New research published in the issue of JAMA Internal Medicine has demonstrated how the electronic health record could be used as a performance coach to help physicians improve patient care. The electronic health record develops real-time performance metrics, and then use these metrics to target interventions based on the electronic record, such as decision support tools and peer comparisons toward individual clinicians.
Unnecessary diagnostic imaging is a prevalent form of medical overuse and leads to unnecessary invasive procedures, radiation exposure, emotional stress, and nosocomial infection. The researchers have focused on how to identify clinicians who are more likely to overuse diagnostic imaging and how to intervene. For example, studies have identified the number of magnetic resonance images (MRIs) that physicians ordered for uncomplicated low back pain and the number of antibiotic prescriptions for upper respiratory tract infections.
The researchers consider the overuse of computed tomographic pulmonary angiography (CTPA) in the diagnosis of pulmonary embolism. They report on the use of “diagnostic yield” (the number of positive studies/total number of studies ordered) as a metric to help identify overuse. These results are in accord with other research showing that a large number of CT scans are being performed in low-risk patients, and suggest that diagnostic imaging is being disproportionately ordered by a select group of clinicians.
Low diagnostic yield can help identify physicians who may be ordering too many CTPAs in low-risk patients. It is important to note, however, that a high diagnostic yield implies that a provider may only be ordering CTPA for the highest-risk patients, thus potentially missing the diagnosis of pulmonary embolism in some. Even in situations where there is inadequate evidence to calculate an expected diagnostic yield, the mean diagnostic yield from a large group of physicians might suggest a reasonable starting point for analysis.
One possibility is to use the electronic health record to develop real-time performance metrics, and then to use these metrics to target interventions based on the electronic record, such as decision support tools and peer comparisons toward individual clinicians. Electronic medical record platforms are sophisticated enough to keep a running calculation of a range of quality metrics per physician, such as dollars spent per diagnosis, and trends in the prescription of various analgesic classes over time.
The clinical data can then be used to provide personalized support to clinicians who are either outliers among their peers or whose metrics are far from the expected value. As a metric for appropriate use of imaging technologies, diagnostic yield has limits. The use of sensitive imaging modalities may result in high numbers of incidental findings that increase diagnostic yield and the cost of care without affecting clinical outcomes. This is the case with the use of carotid ultrasound in the initial workup of syncope, an established form of medical overuse.
In patients with uncomplicated musculoskeletal pain, imaging findings are often poorly correlated with clinical outcomes. Thus, the meaning of a high diagnostic yield would be unclear. However, the study is thought provoking, and demonstrates how the electronic health record can be used as a performance coach to help physicians improve patient care.