LO22: Implementation of an electronic clinical decision support tool to improve knowledge translation and imaging appropriateness for patients with mild traumatic brain injury and suspected pulmonary embolism

Abstract

Introduction/Innovation Concept: Utilization of CT imaging has increased dramatically over the past two decades, but has not necessarily improved patient outcomes. As healthcare spending grows unsustainably and evidence of harms from unnecessary testing accrues, there is pressure to improve imaging appropriateness. However, prior attempts to reduce unnecessary imaging using evidence-based guidelines have met with limited success, with common barriers cited including a lack of confidence in patient outcomes, medicolegal risk, and patient expectations. This project attempts to address these barriers through the development of an electronic clinical decision support (CDS) tool embedded in clinical practice. Methods: An interactive web-based point-of-care CDS tool was incorporated into computerized physician order entry software to provide real-time evidence-based guidance to emergency physicians for select clinical indications. For patients with mild traumatic brain injury (MTBI), decision support for the Canadian CT Head Rule pops up when a CT head is ordered. For patients with suspected pulmonary embolism (PE), the tool is triggered when a CT pulmonary angiogram is ordered and provides CDS for the Pulmonary Embolism Rule-out Criteria (PERC), Wells Score, age-adjusted D-dimer and CT imaging. To study the impact of the tool, all emergency physicians in the Calgary zone were randomized to receive voluntary decision support for either MTBI or PE. Curriculum, Tool, or Material: The tool uses a multifaceted approach to inform physician decision making, including visualization of risk and quantitative outcomes data and links to primary literature. The CDS tool simultaneously documents guideline compliance in the health record, generates printable patient education materials, and populates a REDCap™ database, enabling the creation of confidential physician report cards on CT utilization, appropriateness and diagnostic yield for both audit and feedback and research purposes. Preliminary data show that physicians are using the MTBI CDS approximately 30% of the time, and the PE CDS approximately 40% of the time. Evaluation of CDS impact on imaging utilization and appropriateness is ongoing. Conclusion: A voluntary web-based point-of-care decision support tool embedded in workflow has the potential to address many of the factors typically cited as barriers to use of evidence-based guidelines in practice. However, high rates of adherence to CDS will likely require physician incentives and appropriateness measures.