Objective
Evaluate the impact of evidence-based clinical decision support tools
integrated directly into provider workflow in the electronic health record
on utilization of CT brain, c-spine and pulmonary embolism (PE).
Methods
Validated, well accepted scoring tools for head injury, c-spine
injury and pulmonary embolism were embedded into the electronic health
record in a manner minimally disruptive to provider workflow. This was a
longitudinal, before/after study in 5 emergency departments in a healthcare
system with a common electronic health record. Attending ED physicians
practicing during the entire study period were included. The main outcome
measure was proportion of CTs ordered by provider (total number of CT scans
of a given type divided by total patients seen by that provider) in
aggregate in the pre- and post-intervention period.
Results
There were 235,858 total patient visits analyzed in this study with
an absolute decrease of 6106 CT scan ordering for the three studies. Across
all sites, there was greater than 6% decrease in utilization of CT
brain and CT c-spine [(−10%, 95% CI
(−13%, −7%); p < 0.001);
(−6%, 95% CI (−11%,
−1%); p = 0.03) respectively]. The use of CT
PE also decreased but was not significant (−2%,
95%CI (−9%, +5%); p = 0.42).
For all CT types, high utilizers in the pre-period decreased usage over
14% in the post-period with CT brain (−18%,
95% CI (−22%, −15%), p < 0.001),
CT c-spine (−14%, 95% CI (−20%,
−8%), p = 0.001) and CT PE (−23%,
95% CI (−31%, −14%), p < 0.001).
For all 3 studies, the average utilizers did not change their usage
practices. For CT brain, the low utilizers also did not increase usage but
for CT c-spine and CT PE usage was increased [(+29%,
95% CI (10%, 52%) p = 0.003);
(+46%, 95% CI (26%, 70%), p <
0.001) respectively].
Conclusion
Embedded clinical decision support is associated with decreased
overall utilization of high cost imaging, especially among higher utilizers.
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. Thus, integrating CDS into
the provider workflow promotes usage of validated tools across providers,
which can standardize the delivery of care and improve compliance with
evidence-based guidelines.