During my residency only a little bit more than 14 years ago, I can still remember grabbing a ream of sheets from the bin to check the day’s CT protocols. We would quickly read through each one to make sure that the appropriate test was indicated as was ordered by the referring physician. Somehow, I think this process is currently an anachronism at many radiology residency programs. The pressure to complete studies in rapid fashion have changed the way things are done. It seems almost all the cases come directly from either the emergency room or from the referring physician directly to the scanner. No longer is the resident an intermediary in the process (a potential delay in the system). Instead, there is a corresponding increase in tests with incorrect indications and/or wrong technique, only to increase radiation dosages and the cost to the system. The ordering physicians, not the imaging experts, have hijacked what should be the domain of the radiologist: to decide if imaging examinations are appropriate.
Why do I bring this topic to our attention? First and foremost, of course, patient care suffers. But also, as today’s topic implies, it also affects the education of the radiology resident. So how do we get control back over the reins of imaging from a standpoint of improving resident education? Initially, we have to understand the role of protocols in the education of the radiology resident. And then, I will briefly discuss what imaging clinical decision support systems are and how clinical decision support systems can potentially enhance the education of residents as well as the appropriate use of imaging.
Protocols And Educational Implications For The Radiology Resident
One of the most important roles of radiologist is to be a consultant for the appropriate use of imaging. As I described above, the process of checking protocols significantly enhanced my knowledge on this topic. What may have seemed at the time as a questionable activity bordering on scut, I now see as invaluable. Related to my prior experience with protocoling CT scan studies, I now understand when contrast should be administered, how certain studies are typically performed, and most importantly, what are good indications for a study to be completed. At many programs, this educational opportunity is no longer available due to financial and political pressures upon radiology departments to get through the system. Any study ordered must get done in a timely fashion, no matter whether the study is indicated or not! It only matters that it was ordered. Correspondingly, resident involvement in this process has significantly decreased over time.
So, how does removing this educational opportunity for radiology residents change the knowledge base of the radiology resident? First of all, you are taking away important practical knowledge that can reduce the value of new radiologists as a consultant for determining appropriateness of individual imaging studies. Second, new radiologists will be less likely to understand how to tailor individual studies to the indications of the ordering physician. And finally, the potential implications of issues like when to use intravenous contrast can be underestimated, both from a contrast complication and an appropriate indication point of view. So herein lies the potential savior to return the educational opportunities of protocoling back to the radiology resident- The Clinical Decision Support System!
The Clinical Decision Support System
Here is the definition of clinical decision support systems according to the government– “Clinical decision support (CDS) provides clinicians, staff, patients or other individuals with knowledge and person-specific information, intelligently filtered or presented at appropriate times, to enhance health and health care. CDS encompasses a variety of tools to enhance decision-making in the clinical workflow. These tools include computerized alerts and reminders to care providers and patients; clinical guidelines; condition-specific order sets; focused patient data reports and summaries; documentation templates; diagnostic support, and contextually relevant reference information, among other tools.”
In terms of imaging, the potential implications of a clinical decision support system from a cost and educational standpoint are myriad. No longer are all imaging studies going to be ordered without the approval a computerized system. When can this potentially occur? How would the radiology resident role going to be affected by the implementation of such systems? Let’s talk about both of these questions…
Institution of Clinical Decision Support Systems And The Potential Effect Upon The Radiology Resident
At first, institution of electronic clinical decision support systems were going to be mandatory as January 1, 2017. The date was subsequently changed to January 1, 2018. We will see if this date is going to be the finalized implementation deadline.
But let’s say that a good quality clinical decision support system became mandatory at all institutions for ordering imaging studies at the beginning of 2018. How would that affect the residents? First thing that would you notice, bogus indicated studies would all of a sudden significantly decrease dramatically. The system should theoretically block anything that has a questionable indication from getting through from the clinician order to actual practice. Second, there could potentially be a flood of phone calls. Since any study with a questionable indication or a complex protocol would not be able to get through the system, instead, clinicians would be forced to ask the radiologist what kind of protocol should be implemented for these cases. Not only would this be a boon for patient safety (decreased radiation dosages) and appropriateness of imaging, clinical decision support systems can actually bring the control of image ordering back to the radiologist. More specifically, a good quality clinical decision support system can theoretically allow the radiology resident to protocol examinations appropriately in concert with the ordering physician and tailor examinations to the indication that is needed. Resident protocol education can be restored!!!
Interestingly, a clinical decision support system for imaging was actually one of the few parts of the health care bill that actually had the potential to decrease costs and quality of care in addition to improving resident educational experiences. Ironically of course, it may never be implemented depending upon how the political situation in Washington affects health care.
Clinical Decision Support Systems For Imaging Can Be The Resident Radiologist’s Best Friend
In summary, clinical decision support systems have the potential to be one of the true benefits to the health care system, in terms of costs and quality of care. But, one of the most overlooked implications is actually the potential educational benefits to the radiology resident. No longer would ordering be in the hands of untrained ordering physicians. Instead, control will again lie in the hands of the radiology resident allowing him/her to protocol patients once again appropriately and giving the radiology resident the education he/she needs to become a true imaging expert.
