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

OBJECTIVE: To: 1) describe a System for Coordinating Orders for Radiology Exams (SCORE) which aims to manage unscheduled orders for outpatient diagnostic imaging in an electronic health record (EHR) with embedded computerized physician order entry (CPOE), 2) assess the impact of SCORE and other related factors (e.g., demographics) on 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 in a large academic institution between 10/1/2017–7/1/2019. The design and implementation of SCORE is described, including people (e.g., competencies), processes (e.g., standardized procedures) and tools (e.g., EHR interfaces, dashboard). Rate of unscheduled imaging orders was compared pre-SCORE (10/1/17–9/30/18) and post-SCORE (10/1/18–6/30/19) using chi-square analysis. For 447 randomly selected orders, mode of resolution was obtained from the EHR and factors related to order resolution were assessed via multivariable analysis. Finally, clinical necessity was manually assessed by two physicians. RESULTS: Pre-SCORE, 52,204/607,020 exam orders were unscheduled (8.6% of orders), compared to 20,900/475,000 exam orders (4.4% of orders) post-SCORE (χ(2), p<0.00001), 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. 31.9% of cancellations and 27.7% of expired orders remained clinically necessary and were attributed to scheduling and patient-related factors. CONCLUSION: SCORE significantly reduced unscheduled diagnostic imaging orders. This patient safety initiative may help reduce errors resulting from diagnostic delays due to unscheduled exam orders.