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LIVE FROM RSNA: At Massachusetts General, an Assertive Push into CDS for Radiologists

December 1, 2015
by Mark Hagland
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Dr. Tarik Alkasab is helping to lead a highly innovative CDS initiative at Massachusetts General Hospital
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At Massachusetts General Hospital in Boston, Tarik Alkasab, M.D., Ph.D., service chief for Informatics /IT and Operations, and a practicing radiologist, is helping to lead an important initiative around establishing and expanding a menu of clinical decision support offerings intended to help radiologists at the very busy hospital, which performs nearly one million radiological studies a year, and whose medical staff includes 200 radiologists—about 120 attendings, about 30 residents, and about 50 fellows. Alkasab spoke with HCI Editor-in-Chief Mark Hagland on Tuesday at the McCormick Place Convention Center in Chicago, during the RSNA Conference, sponsored by the Radiological Society of North America. He and his colleagues are using a solution created by the Burlington, Mass.-based Nuance Communications, in collaboration with the National Decision Support Company (NDSC).

As the press release, issued on Monday, Nov. 30, notes, “By leveraging ACR Select™, nationally-recognized Appropriate Use Criteria (AUC) published by the American College of Radiology and exclusively licensed by NDSC, physicians are guided to order the most clinically-appropriate exam for a patient while working within their native electronic health record (EHR) workflow. ACR Select, which is widely deployed and integrated with major EHRs, is used by physicians nearly one million times per month when seeking clinically-validated imaging guidance when ordering exams. This helps healthcare providers comply with federal law that will require physicians to consult qualified decision support criteria when ordering Medicare outpatient advanced imaging exams.”

Tarik Alkasab, M.D., Ph. in the Nuance Communications booth at RSNA15

Below are excerpts from Hagland’s interview with Dr. Alkasab.

Let’s begin by talking about the clinical and organizational context around your and your colleagues’ work in this area.

Yes, certainly. We have a staff of about 200 radiologists altogether, and do nearly a million studies a year. In that context, creating high-quality, low-variability processes is a challenge. We have so many modality machines. And obviously, we’re managing a number of external imaging sites as well. I spend, and the leadership spends, an enormous amount of time thinking about variability—how to manage variability, how to reduce variability.

What kinds of variability are involved?

It’s everything—setting people up to do the right study is complicated in its own right, and we’ve been one of the pioneers in creating decision support for ordering physicians. We also have systems in place to make sure that we do a particular type of study in a consistent way. Beyond that, the reporting process, in terms of how the radiologist handles the process, is next. One of the things that comes up all the time for a radiologist is seeing a nodule in a lung or a patient’s adrenal gland, in a CT, or possibly an MR. The question for the radiologist is—usually, three’s a follow-up imaging study that a radiologist would recommend. It’s unlikely that these things are significant, but if you found out a couple of months later that the nodule is growing, that would be an important finding.

And you are hoping that radiologists who follow the guidelines will become more consistent clinically?

Yes, we want to help the radiologists following the guidelines. There are dozens now. And because the imaging studies we do see so much, there are all kinds of clinical scenarios that might take place from a particular type of study. Looking at abdomen and chest CTs for a day, you’ll probably come across 5 or 6 pulmonary nodules, 1 or 2 adrenal nodules, something in a pancreas, something in a liver, and they should be saying something consistent in what they’re saying and in what a colleague might say tomorrow, reading those same CTs.

The thing is, as physicians, you weren’t trained to necessarily be consistent with standardized norms, correct? Historically, traditional medical school training has focused on physician judgment at the point of diagnosis, in purely individual situations.

Yes.  It is still important for radiologists to carefully consider the clinical context and the individuality of patients. And one of the most valuable things a radiologist can ask is the “what else can it be?” question. That’s one of the most valuable things we do. But the things that we’re talking about tend to be sort of routine, incidental things, and there tends to be a routine way of handling these things. And if guidelines apply, it’s best for the radiologist to use the guidelines; it’s simpler for everyone to understand. And legally, it creates kind of a safe harbor for them, by following a clear standard of care, which is an advantage. And as things get more consistent, it’s easier for the people to have to do the follow-up to have confidence in the recommendations, as opposed to off-the-cuff recommendations, which can introduce ambiguity.

Has there been any resistance among the radiologists at Mass General to becoming more standardized in their practice patterns?