Schneider Erika, Zelenka Stacy, Grooff Paul, Alexa Dan, Bullen Jennifer, Obuchowski Nancy A
Imaging Institute, Cleveland Clinic Foundation, Cleveland, Ohio.
Imaging Institute, Cleveland Clinic Foundation, Cleveland, Ohio.
J Am Coll Radiol. 2015 Apr;12(4):349-57. doi: 10.1016/j.jacr.2014.12.005.
The goal of the study was to determine the effects of guideline implementation strategy using 2 commercial radiology clinical decision support (CDS) systems.
The appropriateness and insurance dispositions of MRI and CT orders were evaluated using the Medicalis SmartReq and Nuance RadPort CDS systems during 2 different 3-month periods. Logistic regression was used to compare these outcomes between the 2 systems, after adjusting for patient-mix differences.
Approximately 2,000 consecutive outpatient MRI and CT orders were evaluated over 2 periods of 3 months each. Medicalis scored 60% of exams as "indeterminate" (insufficient information) or "not validated" (no guidelines). Excluding these cases, Nuance scored significantly more exams as appropriate than did Medicalis (80% versus 51%, P < .001) and predicted insurance outcome significantly more often (76% versus 58%, P < .001). Only when the Medicalis "indeterminate" and "not validated" categories were combined with the high- or moderate-utility categories did the 2 CDS systems have similar performance. Overall, 19% of examinations with low-utility ratings were reimbursed. Conversely, 0.8% of examinations with high- or moderate-utility ratings were denied reimbursement.
The chief difference between the 2 CDS systems, and the strongest influence on outcomes, was how exams without relevant guidelines or with insufficient information were handled. Nuance augmented published guidelines with clinical best practice; Medicalis requested additional information utilizing pop-up windows. Thus, guideline implementation choices contributed to decision making and outcomes. User interface, specifically, the number of screens and completeness of indication choices, controlled CDS interactions and, coupled with guidance implementation, influenced willingness to use the CDS system.
本研究的目的是确定使用两种商业放射学临床决策支持（CDS）系统的指南实施策略的效果。
在两个不同的3个月期间，使用Medicalis SmartReq和Nuance RadPort CDS系统评估MRI和CT检查单的适宜性和保险处理情况。在调整患者组合差异后，使用逻辑回归比较这两种系统的这些结果。
在两个为期3个月的时间段内，共评估了约2000例连续的门诊MRI和CT检查单。Medicalis将60%的检查评为“不确定”（信息不足）或“未验证”（无指南）。排除这些病例后，Nuance将更多的检查评为适宜，高于Medicalis（80%对51%，P<.001），并且更频繁地预测保险结果（76%对58%，P<.001）。只有当Medicalis的“不确定”和“未验证”类别与高效用或中等效用类别合并时，这两种CDS系统才具有相似的性能。总体而言，19%的低效用评级检查获得了报销。相反，0.8%的高效用或中等效用评级检查被拒绝报销。
这两种CDS系统的主要差异以及对结果的最强影响在于如何处理没有相关指南或信息不足的检查。Nuance用临床最佳实践扩充了已发表的指南；Medicalis利用弹出窗口要求提供更多信息。因此，指南实施选择有助于决策和结果。用户界面，特别是屏幕数量和适应症选择的完整性，控制了CDS交互，并且与指南实施相结合，影响了使用CDS系统的意愿。
