Closing the Loop on Unscheduled Diagnostic Imaging Orders: A Systems-Based Approach

Abstract

Purpose: The aims of this study were to (1) describe the System for Coordinating Orders for Radiology Exams (SCORE), the objective of which is to manage unscheduled orders for outpatient diagnostic imaging in an electronic health record (EHR) with embedded computerized physician order entry; (2) assess the impact of SCORE and other related factors (eg, demographics) on the rate of unscheduled orders; and (3) assess the clinical necessity of orders canceled, expired, scheduled, and performed.

Methods: This institutional review board-approved retrospective study was conducted at a large academic institution between October 1, 2017, and July 1, 2019. The design and implementation of SCORE are described, including people (eg, competencies), processes (eg, standardized procedures), and tools (eg, EHR interfaces, dashboard). The rate of unscheduled imaging orders was compared before SCORE (October 1, 2017, to September 30, 2018) and after SCORE (October 1, 2018, to Jun 30, 2019) using χ² analysis. For 447 randomly selected orders, mode of resolution was obtained from the EHR, and factors related to order resolution were assessed using multivariate analysis. Finally, clinical necessity was manually assessed by two physicians.

Results: Before SCORE, 52,204 of 607,020 examination orders (8.6%) were unscheduled, compared with 20,900 of 475,000 examination orders (4.4%) after SCORE (P < .00001, χ² test), a 49% reduction in unscheduled orders. Among 447 randomly selected orders, orders were addressed via cancellation (57%), expiration (21%), scheduling (1%), and performance (11%). Order resolution was not significantly associated with other factors. About 32% of cancellations and 27.7% of expired orders remained clinically necessary, which was attributed to scheduling and patient-related factors.

Conclusions: SCORE significantly reduced unscheduled diagnostic imaging orders. This patient safety initiative may help reduce errors resulting from diagnostic delays due to unscheduled examination orders.

Keywords: Medical order entry systems; delayed diagnosis; diagnostic errors; diagnostic imaging; patient safety.

Figure 1:

System for Coordinating Orders for Radiology Exams Organizational Chart

Figure 2:

Central Model Scheduling Workflow

Figure 3:

Central Scheduling Dashboard