MGH Decision-support Study: A Shot Across the RBM Bow

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A new study1 finding that radiology order-entry (ROE) and decision-support (DS) tools act to curtail utilization rates for advanced imaging is being celebrated as proof that a White House proposal to deploy radiology benefit managers (RBMs) as Medicare gatekeepers is unnecessary and ill conceived.

"This fits right into the work process of the referring physicians. It’s done in conjunction with the actual scheduling of the exam, so there’s no slowdown. Every time they order something, they get immediate feedback on the appropriateness and comparative effectiveness of what they have ordered. If there’s a more appropriate method, they see that instantly—maybe CT instead of MRI, or vice versa.”
--James H. Thrall, M


James H. Thrall, MD

James H. Thrall, MD, FACR, chair of the ACR's board of chancellors and radiologist-in-chief at Massachusetts General Hospital (MGH), Boston, says, “I think this article is an important milestone in shaping the conversation nationally. Until this, we didn’t have scientific evidence of an alternative to RBMs, but now, we have clearly demonstrated that a less intrusive and more patient-friendly option exists. That is the point-of-care–decision approach.”

The study, published this month in Radiology, describes how the use of a computerized ROE system, coupled with a DS system, effectively lowered or stabilized utilization rates for three categories of advanced imaging—CT, MRI, and ultrasound—at MGH between 2000 and 2007.

Thrall, a coauthor of the study, says that it clearly shows that an upward-trending growth line for CT at MGH flattened after a computerized DS tool was installed to guide referring physicians on the appropriateness of ordering specific imaging studies for identified conditions. The ROE and DS systems analyzed in the study were developed at MGH, Thrall says. The DS system has since been licensed to a vendor and is available commercially.

The ROE allows any physician cleared for access to order and schedule an imaging exam electronically. The imaging exam must be specified, along with the name of the patient and any patient information relevant to the exam, such as age, sex, metallic implants, pregnancy, or claustrophobia.

When the exam ordered is high in cost (a category that includes all CT and MRI exams), a DS screen automatically appears. The ordering physician must then review information about the exam before proceeding. If the referrer elects to proceed, the DS software prompts an appropriateness score. A high score would indicate appropriateness; a low score would indicate that the exam is inappropriate, in most cases. The ordering physician would then be prompted to select a more appropriate exam (that would yield a higher appropriateness score) or write an explanation of why the original exam is appropriate, after all. Live consultation with a radiologist is a further option.

According to Thrall, the DS system at MGH is built around appropriateness criteria developed by the ACR, but is structured differently. “They start with disease or condition and then go to relative appropriateness,” he says. “Ours starts with the imaging method and goes to the reason for doing the study.”

While the ACR’s criteria and the MGH DS system are complementary, the latter is more detailed. “The ACR has 300 criteria sets, which we exploded into 12,000 very granular reasons for the imaging. We want to know which of the 20 different kinds of headache we are talking about, for example.”

The Study

The ROE–DS study analyzed outpatient imaging data at MGH between the fourth quarter of 2000 and the fourth quarter of 2007. MGH rolled out its ROE system between 2001 and 2003, and in the last quarter of 2004, it integrated the DS tool. According to Thrall, all the data for the study came from the MGH RIS. Counts of diagnostic imaging exams were obtained for CT, MRI, and ultrasound for periods before and after the implementation of ROE and DS. The usage volumes and growth rates of the three modalities were then compared to see whether changes occurred after ROE and DS were implemented. The assumption was that the computerized tools would act as gatekeepers and educators to curtail inappropriate exams, lowering volumes and cutting or stabilizing growth rates for the modalities studied. That is exactly what researchers found.


For the entire length of the study, there were about 33 CT scans, 22 MRI exams, and 31 ultrasound exams per 1,000 outpatient visits. For CT, there was