Medical imaging is a cornerstone of patient care in Canada. Throughout healthcare, medical imaging procedures are relied upon to identify, diagnose, and treat disease. When requiring imaging it is imperative that patients are receiving the right test at the right time, providing the most relevant clinical value to the patient through their journey.
The Canadian Association of Radiologists (CAR) is advocating for the implementation of national electronic referral systems incorporating Clinical Decision Support (CDS) tools for medical imaging, to ensure that patients receive more timely access to imaging. Integrating CDS tools into clinical workflows across the country would help patients receive the most suitable test based on their symptoms. The goal of these systems is not only to help to reduce further backlogs for medical imaging but also provide support for referring practitioners in selecting the best imaging procedure for their patients.
The CAR with the support of the Canadian Medical Association and working with the Canadian Association of Emergency Physicians, the College of Family Physicians of Canada, the Nurse Practitioners Association of Canada, and the Society of Rural Physicians of Canada, have already embarked on a national project focused on the creation and integration of Canadian-specific diagnostic imaging referral guidelines into CDS systems. These evidence-based, peer-reviewed guidelines will be freely available to help guide healthcare professionals decision-making processes, enhance care and enable better communication among healthcare providers.
“Ensuring that patients receive the medical imaging referral that provides the most clinical value at the right time, while also reducing risks as much as possible is the goal,” said Dr. Ryan Margau, co-chair, CAR Imaging Referral Guidelines Working Group and chief and medical director, Medical Imaging, North York General Hospital. “Widespread adoption of CDS tools will allow for referring medical professionals to have access to latest evidence-based knowledge as part of their regular workflow – taking some of the unknowns out of ordering medical imaging.”
Canada is behind other industrialized countries when it comes to e-referrals underpinned by CDS. CDS systems for medical professionals referring to radiology have been implemented with considerable success in other countries. The Royal College of Radiologists in the United Kingdom has partnered with MedCurrent Corporation, a leading Canadian CDS software company, to incorporate the UK-focused radiological referral guidelines into a CDS software platform called MedCurrent iRefer CDS. This system provides UK clinicians with robust referral guidelines directly at the point-of-care.
Moreover, the National Health Service (NHS) in England has invested millions to deploy CDS throughout the country. Over the next few years, they will embark on a Digital Diagnostic Capability Program (DDCP) initiative to improve access to diagnostic services to English citizens.
In 2014, the United States Congress passed the Protecting Access to Medicare Act (PAMA) that requires referring providers to consult US-based referral criteria guidelines, in conjunction with approved CDS Systems, prior to ordering advanced diagnostic imaging services (CT, MR, Nuclear Medicine and PET) for Medicare and Medicaid patients.
While these developments have not gone unnoticed in Canada, only a few Canadian hospitals have started implementing CDS solutions. North York General Hospital, in Toronto, has implemented a MedCurrent iRefer CDS system that is integrated into the ordering module of their hospital electronic medical record (EMR) system.
The Jewish General Hospital (JGH) in Montreal has also implemented MedCurrent iReferr CDS. Dr. Huy Le, the chief of Radiology at the JGH says his institution is at Canada’s forefront of implementing CDS because of its history of integrating technology. “Dr. Lawrence Rosenberg, the CEO of our institution, had a vision for adopting digital health many years ago, which included pertinent applications in medical imaging.”
Dr. Le says this approach led JGH to successfully create an electronic Order Entry System (OES) earlier this year, now in production and testing phases with clinicians. The interfacing of CDS with the OES was done in parallel with testing and is currently functional.
Meanwhile, Alberta Health Services has integrated a CDS system, called CareSelect, which is primarily focused on CT and MRI. CareSelect is integrated with their Epic EMR, AHS’s electronic health record system and it is about two thirds of the way through provincial implementation. CareSelect relies on referral guidelines from the American College of Radiology (ACRselect) to categorize referrals as low, medium, or high value.
Dr. Bill Anderson, former Provincial medical director, AHS, says the current status of the CDS implementation is a data gathering mode; he believes this technology can be used for targeted quality improvement work. He further states that “in the future this system can incorporate active alert messages to referring physicians, which will help to guide referrals to medical imaging for patients.”
In Canada we need to look to these examples and build on the successes, identifying best practices for the development of CDS referral system for radiology. This is not limited to medical imaging. Once developed, this system could act as a blueprint for other specialties in Canada.
“Imaging referral guidelines should be collaborative non-punitive tools, designed to improve quality, safety, and relevance. Our work in bringing a CDS solution online at North York General Hospital has demonstrated the need for Canadian-specific referral guidelines. Collaboration with all stakeholders, including patients and referring providers is needed to create comprehensive Canadian guidelines, designed to improve care for Canadian patients and families,” said Dr. Margau.
It is not only radiologists who agree with this approach. Dr. Paul Pageau, co-chair, CAR Imaging Referral Guidelines Working Group and director, Point-of-Care US, Department of Emergency Medicine, The Ottawa Hospital and assistant professor, University of Ottawa says that “we need to work collaboratively with the broad spectrum of referring medical professions to make informed decisions regarding the selection of medical imaging tests and treatments. Having easily accessible Canadian guidelines will help us achieve this.”
The federal government has committed to investing $2 billion in new funding to address wait times for procedures including diagnostic imaging. This will help to increase the number of CT and MRI scanners across the country. The national implementation of CDS would help ensure that these new resources are used as efficiently as possible.
There is an opportunity to improve overall effectiveness of referrals for medical imaging in Canada. By integrating CDS systems in all jurisdictions, radiology departments could potentially reduce diagnostic imaging backlogs, streamline care for priority procedures, improve radiologist workload, and better measure and assess imaging requests across the country. The ultimate goal is improved patient care for Canadians and enhanced productivity for provincial healthcare systems.