NHS installs iRefer CDS solution to enhance radiology test decisions

Thirty-four NHS Trusts in England are currently rolling out iRefer CDS – a cloud-based clinical decision support (CDS) solution that provides clinicians with access to evidence-based radiological investigation guidelines at the point-of-care to ensure patients get the correct imaging scan the first time. In turn the CDS will help minimise patient exposure to ionising radiation and reduce the financial burden of unnecessary radiological tests.

The rollout has been made possible as part of the £248 million fund from the Department of Health and Social care to modernise diagnostics. More NHS Trusts are expected to follow this initial rollout.

Milton Keynes University Hospitals NHS Trust, the first Trust in England to implement iRefer CDS in secondary care, saw the software recommend that the referring clinician change or cancel an inappropriate referral for imaging in 8.4% of cases. Using FY21-22 data, iRefer CDS also has the potential to save approximately 220 hours of radiology workforce time annually with the implementation of a semi-automated vetting workflow using the CDS appropriateness ratings. Ordering the correct scan, the first time around, can protect the patient from unnecessary radiation exposure, as well as delays in care or unnecessary trips to the hospital. The solution also factors in the patients’ clinical history, such as lab results and previous imaging, to ensure that recommendations are specific to each patient’s unique health profile and ultimately support better health outcomes.

Clinical Radiology is chronically understaffed, with a shortfall of 1,669 consultant radiologists in England. Reducing the time they spend reviewing inappropriate referral requests frees them up, significantly improving capacity, which is in short supply.

Royal College of Radiologists
iRefer CDS — a collection of over 300 evidence-based radiology referral guidelines to provide recommendations for everyday use of clinical imaging services – was developed by the Royal College of Radiologists (RCR) and their CDS partner, MedCurrent, a physician-founded CDS company. The CDS solution is an evolution of the publication of the NICE (National Institute for Health and Care Excellence) accredited, iRefer guidelines, which have been compiled by the RCR since 1989.

The guidelines are aimed at clinicians, radiologists, radiographers and other healthcare professionals to determine the most appropriate imaging procedures for a wide range of clinical problems and to help clinicians to meet their obligations under the Ionising Radiation (Medical Exposure) Regulations (IRMER).

iRefer evaluates clinical evidence from diverse sources and uses a network of clinical experts to validate information. It reflects current best practice.

“Radiology is under severe pressure because of chronic understaffing and the COVID-19 backlog. Tools like iRefer CDS can improve patient outcomes as well as saving money and the time of our clinical collea-
gues. This is good news all-round,” said Dr Jeanette Dickson, President of the Royal College of Radiologists.

iRefer provides a single-entry point to common clinical problems seen in primary and emergency care and offers practical advice on the right test at the right time that should be provided to patients.

Dr Steve Herman, MedCurrent CEO, said: “The iRefer guidelines from the Royal College of Radiologists are of world-leading quality and are recognized globally as such. We are very pleased to have been selected by the RCR to bring them to practicing physicians via our software tools.”

The solution integrates directly into existing Order Communications and Electronic Health Record (EHR) systems, such as Clinisys Integrated Clinical Environment (ICE) and Cerner Millennium, to optimise clinical workflow and efficiency.

Additionally, the iRefer CDS solution includes a comprehensive Analytics module that enables the NHS Trust hospitals to derive additional insights from the usage of the CDS and help drive further quality improvement initiatives within the facilities.

Penny Storr, Network Director at the East Midlands Imaging Network, a partnership of eight NHS Trusts providing radiology services across the region, said: “We are delighted to be working with the Royal College of Radiologists and MedCurrent on the iRefer tool across our region and we are looking forward to seeing the benefits that it will give in supporting requests for scans.”

Research shows benefits of iRefer guidelines
A number of studies have been conducted to assess the benefits of the iRefer guidelines.

A recent study – doi: https://doi.org/10.4103/jfmpc.jfmpc_1193_21 – published January 2022 in the Journal of Family Medicine and Primary Care, notes that “inappropriate completion of abdominal radiographs results in unnecessary exposure to ionizing radiation”. A quality improvement project was initiated. The project aimed to reduce the number of inappropriate abdominal radiographs performed in the emergency department.

Abdominal radiograph request forms were analyzed with reference to the Royal College of Radiologists iRefer guidance. A teaching session was then delivered to ED clinicians and posters were disseminated within the department. Post-intervention data collection followed.

Following the intervention, there was an increase in the proportion of abdominal radiographs meeting iRefer guidance, which was accompanied by an increased diagnostic yield of these investigations. There was a reduction in the number of requests post-intervention. The author’s concluded that the iRefer guidelines will help reduce inappropriate requests. This in turn will help reduce unnecessary radiation exposure, whilst also reducing the financial burden.

Three-month iRefer CDS pilot
Data from a three-month pilot of the system in 2021 at Norfolk and Norwich University Hospitals (NNUH) NHS Foundation Trust, showed:

• Over the 3-month period (1 March – 31 May 2021), iRefer CDS processed 1,771 radiology referrals for NNUH and presented evidence-based recommendations for 98.3% of referrals (i.e. CDS coverage).
• Using MedCurrent’s Analytics module, further analysis indicates that 6.7% of all radiology referrals were changed to a different imaging test, and 6.7% of all referrals were cancelled by the referring GP.
• Overall, the appropriateness of all referrals was 89.5%. GPs cancelled 54.7% of inappropriate tests when prompted to do so by CDS, while 38.6% of inappropriate tests were changed when it was suggested by CDS.

Looking at these results, the iRefer CDS clearly improves the appropriateness and quality of radiology referrals, highlighted by a change and cancellation rates of 6.7% and 6.7% respectively.

The financial benefits were also apparent. For the pilot group, iRefer CDS provided cost avoidances of £7,696 within the first 3-month period of implementation. Extrapolation of this data yields an estimated annual savings of £30,869 in tariffs.

The rollout of the iRefer CDS to the NHS Trusts will benefit patients by providing prompt diagnosis that will lead to the patient having the most appropriate treatment. Early exclusion of serious pathology will also reassure and empower patients and referring clinicians. Also, the correct imaging will lead to patient referral to the appropriate specialty (if needed) and reduce inappropriate specialist referral. This in turn will improve efficiencies and reduce costs for the NHS.

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