Evaluating the Effect of Unstructured Clinical Information on Clinical Decision Support Appropriateness Ratings

To determine the appropriateness rating (AR) of advanced inpatient imaging requests that were not rated by prospective, point-of-care clinical decision support (CDS) using computerized provider order entry.

During 30-day baseline and intervention periods, CDS generated an AR for advanced inpatient imaging requests (nuclear medicine, CT, and MRI) using provider-selected structured indications from pull-down menus in the computerized provider order entry portal. The AR was only displayed during the intervention, and providers were required to acknowledge the AR to finalize the request. Subsequently, the unstructured free text information accompanying all requests was reviewed, and the AR was revised when possible. The percentage of unrated requests and the overall AR, before and after radiologist review, were compared between periods and by provider type.

CDS software prospectively generated an AR for only 25.4% and 28.4% of baseline and intervention imaging requests, respectively; however, radiologist review generated an AR for 82.4% and 93.6% of the same requests. During the respective periods, the percentage of baseline and intervention imaging requests considered appropriate was 18.7% and 22.9% by prospective CDS software rating and increased to 82.4% and 88.7% with radiologist review.

Despite limited effective use of CDS software, the percentage of requests containing additional, relevant clinical information increased, and the majority of requests had overall high appropriateness when reviewed by a radiologist. Additional work is needed to improve the amount and quality of clinical information available to CDS software and to facilitate the entry of this information by appropriate end users.