ACR Bulletin

Covering topics relevant to the practice of radiology

Circling the Wagons for CDS

One health system changed CDS from a top-down mandate to a team-based, patient-centered goal.
Jump to Article

I’ve learned that having systems for quality improvements like CDS not only makes us more efficient, but it keeps us up to date on the highest quality care for our patients.

—Kirsten Meisinger, MD
November 15, 2018

When Cambridge Health Alliance (CHA) set out to introduce clinical decision support (CDS), leaders carefully planned the logistics for its implementation. However, they also started early, getting buy-in from referring clinicians and radiologists — the ones who would actually be using the tools. Two CHA physicians (one radiologist and one family medicine physician) explain how it all came together and how CDS benefits both patients and clinicians.

Carol A. Hulka, MD
Chief of Radiology

CHA is a vibrant safety net system in the Boston area with an extensive ambulatory primary and specialty care network of community-based providers and two hospitals. In 2016, we took our first steps toward implementing CDS for imaging ordering. While our provider community already had a very low rate of ordering advanced imaging studies and excellent quality metrics for appropriate imaging ordering, we recognized there were still opportunities to reduce costs and enhance efficient decision-making for imaging order entry. We also knew CMS was moving toward requiring CDS as part of PAMA.

We selected our CDS vendor after first identifying best practices locally and confirming we met all CMS requirements. We then assembled a multidisciplinary team to meet regularly with the vendor team to work through various configurations of their CDS product prior to implementation.

Our implementation team included radiology department members, the chief of surgery, chief of emergency medicine, chief medical informatics officer (who is also a family physician), and the IT team.

—Carol A. Hulka, MD

We worked on configuring tailored study lists and common clinical indications for various departments. Our IT team worked with stakeholders and the vendor to streamline workflow and minimize the number of clicks for the ordering provider.

In the summer of 2017, prior to implementation, radiology department members and IT met with numerous departments to demonstrate the CDS-enabled workflow. We highlighted the potential benefits of CDS not only in reduction of low-value imaging but also to improve patient experience of care (by avoiding unnecessary procedures and radiation exposure, last-minute imaging orders, and potential follow-up clinic cancellations). The team delivered many online presentations, which most providers found very helpful.

Working with our vendor team to provide in-person and web-based demonstrations and explanations of the tool, how it works in practice, how clinicians gain confidence in decision-making with access to the evidence, and how much autonomy clinicians continue to have using CDS — all of this helped our implementation go much smoother when it was rolled out in February of 2018.

Kirsten Meisinger, MD
Family Medicine Physician and President of Medical Staff

So how did this feel to a practicing family physician who was not part of the implementation team? CHA has a rigorous system of provider and staff education for both ongoing training needs and new initiatives, so I felt very supported. All sites meet monthly to review training needs and provide valuable feedback to the teams implementing change across the organization.

Our baseline low level of imaging ordering meant that feedback took a while, but any questions or needed changes happened quickly and respectfully. The challenges I experienced were along the lines of what a practicing provider deals with every day: trying to think through something in the exam room while the patient is there or leaving it until later. CDS slowed me down enough to allow me to think through the imaging order in the room with guidance about which was the best test. Within a few months, we all started to notice improvements in our ordering habits (for example, is that CT with and without contrast or just with or without?) and efficiencies when we no longer had to call a radiologist to ask those questions.

During my time as a national faculty coach for CMS’s Transforming Clinical Practice initiative (TCPi), I’ve learned that having systems for quality improvements like CDS not only makes us more efficient, but it keeps us up to date on the highest quality care for our patients. Having the American Board of Family Medicine and the ACR teams also participating in TCPi as two of the ten Support and Alignment Networks has helped us surface and now disseminate best practices like these to our family medicine and radiology colleagues. This is especially important as PAMA goes into effect in January of 2020.