Guiding principles:10 guidelines for developing clinical decision support programs

In light of a national effort to optimize high-cost medical imaging, a newly published article offers 10 guidelines for effective clinical decision support (CDS) in diagnostic imaging.

Looking to improve quality and reduce waste in imaging across the country, Ramin Khorasani, MD, MPH, of Brigham and Women’s Hospital in Boston, and colleagues highlighted what they found to be the most effective and efficient methods in CDS in radiology and published their suggestions this month in the American Journal Roentgenology.

The commandments include:

• Effective Imaging CDS Should Be Viewed as a Multidisciplinary Clinical Program Rather Than an Information Technology Initiative

An effective imaging CDS program requires leadership to manage change and requires resources beyond health IT to establish structure and processes to set clinical goals.

• The Strength of Evidence Supporting the Clinical Actions and Recommendations Embedded in Imaging CDS Must Be Transparent to the User at the Time of Order Entry

Korasani and colleagues believe providers are more likely to accept a recommendation when they are given the ability to evaluate its strength. Additionally, the clinical reasoning underlying each CDS recommendation should be presented and made available to stakeholders.

• Sources of Evidence Embedded in Imaging CDS Must Be Diverse

Evidence is available from a range of sources including various professional society guidelines, peer-reviewed publications, and other evidence-based practice.

• Evidence Must Be Current

Evidence that is either no longer applicable or missing key new discoveries harms its clinical validity and may lead to suboptimal patient care.

• Clinical Recommendations and Assessments Embedded in Imaging CDS Must Be Brief, Unambiguous, and Actionable

Providers are busy and the use of ambiguous or elaborate language to communicate recommendations can confuse and frustrate them while decreasing system effectiveness.

• Respect Ordering Provider Work Flow

Avoid unnecessary input work on behalf of the provider—rid programs of unnecessary screens, interface and mouse clicks.

• Establishing Consequences for Ignoring CDS Recommendations Will Enhance the Impact of Imaging CDS as Education Alone

In its purest sense, clinical decision support is real-time education through presentation of evidence at the point of care, despite various responses from physicians to the same piece of evidence. The authors suggest consequences for ignoring CDS recommendations.

• Imaging CDS Initiatives That Target Well-Defined Clinical Performance Gaps Are More Likely to Be Effective

Improvement initiatives are more likely to be effective when targeting specific clinical presentations and care settings where strong, high-quality evidence exists.

• Imaging CDS Must Enable Measurement of Its Impact

Metrics can be used to track the effectiveness of CDS initiatives and thse measures can create a broad measure of adherence.

• Position Imaging CDS to Improve Work-Flow Efficiencies for Patients, Providers, and Payers

Khorasani and team suggest identifying performance gaps and creating value using imaging decision support initiatives to promote its use. They believe creating work-flow efficiencies whenever possible will help encourage and facilitate use of imaging clinical decision supports.

Khorasani and colleagues wrote that the 10 commandments presented in the paper represent their shared experiences in creating effective CDS initiatives and stress that many challenges remain for such programs. But to the authors, the benefits of CDS are well worth the effort.

"[T]he principles that we have described here should facilitate the adoption of effective imaging CDS to improve quality and reduce waste in our health care system,” they wrote.