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EHR Reminders Nudge ED Physicians to Right-Size Imaging Usage

Is your emergency department trying to decrease overall utilization of high-cost imaging, especially among clinicians who appear to turn to the tools too often?

A new study published in Academic Emergency Medicine (AEM), a journal of the Society for Academic Emergency Medicine, suggests that clinical decision support (CDS) embedded directly into the patient's electronic medical record is linked to overall usage of pricey imaging. The benefit isn’t just decreasing inappropriate usage but also increasing usage when appropriate, the article points out.

Researchers at University of Colorado School of Medicine sought to evaluate the effect of evidence-based CDS tools integrated directly into provider workflow in the EHR related to use of computed tomography (CT) imaging for brain, C-spine, and pulmonary embolism (PE) patients.

To accomplish that, the study team embedded widely accepted scoring tools for head injury, C-spine injury, and PE in the common EHR of five EDs, avoiding disruptions in healthcare provider workflow. Attending ED physicians in the healthcare system were included if they were practicing during the entire study period.

The proportion of CTs ordered by provider — calculated by dividing the total number of CT scans of a given type by total patients seen — was the primary outcome in the pre- and post-intervention period.

Focusing on 235,858 total patient visits, study results indicated an absolute decrease of 6,106 CT scans ordered for the three studies. That included a greater than 6% decrease in utilization of CT brain and CT C-spine.

Although the usage of CT PE also decreased, that was not as significant, with an average decline of 2%, the study noted.

For all CT types, high utilizers in the pre-intervention period decreased usage more than 14% in the post-intervention period for all categories.

At the same time, average utilizers did not change their usage practices, nor did low utilizers for CT brain. For CT C-spine and CT PE usage, however, the low utilizers increased usage 29% and 46%, respectively.

“Embedded clinical decision support is associated with decreased overall utilization of high-cost imaging, especially among higher utilizers,” study authors conclude. “It also affected low utilizers, increasing their usage consistent with improved adherence to guidelines, but this effect did not offset the overall decreased utilization for CT brain or CT C-spine.”

“Getting CDS delivered at the right time to the right person seamlessly within their workflow is the key to driving compliance with standardized, evidence-based, best practices,” added lead author Kelly Bookman, MD, associate professor of emergency medicine and medical director for the Department of Emergency Medicine at University of Colorado School of Medicine.

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