Non-compliance with diagnostic imaging pathways: Can information-communication technology help?

Phillip J. Bairstow, University of Notre Dame Australia
R Mendelson
Jennifer Persaud, University of Notre Dame Australia
R Grabinski
K Ho
L Nguyen
A Thelander

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Background: An ‘on-line’ application called Diagnostic Imaging Pathways (DIP) was developed at Royal Perth Hospital (RPH), Western Australia. DIP is an evidence-based decision support tool designed to assist clinicians to request the most appropriate examinations to achieve a diagnosis. The application is accessed from the ‘desk-top’ and the Internet ( Clinicians at RPH are regularly alerted to the desirability of complying to DIP recommendations.

Purpose: To evaluate compliance between diagnostic imaging requests and recommendations in DIP.

Methods: Retrospective audits, followed by intervention and re-audits were carried out in the Emergency Department (ED). Pathways targeted were:

‘Suspected Pulmonary Embolism’


‘Ankle Injury’


‘Suspected Renal Colic’


and ‘Non Traumatic Acute Abdominal Pain’


Interventions included education on DIP recommendations, request forms requiring proof of adherence to pathways, and refusal of inappropriate examinations.

Results: In the initial audits (N= 658), 285 (43%) received imaging of doubtful appropriateness whilst 158 (24%) received examinations without indications. Follow-up audits demonstrate only partial improvements in compliance. Requesters failed to follow recommendations for many reasons including; insufficient time to learn about recommendations, disbelief in their validity, and not understanding the importance of adhering to recommendations. Requesters then provide inaccurate pre-requisite information or ‘pressurise’ providers to accept a request without pre-requisites. Providers fail in their ‘gatekeeper’ function because of insufficient time to deliver education, difficulty obtaining pre-requisite information, and reluctance to resist a demand.

Discussion: The easy availability and marketing of DIP did not eliminate inappropriate diagnostic imaging. Targeted interventions failed to eliminate non-compliance. In planning for electronic ordering linked to decision support, we need to investigate the extent to which information-communication technology can suppress inappropriate practice.