Quality improvement time-saving intervention to increase use of a clinical decision support tool to reduce low-value diagnostic imaging in a safety net health system

Abstract

Importance Electronic health record (EHR) clinical decision support (CDS) tools can provide evidence-based feedback at the point of care to reduce low-value imaging. Success of these tools has been limited partly due to lack of engagement by busy clinicians.Objective Measure the impact of a time-saving quality improvement intervention to increase engagement with a CDS tool for low back pain imaging ordering.Design, setting and participants We conducted a quasi-experimental difference-in-differences analysis at (BLINDED), examining back pain imaging orders from 29 May 2015 to 07 January 2016. The intervention site was (BLINDED) Emergency Medicine/Urgent Care Center (n=5736) and control sites included all other (BLINDED) hospitals and clinics (n=1621). In May 2015, the Department of Health Services installed a CDS tool that triggered a survey when clinicians ordered an imaging test, generating an ‘appropriateness score’ based on the American College of Radiology guidelines. Clinicians often bypassed the tool, resulting in ‘unscored’ tests.Intervention To increase clinician engagement with the tool and decrease the rate of unscored imaging tests, a new policy was implemented at the intervention site on 15 August 2015. If clinicians completed the CDS survey and scored an appropriateness score >3, they could forego a previously mandatory telephone call for pre-imaging utilisation review with the radiology department.Main outcomes and measures We used EHR data to measure pre–post-intervention differences in: (1) percentage of unscored tests and (2) percentage of tests with high appropriateness scores (>7).Results Percentage of unscored tests decreased from 69.4% to 10.4% at the intervention site and from 50.6% to 34.8% at the control sites (between-group difference: −23.3%, p<0.001). Percentage of high scoring tests increased from 26.5% to 75.0% at the intervention site and from 17.2% to 22.7% at the control sites (between-group difference: 19%, p<0.001).Conclusion Workflow time-saving interventions may increase physician engagement with CDS tools and have potential to improve practice patterns.