NYGH deploys clinical decision support for DI

TORONTO – To improve the ordering of diagnostic imaging exams, North York General Hospital has implemented one of Canada’s first “clinical decision support” systems that quickly shows referring physicians what the best options are for imaging their patients.

“The CDS tool is a continuation of what we’ve already been doing with Choosing Wisely. We’re leaders there too,” said Dr. Ryan Margau, chief and medical director, Medical Imaging, at North York General.

Choosing Wisely is an international program that encourages physicians to check on the appropriateness of the tests and procedures they order. The new system, however, gives doctors a tool that’s integrated into the ordering module of their electronic record system, so they’ve got a quick guide at the touch of a few buttons.

“It’s embedded into the EMR, and it helps facilitate decisions using evidence-based guidelines,” said Dr. Margau.

The Clinical Decision Support system installed by NYGH, called iRefer CDS, is from Toronto-based MedCurrent, a company launched by radiologist Dr. Stephen Herman.

Dr. Herman, a specialist in thoracic imaging at the University Health Network, created MedCurrent in 2013. As it happens, until now all of MedCurrent’s sales have been made outside of Canada – the installation at North York General is the company’s first in this country.

“We look forward to bringing the benefits we have seen in other regions to NYGH, including reducing patient exposure to radiation, optimizing clinical workflow and achieving operational cost savings,” said Dr. Herman.

The MedCurrent CDS platform embeds the latest version of iRefer, a set of internationally recognized referral guidelines from the Royal College of Radiologists in the UK, into a cloud-based offering that leverages Microsoft Azure. The platform also provides a business intelligence module and content authoring tool that allows organizations to embed various best practice guidelines, such as Choosing Wisely or iRefer, into their existing electronic workflows.

So far, the MedCurrent system has been applied to the use of MRI exams at the hospital.

Dr. Margau explained that MRI is a sophisticated modality with many nuances. It’s not just a matter of whether or not a patient should receive an MR exam, but what kind.

“There are issues of whether the exam should be contrast-enhanced, of the sequences that are used, and other factors,” he noted.

Because the system has been integrated into the Cerner electronic health record solution used at the hospital, it can automatically pull data from the EMR to determine whether the patient has conditions that should be noted. It will then provide a caution to the referring physician.

“It will customize the exam recommendation by accounting for the patient’s age, gender, kidney function, allergies, and other variables,” said Dr. Jeremy Theal, NYGH’s chief medical information officer and a gastroenterologist. “It takes all of this from the EHR.”

It can also show him or her what other DI exams the patient has had, and in this way, the doctor can avoid duplication.

Already, after just one month of usage, “providers are changing the type of MRIs they’re ordering at least 10 percent of the time,” said Dr. Margau.

As well, the MedCurrent system has prompted them to cancel their MRIs in 2 percent to 3 percent of the cases. “They’re deciding instead to do other kinds of exams, such as ultrasound,” he said.

Another advantage of the system is that it has turned MRI ordering from a paper-based process at the hospital to an electronic one. Before now, ordering for all modalities was done digitally, except for MRI.

“The message that we’re getting from the doctors is that this has been great, they no longer have to go looking for a paper form,” said Dr. Theal. “It’s a huge convenience.”

Dr. Theal said he’s heard no complaints from the ordering physicians about the switch to the decision support system for MRI. That in itself is an endorsement. “If physicians don’t like something, you hear about it,” said Dr. Theal. “Especially when you’re introducing new steps in the ordering process.”

So far at the hospital, since the iRefer CDS solution has been implemented, the majority of MRI exams have been ordered by general internists, neurologists, GI specialists and ER physicians.

Dr. Theal noted that iRefer CDS provides analytics, and can show trends and patterns for modalities, patients and physicians. If a physician’s ordering pattern seems to be an outlier, “we can have a conversation to see how to optimize their ordering practices,” he said.

It’s not meant to be a punitive issue, however, but an educational one.

In the future, the hospital plans to extend the use of the MedCurrent system to other modalities, such as CT and ultrasound. In this way, patients will receive the optimal test, with customized procedures.

NYGH also intends to extend the CDS system to outside physicians – such as family doctors – who direct their patients to the imaging department at North York General.

At the moment, the roadblock is that these physicians are using EMRs other than Cerner, such as OSCAR, Accuro or Practice Solutions. But Dr. Margau said it’s just a matter of building the integration from one system into the other.

Since clinical decision support in DI has benefits for the hospital and patients, one may wonder why more hospitals in Canada haven’t adopted the systems, especially since they’re widely used in the United States and the United Kingdom.

Dr. Theal noted that CDS requires a higher level of computerized infrastructure than is found in most Canadian hospitals.

“In Canada, we’re still below average when it comes to HIMSS EMRAM,” he said, referring to the scale that’s used to measure the level of sophistication that a hospital has, in terms of computerized equipment and software applications. The scale runs from 0 to 7, with 7 indicating a very high-performing facility.

“Unless you have electronic ordering, you can’t take advantage of this,” he said, noting that hospitals with computerized provider order entry (CPOE) are at the EMRAM 4 level or higher. Canada has a relatively small proportion of hospitals at this stage of development.

“And even those who have e-ordering are still at the early stages of their implementation,” he said. “They may be working on other priorities.”

For its part, North York General is a highly computerized hospital, and has achieved Level 6 on the EMRAM scale. It is a Canadian leader when it comes to adopting new solutions to enhance patient safety and medical outcomes, and scores highly in international surveys of top performing hospitals.

A recent Newsweek study lists NYGH as the second highest-performing hospital in Canada, just behind the University Health Network. Adopting CDS is another step on the ladder of continuous improvement.