The EU Council Directive 2013/59/Euratom states in article 58c that referral guidelines for medical imaging,
taking into account radiation doses,
shall be available to referring physicians by February 2018 in all member states.
Currently clinical decision support (CDS) for referral physicians does not exist in Sweden.
The main purpose of a CDS system is to improve the appropriateness and justification of referrals for radiological procedures,
in order to reduce unnecessary radiation exposure and financial costs.
The European Society of Radiology (ESR) and its expert senior radiologists,
have adapted the American College of Radiology clinical decision support (CDS) system: ACR Select.
This European clinical support system has been named ESR iGuide.
ESR iGuide contains evidence-based and patient-tailored referral guidelines for medical imaging (exams within the fields of Radiology,
Nuclear Medicine and Clinical Physiology).
The aim is to cover 80% of the daily requests from referring physicians,
by reviewing clinical scenarios,
indications and recommendations for the topic groups breast,
cardiac,
gastrointestinal,
musculoskeletal,
neurologic,
thoracic,
urologic,
vascular and women’s imaging.
A clinical decision support system like ESR iGuide will thus help with the reduction of radiation by standardising and implementing evidence-based appropriateness criteria,
as well as meeting the EU Council Directive.
ACR Select has been implemented in many hospitals and states in the USA,
and is well integrated in leading Electronic Medical Records (EMRs).
Before the implementation of ACR Select the behaviour of the referring physicians has been mapped,
so measurements of the impact a CDS system had on the number of unnecessary exams were measured as well as the resulting cost reductions.
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Mass General Hospital had a reduction in CT examinations of 21%.
The yearly growth rate in CT exams was lowered from average 12% per year to 1% (Sistrom et al.,
2009)
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The state of Minnesota (population 5,3 M) lowered its healthcare spending over 3 years with 168 M$ (ICSI,
white paper accessed online 2017).
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It has also been shown in studies in USA that the implementation of CDS decreased the time for the referrers to order the appropriate exam,
as well as for the radiologist to judge the appropriateness of the exams.
The ESR guidelines have been incorporated in ESR iGuide and therefore can be integrated into the electronic medical journals and electronic referral systems to make the guidelines available at the point of ordering in the form of a simple scoring tool (1..9).
The electronic format makes it easier for the referral physicians to use,
and,
as the system resides in the European cloud,
new guidelines are available instantly to all referrers.
It will also be possible to monitor referral behaviour,
which will help identify physicians that need more training as well as being a tool for the Healthcare Regions in Sweden to establish their true needs for radiological equipment.
The ESR iGuide system from the ESR is currently piloted in several countries in Europe and the Middle East.
In Sweden,
it has been endorsed by the Swedish Society of Radiology (SFMR) and Swedish College of General Practitioners (SFAM).
Several healthcare regions and counties are interested in ESR iGuide,
and the region Jönköping county is implementing a pilot project,
to reduce the number of unnecessary exams as quickly as possible,
as well as to facilitate implementations of a CDS system in the rest of the country.
The purpose of the CDS system testing is to evaluate a CDS system,
ESR iGuide,
in order to study:
- If there are any changes in the behaviour of referring physicians in prescribing diagnostic examinations when using ESR iGuide.
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If there is a time increase or decrease for referring physicians when requesting exams via ESR iGuide.
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The overall potential to decrease the total Swedish population radiation dose,
by decreasing unnecessary radiological exams.
Specifically for this poster,
the purpose is to describe how to implement a CDS pilot in the Swedish healthcare environment,
and how to facilitate implementations elsewhere in Swedish and Nordic healthcare systems.