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The purpose of this study was to evaluate the impact of an appropriate use criterion (AUC) for renal colic based on local best practice, implemented as electronic clinical decision support (CDS), on the emergency department (ED) use of CT for patients with suspected nephrolithiasis.This retrospective cohort study was performed in the EDs of a level I trauma center (study site) and local comparable hospital (control site). An AUC for patients younger than 50 years with a history of uncomplicated nephrolithiasis presenting with renal colic was developed by an interdisciplinary emergency medicine, emergency radiology, and urology team and embedded as CDS. AUC-consistent CT of ureter requests received no CDS alert. Otherwise, the orderer was alerted to consider a trial of symptomatic control or discharge without CT. A natural language processing tool mined ED notes for visits in September 2010-February 2012 (before AUC implementation) and April 2013-September 2014 (1 year after implementation) for concept unique identifiers of flank tenderness or renal or ureteral pain. Manual review excluded noneligible cases; the others were reviewed by a multidisciplinary team. Chi-square tests were used to assess for CT rate differences, the primary outcome.The final sample included 467 patients (194 study site) before and 306 (88 study site) after AUC implementation. The study site's CT of ureter rate decreased from 23.7% (46/194) to 14.8% (13/88) (p = 0.03) after implementation of the AUC. The rate at the control site remained unchanged, 49.8% (136/273) versus 48.2% (105/218) (p = 0.3).Implementing an AUC based on local best practice as CDS may effectively curb potential imaging overuse in a subset of ED patients with renal colic unlikely to have a complicated course or alternative dangerous diagnosis.

The efficacy of imaging clinical decision support (CDS) varies. Our objective was to identify CDS factors contributing to imaging order cancellation or modification.This pre-post study was performed across four institutions participating in the Medicare Imaging Demonstration. The intervention was CDS at order entry for selected outpatient imaging procedures. On the basis of the information entered, computerized alerts indicated to providers whether orders were not covered by guidelines, appropriate, of uncertain appropriateness, or inappropriate according to professional society guidelines. Ordering providers could override or accept CDS. We considered actionable alerts to be those that could generate an immediate order behavior change in the ordering physician (i.e., cancellation of inappropriate orders or modification of orders of uncertain appropriateness that had a recommended alternative). Chi-square and logistic regression identified predictors of order cancellation or modification after an alert.A total of 98,894 radiology orders were entered (83,114 after the intervention). Providers ignored 98.9%, modified 1.1%, and cancelled 0.03% of orders in response to alerts. Actionable alerts had a 10 fold higher rate of modification (8.1% vs 0.7%; p0.0001) or cancellation (0.2% vs 0.02%; p0.0001) orders compared with nonactionable alerts. Orders from institutions with preexisting imaging CDS had a sevenfold lower rate of cancellation or modification than was seen at sites with newly implemented CDS (1.4% vs 0.2%; p0.0001). In multivariate analysis, actionable alerts were 12 times more likely to result in order cancellation or modification. Orders at sites with preexisting CDS were 7.7 times less likely to be cancelled or modified (p0.0001).Using results from the Medicare Imaging Demonstration project, we identified potential factors that were associated with CDS effect on provider imaging ordering; these findings may have implications for future design of such computerized systems.

The purpose of this study was to assess whether implementing emergency department (ED) physician performance feedback reports improves adherence to evidence-based guidelines for use of CT for evaluation of pulmonary embolism (PE) beyond that achieved with clinical decision support (CDS) alone.This prospective randomized controlled trial was conducted from January 1, 2012, to December 31, 2013, at an urban level 1 adult trauma center ED. Attending physicians were stratified into quartiles by use of CT for evaluation of PE in 2012 and were randomized to receive quarterly feedback reporting or not, beginning January 2013. Reports consisted of individual and anonymized group data on guideline adherence (using the Wells criteria), use of CT for PE (number of CT examinations for PE per 1000 patients), and yield (percentage of CT examinations for PE with positive findings). We compared guideline adherence (primary outcome) and use and yield (secondary outcomes) of CT for PE between the control and intervention groups in 2013 and with historical imaging data from 2012.Of 109,793 ED patients during the control and intervention periods, 2167 (2.0%) underwent CT for evaluation of PE. In the control group, guideline adherence remained unchanged between 2012 (78.8% [476/604]) and 2013 (77.2% [421/545]) (p = 0.5); in the intervention group, guideline adherence increased 8.8% after feedback report implementation, from 78.3% (426/544) to 85.2% (404/474) (p0.05). Use and yield were unchanged in both groups.Implementation of quarterly feedback reporting resulted in a modest but significant increase in adherence to evidence-based guidelines for use of CT for evaluation of PE in ED patients, enhancing the impact of CDS alone. These results suggest potentially synergistic effects of traditional performance improvement tools with CDS to improve guideline adherence.

The purpose of this study was to measure the effects of use of a structured physician order entry system for trauma CT on the communication of clinical information and on coding practices and reimbursement efficiency.This study was conducted between April 1, 2011, and January 14, 2013, at a level I trauma center with 59,000 annual emergency department visits. On March 29, 2012, a structured order entry system was implemented for head through pelvis trauma CT, so-called pan-scan CT. This study compared the following factors before and after implementation: communication of clinical signs and symptoms and mechanism of injury, primary International Classification of Diseases, 9th revision, Clinical Modification (ICD-9-CM) code category, success of reimbursement, and time required for successful reimbursement for the examination. Chi-square statistics were used to compare all categoric variables before and after the intervention, and the Wilcoxon rank sum test was used to compare billing cycle times.A total of 457 patients underwent pan-scan CT in 2734 distinct examinations. After the intervention, there was a 62% absolute increase in requisitions containing clinical signs or symptoms (from 0.4% to 63%, p0.0001) and a 99% absolute increase in requisitions providing mechanism of injury (from 0.4% to 99%, p0.0001). There was a 19% absolute increase in primary ICD-9-CM codes representing clinical signs or symptoms (from 2.9% to 21.8%, p0.0001), and a 7% absolute increase in reimbursement success for examinations submitted to insurance carriers (from 83.0% to 89.7%, p0.0001). For reimbursed studies, there was a 14.7-day reduction in mean billing cycle time (from 68.4 days to 53.7 days, p=0.008).Implementation of structured physician order entry for trauma CT was associated with significant improvement in the communication of clinical history to radiologists. The improvement was also associated with changes in coding practices, greater billing efficiency, and an increase in reimbursement success.

OBJECTIVE. The purpose of this study was to determine the impact of requiring clinical justification to override decision support alerts on repeat use of CT. SUBJECTS AND METHODS. This before and after intervention study was conducted at a 793-bed tertiary hospital with computerized physician order entry and clinical decision support systems. When a CT order is placed, decision support alerts the orderer if the patient's same body part has undergone CT within the past 90 days. The study cohort included all 28,420 CT orders triggering a repeat alert in 2010. The intervention required clinical justification, selected from a predetermined menu, to override repeat CT decision support alerts to place a CT order; otherwise the order could not be placed and was dropped. The primary outcome, dropped repeat CT orders, was analyzed using three methods: chi-square tests to compare proportions dropped before and after intervention; multiple logistic regression tests to control for orderer, care setting, and patient f...

OBJECTIVE. The objective of our study was to assess radiology utilization trends for emergency department (ED) patients from 1993 through 2012. MATERIALS AND METHODS. For this retrospective study, we reviewed radiology utilization at a 793-bed quaternary care academic medical center from January 1, 1993, through December 31, 2012, during which time the number of ED patient visits increased from approximately 48,000 to 61,000, and determined the number of imaging studies by modality (radiography, sonography, CT, MRI, other) and associated relative value units (RVUs). We used linear regression to assess for trends in the number of imaging RVUs and imaging accession numbers, our primary and secondary outcomes, respectively. RESULTS. The total RVUs attributable to ED imaging per 1000 ED visits increased 208% from 1993 to 2007 (p < 0.0001) and then decreased 24.7% by 2012 (p = 0.0019). The total number of imaging accession numbers per 1000 ED visits increased 47.8% from 1993 until 2005 (p = 0.0003) and then de...