchers standardize the terminology, study design and analytic
techniques used in this domain of implementation science. It is not the objective of this
manuscript to compare and discuss all of these frameworks but rather to mention some of
those most widely accepted and used to study barriers and facilitators to ED-based
interventions.
The Clinical Practice Guidelines Framework for Improvement is one highly regarded means to
evaluate barriers to evidence-based guidance uptake in health care [Cabana 1999]. It consists of
7 distinct domains across three themes: Knowledge, Attitudes and Behavior. The domains
include: 1) Awareness of guidelines, 2) Familiarity with the guideline, 3) Agreement with the
recommendations, 4) Self-efficacy (perception that one can carry out the recommendations), 5)
Outcome Expectancy (perception that following the guideline will lead to improved outcomes),
6) Inertia of previous practice, and 7) External Barriers. Though this framework could be used to
guide studies to evaluate the determinants of evidence-based guidance use in the ED for
diagnostic imaging, we were unable to identify research that has done so.
Some studies looking at the use of prediction rules/guidelines for ED imaging have used the
Theoretical Domains Framework (TDF). The TDF integrates constructs from 33 behavior change
theories and consolidates them in a more accessible arrangement of 12 theoretical domains
[Curran 2013]. The 12 domains are 1) knowledge, 2) skills, 3) social/professional role and
identity, 4) beliefs about capabilities, 5) beliefs about consequences, 6) motivation and goals, 7)
memory, attention and decision processes, 8) environmental context and resources, 9) social
influences, 10) emotion regulation, 11) behavioral regulation, and 12) nature of the behavior
[Michie 2005]. Curran et al. assessed whether the TDF could be used to retrospectively identify
the determinants of use of the Canadian Head Computed Tomography (CT) rule after an
implementation trial [Curran 2013]. The authors concluded that 6 of the 12 domains were likely
to have impacted the response of emergency physicians to the implementation of this CDI. The
TDF was also used to analyze factors thought to influence the use of CPGs and CDIs for the
management of mild traumatic brain injury in Australians EDs. The authors concluded that
these determinants ranged across a variety of theoretical domains, which could serve as targets
for future interventions [Tavender 2014]. Further studies, using existing conceptual
frameworks, are justified to explore which factors influence the use of EBIs for ED diagnostic
imaging in general, as well as in specific clinical scenarios where well-validated and accepted
CDIs exists, e.g. Ottawa ankle/foot rules, NEXUS criteria for cervical spine imaging, the Canadian
Head CT rules for adult blunt head trauma, and the PECARN criteria for pediatric blunt head
trauma. Make it more specific.
To better understand the determinants of evidence use in the ED, qualitative designs, such as
focus groups and stakeholder interviews, are often required both at the intervention (e.g.
decision support) planning phase and post-implementation phase. Unfortunately, these studies
are infrequently completed (Neta 2015, Sheehan 2013). The qualitative research must study ED
providers as well as patients and administrators (who influence decision-making). Other
research to understand determinants to use/lack of use of evidence-based guidance includes
ethnographic studies (e.g. workflow analyses) of ED clinicians making imaging decisions in realtime, and surveys of ED clinicians (and patients) to understand the regional and national
perspectives. Studies employing the Delphi method using key Emergency Medicine opinion
leaders could also provide valuable data in this area. Since each ED possesses unique
organizational, professional, individual and cultural characteristics, the identification of specific
barriers and facilitators may be most useful to inform the implementation of a particular
intervention in a given ED. Finally, meta-analyses of studies evaluating determinants of
knowledge use, accounting for heterogeneity across studies, could also be helpful. Collectively,
this research agenda would help delineate and describe the barriers and facilitators of
emergency clinicians’ use of evidence-based guidance for diagnostic imaging.
Research Question 2: What implementation strategies can improve the use of validated clinical
decision instruments and evidence-based imaging guidelines?
The small number of implementation studies aimed to impact diagnostic imaging in emergency
departments (Stiell 1994 and 2010, Hassan 2005, Mooney 2011) provides the opportunity and
need to study a host of implementation strategies. *****
Implementation interventions from other health care settings have effectively studied
guideline-based behavior change (hand washing, intravenous line infections, etc.), basing the
interventions on a variety of conceptual frameworks (Frankish 1998, Glasgow 1999, Carayon
2006, Glanz 2008). However, objective assessment of implementation strategies across all fields
of medicine suffers from inconsistent terminology and variable methods (Michie 2009).
Studies of imaging CDIs have typically lacked conceptual frameworks and thus failed to provide
guidance for future implementation efforts by overlooking the larger process of
implementation, fidelity, adaptability, sustainability. These limitations can be expected, as the
degree of understanding and rate of adoption are more easily measured objectively (e.g. XXXX)
than factors related to practice setting, financial inducements, peer beliefs, and patient needs
and resources. Initiatives like the Consolidated Framework for Implementation Research
(Damschroder 2009) have attempted to make implementation science more approachable by
consolidating and unifying key constructs across implementation theories that evaluate the (1)
type of intervention, (2) the setting of the implementation, (3) provider-specific factors and the
(4) rollout of the implementation.
When deciding to implement an imaging guideline, six types of administrative and educational
strategies should be considered (Powell 2012): (1) effective planning that includes a needs
assessment and stakeholder engagement, (2) education, whether at a local level, or by
publication and wide-reaching social media, (3) financial incentives that motivate guideline
adoption, (4) restructuring of existing roles and services, (5) quality management to assure that
data systems support guideline use and (6) policy changes and public campaigns. Examples of
planning strategies include sociotechnical analyses (Sheehan 2013), education strategies
include academic detailing, financial strategies include incentives for use of clinical decision
support (e.g. Meaningful Use), restructuring strategies include checklists (Winters 2009), quality
management strategies include audit and feedback (Ivers 2012), and policy strategies include
tort reform. Blended strategies utilize elements from different strategy types, such as
implementation toolkits (Barac 2014, AHRQ 2012).
When implementing an intervention such as a clinical decision instrument or imaging guideline,
success with relevant implementation outcomes is usually a precondition for success in the
desired clinical outcome. Conversely, if an intervention fails to achieve the desired clinical
outcome, such as reports of no change in ordering imaging study rates after implementation
(Mooney 2011, Hassan 2005, Bressan 2012, Sultan 2004), it is useful to know if this is due to
some aspect of the implementation rather than the intervention itself. Selecting an optimal
implementation strategy and evaluating its success may vary based on the most relevant and
important implementation outcomes. Proposed constructs include but are not limited to
acceptability, appropriateness, adoption, cost, feasibility, fidelity, penetration, sustainability
(Proctor 2010). Acceptability of an intervention to relevant stakeholders is usually key for
success and along with perceived appropriateness of an intervention and is best evaluated with
primarily qualitative measures including questionnaires, surveys, interviews and focus groups.
Adoption, or uptake, can be at the provider or organization level and might be measured with
mixed methods while penetration refers to the proportion of providers utilizing an intervention
or the number of eligible patients for whom an intervention was used, both of which require
rigorous statistical approaches. Incremental cost of an implementation and feasibility (which
might include resource requirements) should use quantitative methods, while fidelity, or the
extent to which the implementation of an intervention is true to the way the CDI was derived
and validated, could evaluate adherence to a protocol. Research plans should also address
sustainability of implementations to address possible abandonment of the tested instrument
after a study period ends.
We recommend that future implementation studies address the following questions as part of
their design:

What structured approach to planning the implementation was undertaken?

What were the a priori expectations of the outcome of implementation?

What statistical tools were used to correlate implementation outcomes to clinical
outcomes?

How was the durability of the implementation tested?
We further recommend that study design should combine qualitative and quantitative
approaches with a holistic perspective to provide a richer assessment of the components of CDI
implementation. Intervening during the rollout phase should not be prohibited, so long as
iterative changes are documented through ongoing qualitative and quantitative data collection.
To begin with the end in mind, designing studies with an implementation evaluation framework
would be useful (Albrecht 2013, Neta 2015). In particular, quantitative dimensions of the
project need appropriate controls, which can be achieved with designs like clusterrandomization, or a difference-in-differences (Dimick 2014). Though quasi-experimental designs
are also reasonable (Compton 2007, West 2008), before-and-after study designs are less suited
for quantitative measurements (knowledge tests or use rates) due to multiple potential biases
(but may provide valuable information for qualitative studies).
Research Question 3: What interventions at the healthcare policy level can facilitate adoption
of EBI for ED imaging?
A number of interventions at the healthcare policy level may facilitate adoption of evidencebased interventions (EBIs) for ED diagnostic imaging. Here, we will focus on four that require
investigation regarding their impact: quality measures, government and professional society
guidelines, legislation, and malpractice reform.
Quality measures, often accompanied by public reporting and financial implications, are
commonly used to drive performance. Such measures may present opportunities to improve
uptake of evidence for ED imaging. Imaging-related measures that are provisionally endorsed
by the National Quality Forum that could be used in this fashion include ultrasonographic
determination of pregnancy location for pregnant patients with abdominal pain (NQF #0651)
and inappropriate pulmonary CT imaging for patients at low risk for pulmonary embolism (NQF
#0667). These measures require testing and validation, which poses a significant burden for
measure developers, as these steps typically must be performed prior to endorsement and
promulgation. However, it is critical that the emergency medicine community be involved in
measure development to assure the appropriateness and valid measurement design. If not
done, this risks problematic measures being advanced. [Raja 2010, Shuur 2011, Shuur 2011]
Measures can be strengthened when they consider and include evidence-based policies from
national emergency medicine groups.
Evidence-based imaging guidelines developed by government agencies and professional
societies may potentially facilitate adoption because of their widespread dissemination and
awareness by practitioners, as well as the authority of the source. One successful recent
example of widespread professional society imaging guideline dissemination is the American
Board of Internal Medicine Foundation’s Choosing Wisely campaign, which has been adopted
by over 60 U.S. professional societies. The American College of Emergency Physicians has listed
10 practices that should be questioned as potentially unnecessary by patients and their
physicians, five of which involve ED imaging: CT chest for suspected pulmonary embolism, CT
head for select patients presenting with blunt head trauma and syncope, lumbar spine imaging
for patients with acute back pain, and renal CT for suspected kidney stone
[http://www.choosingwisely.org/wp-content/uploads/2013/10/093013_F64-40-ACEP-5thingsList_Draft-3d.pdf]. However, at this point, existing evidence regarding the effectiveness of this
strategy in emergency medicine is limited to a single study, which found that compliance with
the United Kingdom National Institute for Health and Care Excellence (NICE) head injury
guidelines was excellent in adult patients but quite poor in pediatric patients [Mooney
2011]. Another study of the NICE guidelines for imaging after urinary tract infections found
mixed adherence [Judkins 2013], and North American authors found that governmental
guidelines for magnetic resonance imaging in low back pain resulted in only modest (if any)
change in image ordering practice [Rao 2012, Kennedy 2014].
In addition to the development of quality measures and imaging guidelines, governmental
agencies may attempt to increase the adoption of evidence-based imaging practices by simply
mandating their use. Recently, the U.S. Congress did exactly this. As part of the Protecting
Access to Medicare Act of 2014, they legislated that EDs (in addition to other hospital settings)
must use “applicable appropriate use criteria for applicable imaging services only from among
appropriate use criteria developed or endorsed by national professional medical specialty
societies or other provider-led entities” [govtrack.us 2014]. This mandate requires the Secretary
of Health and Human Services to determine, no later than November 15, 2015, which
“appropriate use criteria” will be allowable, noting that these criteria should have stakeholder
consensus, be scientifically valid, and be based on studies that are published and reviewable. If
chosen correctly, these criteria may facilitate adoption of evidence-based imaging guidelines.
Future research in this area might focus on effective methods for increasing physician
awareness of imaging related policies (including quality measures, legislation, and
government/specialty-specific guidelines), as well as the direct and indirect impacts of these
policies on imaging practices.
There is some evidence to suggest a link between fear of malpractice and the ordering of
unnecessary imaging [Sathiyakumar 2013, Studdert 2005, Wong 2011] while other studies have
not shown this association [Andruchow 2012]. It would follow logically then, that meaningful
malpractice reform might decrease the number of unnecessary imaging studies. However, a
recent study found this not to be the case: states with recently passed tort reform have not
seen a significant decrease in imaging studies ordered by emergency physicians [Waxman
2014]. It should be noted, however, that this was a single study with only seven years of followup (notable because an Institute of Medicine report points out that it takes an average of 17
years for new knowledge to reach the bedside) [IOM Quality-Chasm. March 2001].
Furthermore, certain physician personality traits (e.g. stress from uncertainty and risk-tolerance
[rather than fear of litigation]) have been identified as playing a role in the decision to order
imaging studies [Pines 2009]. Future research in this area might involve mixed-methods
approaches, including structured interviews with physicians practicing pre- and post-tort
reform in order to better understand its effect on their practice. In particular, a more granular
understanding of the specific facets of tort reform that might affect practice (ease of bringing
lawsuits, caps on monetary awards, etc.) may better inform reform initiatives.
Research Question 4: How can health information technology, including electronic health
records, clinical decision support, and health-information exchanges, be used to increase
awareness, use and adherence to EBIs for ED imaging?
XXXXXXXXXXXXXXXXX
a) How can Health Information Technology (HIT) be leveraged to aid in appropriate
imaging decision-making in the ED?
b) Can clinical decision support systems (CDSS) increase uptake of evidence-based
guidance for ED imaging?
a. What barriers and facilitators affect use of EHRs to promote improved imaging
decision-making in ED practice (institutional, financial, policy, opinion leaders)?
b. Can EBG in EHRs be used to de-implement inefficient or ineffective diagnostic
imaging practice behavior?
c. How can EBGs best be integrated in EHRs to allow for maximal adoption and
maintenance of use?
c) What other components of EHR and HIE decrease (or increase) image ordering?
a. What data can health informatics deliver to clinicians real-time or post-care to
improve diagnostic imaging efficiency?
b) What factors promote or inhibit uptake of HIT to guide ED imaging at the level of the
individual clinician, department, hospital, and healthcare system
c) Since real-world bedside care is often fluid, frequently interrupted, and responsive to
changing levels of ancillary information, what outcomes can HIT hope to improve?
d) What are the unintended consequences of promoting HIT to facilitate “improved”
image decision-making?
a. What are the unintended consequences of increased data to clinicians?
e) What role does Radiology serve in developing, implementing, and monitoring order
sets?
a. Who will define diagnostic imaging efficiency and will this be a retrospective
definition
Health information technology (HIT) has the potential to improve quality and efficiency while also
increasing observance of care guidelines and decreasing errors.1 Electronic health records (EHR) are
expected to improve care, advance safety and decrease costs. 2-4 Clinical decision support systems
(CDSS), computerized provider order entry (CPOE) and health information exchanges (HIE) are
considered to be some of the most vital aspects of EHRs and HIT5, and have strong roles to play
concerning decision-making in the ED. A recent decrease in the utilization of certain imaging modalities
is attributed to improved adherence to clinical practice guidelines and implementation of HIT
interventions9,10.
CDSS’ are designed to improve provider decisions. When well designed and implemented, CDSS can
improve patient safety, clinical workflow, guideline adherence and quality of care. 1,11-18 Evidence
suggests that CDSS may also decrease malpractice events. 19 CDSS are expected to reduce unnecessary
imaging by providing guidelines and appropriateness criteria for imaging. 20,21 Adherence to imaging
guidelines is associated with more appropriate diagnostic imaging usage,22-24 and evidence supports the
superiority of electronic CDSS to paper.25,26
Raja et al demonstrated that a CDSS intervention decreased the inappropriate use of CT in patients with
suspected pulmonary emboli.27 Another study demonstrated a reduction in unnecessary head CTs and
improved adherence to guidelines in mild traumatic brain injury. 28
Despite the positive qualities of CDSS, some research demonstrates a low rate of adjustment of
behavior. Curry et al found that 24% of imaging studies in the primary care setting were identified as
inappropriate by a CDSS system with integrated best-practice prompting. Of these, only 25% of the
orders were modified to follow practice guidelines. Workflow integration was cited as the main issue in
compliance with the CDSS prompting; 35 appropriate integration into workflow is of the utmost
importance for successful adoption.36
1. To provide a fluid workflow, we propose research that studies the best ways to
integrate imaging CDSS into the EHR. At what time in order entry should evidencebased criteria be requested? Should links to guidelines or forced data entry be
integrated? Case-based simulation and usability testing of CDSS systems should be
undertaken with major HER vendors.
2. We propose research to create defined rules engines for CDSS alert firing, specific to
individual EBI adherence based on information provided by the clinician and
supplemented by data in the EHR.
3. We propose further evaluations of the roles CDSS can play in reducing cost and
improving safety while also reducing risk to providers of malpractice claims.
Some studies demonstrate successful integration of audit and feedback in ED imaging interventions.
9,37,38
However, there is a lack of research on adoption and usage of CDSS.39,40 Given that CDSS allows for
physician deviation from practice guidelines, there are few studies that monitor modification of
physician behavior.39,41 Much of the literature examines the adherence to the guideline or the adoption
of the CDSS, but few studies examine long-term outcomes of both the intervention and adherence.
4. We propose more research monitoring not only physician utilization of guidelines
through CDSS but also research focusing on long-term adherence and patient
outcomes.
Computerized provider order entry (CPOE) has the potential to reduce errors associated with paperbased ordering systems.5 The provisions of accurate and relevant clinical information have been shown
to improve the accuracy of radiologic interpretations.42-44 CPOE systems have been shown to improve
communication between emergency physicians and radiologists, and improve billing and
reimbursement,45 though some studies have shown an increase in radiology testing in the ED after CPOE
implementation. 46
HIT systems have the capacity to provide alerts to providers when they order duplicate examinations.
O’Connor et al demonstrated a 23% relative change in dropped CT scan orders after integrating a system
of alerts for the same radiology study performed within 90 days.29
An added benefit of CPOE is the ability to monitor wrong-patient ordering. Green et al demonstrated
that up to 15% of diagnostic tests ordered on the wrong patient were radiology studies, and integration
of an alerting system resulted in a post-intervention reduction of 30% overall.47
5. We propose further research into CPOE, including time and safety analysis as well as
ways to further improve communication between emergency physicians and
radiologists at the time of order entry.
In addition to improving imaging utilization at the time of order entry, HIT integration is also expected to
improve follow up, with alerting systems integrated into EHR that can provide details of abnormal and
emergent findings on radiology studies. However, it has been demonstrated that some of these alerts
do not receive appropriate actions, and lack of follow-up can lead to important changes in clinical
outcomes.48
6. We propose further long-term analysis of EHR-mediated alerts of abnormal findings
on medical imaging, with retrospective reviews of missed diagnoses and prospective
analysis of alerts and interventions.
While EHRs are capable of reducing duplicate testing in a single institution, patients who visit multiple
clinical settings run the risk of missing clinical data from their previous encounters. 30-32 Health
information exchange (HIE) creates interoperability between healthcare systems,5 and with this comes
many expected potential benefits including reductions in cost and improvements in quality and safety.4955
HIE has been shown to reduce unnecessary testing55-57 and there is some evidence that it may reduce
unnecessary imaging studies.52,53 Reductions in cost from decreased medical imaging and other tests is
projected to be substantial. 58 However, few studies have examined the rate at which unnecessary
duplicative imaging studies are being performed across an HIE.
1. We propose research to assess what are the best technical approaches to
integrating HIE-based imaging data into EHR systems. Imaging specific CDSS that
utilizes HIE-based imaging data should be evaluated with EHR vendors.
2. We propose research which attempts to define the problem of how often
unnecessary duplicative imaging studies are performed across an HIE with large
retrospective observational analyses.
Despite the expected benefits, many barriers to full utilization of HIE exist to improve imaging
utilization. Though it is possible to map proprietary institutional imaging codes to a common
standardized terminology, such as the Logical Observation Identifiers Names and Codes (LOINC) and the
Radiological Society of North America’s Radiology Lexicon (RadLEX) 34,59, this is often not done in an HIE
making measurement across institutions impossible.
3. We propose research to determine the feasibility and reliability of mapping
proprietary imaging codes to a standard, and development of automated processes
for mapping to promote adoption.
4. To compare imaging of similar anatomical regions across an HIE we propose
research which focuses on development of a semantic anatomical ontology to
determine if prior similar imaging can reduce unnecessary duplicate testing.
5. What additional factors such as time between studies and indication for imaging
should affect alert firing for potentially avoidable duplicate studies across and HIE?
6. With the integration of HIE-linked alert systems for potentially avoidable duplicate
studies, should the presence of prior studies be quantified? Should cumulative
radiation dose be calculated? Are there unintended consequences of implementing
these types of systems? Additional case-based testing with HIE-integrated alerting
systems should be pursued with EHR vendors.
While evidence suggests that HIT can improve imaging utilization there are many barriers to complete
integration and use. Physician knowledge and familiarity with guidelines affect usage.5 It has been
established that physicians routinely do not follow guidelines even when they are aware of them.60
Researchers have further suggested that those who do not follow CDSS may be less likely to follow
guidelines overall.61 An overall lack of established practice and imaging guidelines leads to an inability to
create adoptable and integrated CDSS5, and ambiguous elements of guidelines are difficult to implement
into electronic systems.65
While the goal of medical imaging HIT is to aid in appropriate utilization in the ED, unintended
consequences do exist. Although CDS can improve adherence to guidelines, this can lead to unexpected
results. The American Headache Society and American College of Radiology both make Choosing Wisely
recommendations to avoid neuroimaging in patients with stable or uncomplicated headaches.66,67
However Hawasli et al found in a small retrospective review that between 3% and 7% of the patients
they studied might have had a delayed or missed diagnosis of brain tumor if these guidelines had been
adhered to. 68
CPOE systems are designed to improve order entry, however a consequence of this is increased time
involved in order entry.69 This may however be offset by further detailed information available at the
point of care.69,70 Additional unintended consequences of CPOE include: new or more work involved in
order entry, negative effects on workflow, requirements for the implementation and upkeep of new
systems, changes in the way physicians communicate, new kinds of errors including omissions, wrong
patient orders and desensitization to alerts, and a new dependence on technology with poor
productivity during downtime.70
There are additional concerns regarding EHR safety. Errors in software configuration and updates as
well as untrained staff can lead to hardware and software failures as well as workflow disruption.
Additionally, miscommunication between systems can lead to errors such as incorrect imaging studies
being displayed for a specific patient in the EHR. 71
Overall, emergency physicians view overutilization of diagnostic imaging as a problem and are interested
in clinical decision support to reduce unnecessary imaging. 72 HIT has been shown to improve adherence
to multiple clinical decision instruments and guidelines.5 As the cost of healthcare continues to rise,
there is a need for increasing the speed of knowledge translation to improve quality while containing
costs. HIT is expected to be an asset.73 Future research should further monitor the effects of HIT on
physician’s decisions and usage.63 Cooperation between those providing care, creating policies and
managing information systems will be necessary to allow for successful workflow integration.73
Conclusion
The recent rise in ED diagnostic imaging rates combined with lack of evidence to suggest an
associated improvement in clinical outcomes suggests that there exists a large potential for
optimizing imaging utilization. Given the robust body of evidence which exists to aid clinicians
in appropriate image ordering, it is critical to address its dissemination and implementation. In
this manuscript, we have complied and discussed four key research questions we believe are
essential to moving this field forward to determine how we can use evidence-based
interventions to decrease unnecessary imaging while delivering safe, high-quality care to our ED
patients.
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