Use of Imaging Appropriateness Criteria for Decision Support During Radiology Order Entry: The MGH Experience

Abstract

This chapter will focus on the institutional perspective of The Massachusetts General Hospital (MGH) in Boston during the first decade of the twenty-first century. We will describe the MGH experience with design, implementation, adoption and current use of a computerized radiology order entry system that displays explicit normative “appropriateness scores” for outpatient CT, MR, and nuclear cardiology procedures and is embedded in routine clinical workflow. The radiology order entry (ROE) and decision support (DS) system has come to be known as ROE-DS within MGH and among a broader community of US radiologists, various industry stakeholders, and policy makers working in the field. One key point that will be emphasized is that a system like ROE-DS in wide use is a necessary, though by no means sufficient, first step in executing comprehensive institutional programs of imaging utilization management, quality improvement, and radiation dose mitigation.

The chapter will take the form of a historical narrative with emphasis on the following aspects over time: external stakeholders (payers, patients), internal stakeholders (physician’s organization cost and quality management), service providers (radiology informatics, radiology leadership), and users (referring clinicians). Historical periods covered include time leading up to decision to create ROE-DS (up to 2003), planning and architecture (2003–2004), implementation and deployment (2004–2005), refinement and evaluation (2005-present), and future directions. Prior to telling the story of ROE-DS at MGH, it is useful to briefly describe a broader historical context about the concepts of utilization variation and appropriateness, the RAND/UCLA Appropriateness Methodology, and the ACR Appropriateness Criteria for diagnostic imaging.