Implementing an evidence-based decision support tool to reduce inappropriate medical imaging services

An ‘on-line’ evidence-based decision support tool called Diagnostic Imaging Pathways (DIP) was developed at Royal Perth Hospital (RPH) to assist clinicians request the most appropriate examinations to achieve a diagnosis. DIP is accessed from the ‘desk-top’ and the Internet (www.imagingpathways.health.wa.gov.au). Clinicians at RPH are regularly alerted to DIP recommendations at the ‘Grand Round’, in medical newsletters and in the orientation and induction of junior doctors. In the current study retrospective audits targeting four pathways were carried out on referrals from the Emergency Department (ED) over defined periods. Request forms and medical records were reviewed and the proportion of patients receiving non-compliant examinations was documented. Interventions included targeted education of ED clinicians on DIP recommendations, introduction of request forms requiring ‘proof’ of adherence to pathways, and refusal of inappropriate requests. A second audit measured the impact of the interventions. In the initial audits (N=638), there were 347 (54%) incidences of non-compliance with the recommended pathways. In the re-audits (N=432), inappropriate incidences were 132 (31%). Active ‘marketing’ and targeted interventions improved compliance but did not eliminate inappropriate imaging. Requesters failed to follow recommendations and imaging specialists failed in their ‘gatekeeper’ function for many reasons. DIP needs to be embedded in the clinical decision workflow if maximum and sustained reductions of inappropriate imaging are to be achieved. The best approach is to convert the current paper-based referral processes to an electronic process (Electronic Order Entry - EOE) and to progressively link EOE to decision support afforded by DIP