Patient and doctor experience WITHOUT access to CDS: John Doe’s back was killing him!

He’d tried to keep up with his customary 5-mile run that morning, he just couldn’t do it. He was bummed out and fed up. “I’m only 35,” he said to himself, “and I haven’t done anything except moving those boxes last night! Why am I feeling like 90-year-old man? There’s got to be something else going on. No way am I in that bad a shape!”

He did some research online and discovered that his symptoms lined up with those of a herniated disk; it was time to go have an MRI of his back.

He knew he needed a referral for that study, so he made an appointment to see his primary care doc the next day.

John showed up at Dr. Smith’s office with his iPAD primed with his online research (everything from the Mayo Clinic to his community message board) ready to share the next steps with Dr. Smith.

At the appointment, Dr. Smith examined John and took detailed notes about his history. Even though she was only allotted 15 minutes for the appointment with John, she took the time to look online for the American College of Radiology’s Appropriateness Criteria to guide her decision making on the next best imaging study to uncover the reason for John’s back pain. She’d heard him say that he wanted the test and, as a proponent of shared decision making with her patients, she wanted to be sure she had the evidence available as she tried to explain to John why the expensive test was unnecessary.

While Dr. Smith was conducting this search, John kept pointing to the article he had already found on line that suggested an MRI was the best way to uncover the herniated disk he was convinced he had. John was clearly getting frustrated and Dr. Smith was starting to feel under the gun to make a decision.

Dr. Smith ran out of time with patients queuing up in the next room and felt ill-equipped to present evidence-based information to John.

John wasn’t even thinking about his high-copay and Dr John wasn’t even thinking about his high-copay and Dr. Smith wasn’t comfortable advising him about cost even if she’d known about it.

Neither one of them was armed with the cost-benefit information including coverage, deductible, co-pays, and approved sites in network.

John just knew his back hurt, and he wanted to get back to work John just knew his back hurt, and he wanted to get back to work. Couldn’t Dr. Smith just write the order already?

Under escalating pressure, Dr Under escalating pressure, Dr. Smith abandons her search for guidelines and decides to follow what she thinks is the “safest” approach. John gets his MRI.

Dr. Smith gets the report from the radiology practice and contacts John to let him know that the MRI shows no evidence of a herniated disk or any other serious injury. John tells her the pain is still occurring.

Dr. Smith prescribes the conservative treatment she had hoped John would agree to in the first place.

Both John and Dr. Smith are left with a “bad taste in their mouths” about the clinical encounter. Dr. Smith is disappointed that she wasn’t able to provide the evidence-based care that John deserved and John still doesn’t understand why he isn’t feeling well.

What’s more, he now has a hefty out-of-pocket expense to pay.

Patient and doctor experience WITH access to CDS: John Doe’s back was killing him!

He’d tried to keep up with his customary 5-mile run that morning, he just couldn’t do it. He was bummed out and fed up. “I’m only 35,” he said to himself, “and I haven’t done anything except moving those boxes last night! Why am I feeling like 90-year-old man? There’s got to be something else going on. No way am I in that bad a shape!”

He did some research online and discovered that his symptoms lined up with those of a herniated disk; it was time to go have an MRI of his back.

He knew he needed a referral for that study, so he made an appointment to see his primary care doc the next day.

John showed up at Dr. Smith’s office with his iPAD primed with his online research (everything from the Mayo Clinic to his community message board) ready to share the next steps with Dr. Smith.

After an examination, the physician must quickly determine which of many possible diagnostic imaging exams is the most appropriate for the patient’s condition. She accesses her practice’s clinical decision support (CDS) tool, inputs the patient information, and marks the indications.

The information is sent to the software tool for immediate clinical decision support.

Within seconds, the guidelines indicate that no MR exam is required and the physician should treat the patient with an NSAID.

Within seconds, the guidelines indicate that no MR exam is required and the physician should treat the patient with an NSAID.

Within seconds, the guidelines indicate that no MR exam is required and the physician should treat the patient with an NSAID.

Initially, the John continues to advocate for an MRI of the low back.

But he and his doctor sit together and review the results of ACR Select™ and Choosing Wisely, including discussing the evidence supporting NSAID treatments opposed to an MRI.

Together, they decide that no MRI is needed at this point and that the patient will begin NSAIDs and undergo physical therapy instead.

Because the CDS tool was integrated into the doctor’s EHR, she clicks the recommended treatment plan, and the EHR is updated with decision support data in the patient record.

A few weeks later, the John is feeling better — no more back pain, no unnecessary imaging test, and no bill!