"My attending really wants it!" Manual clinical decision support adjudicating the "better look" inpatient MRI at an academic medical center.

Objective: MRI utilization in the United States is relatively higher than in other parts of the world and inpatient MRI utilization is particularly difficult to manage given the lack of direct reimbursement. Body MRI studies present an opportunity to reduce inpatient MRI utilization since they are generally the least emergent. Our objective was to use a targeted questionnaire to probe the necessity of inpatient body MRI orders and present an opportunity to either cancel them or transition them to the outpatient realm METHODS: A 9-item questionnaire was devised asking questions about the urgency of the inpatient MRI order including the urgent management question, an inpatient procedure or whether it was recommended by a consultant. Peer-to-peer discussion walking through each of the questions was conducted by radiology housestaff with the ordering clinicians and responses recorded.

Results: 845 recorded responses reported a lack of specific clinical question in 23.9% of orders, 68.9% were recommended by a non-radiology consulting service and 16.1% were recommended by radiology studies. 17.0% orders were felt to be outpatient appropriate and 23.3% were considered possibly appropriate for the outpatient setting. 3.9% were canceled and 4.9% were transitioned to outpatient orders.

Discussion: Engaging in a focused discussion about the urgency and appropriateness of an inpatient MRI body order following a list of scripted questions has the potential to reduce utilization. This approach also highlights the relatively high rate of indication uncertainty among ordering clinicians and the central role of consultants in prompting orders.