[display_podcast]
Date: July 11th, 2017
Reference: Bookman K et al. Embedded Clinical Decision Support in Electronic Health Record Decreases Use of High-cost Imaging in the Emergency Department: EmbED study. AEM July 2017.
Guest Skeptic: Dr. Justin Morgenstern is an emergency physician and the Director of Simulation Education at Markham Stouffville Hospital in Ontario. He is the creator of the excellent #FOAMed project called First10EM.com
Case: You are working a very busy shift in the emergency department. Your first patient was involved in an motor vehicle collision (MVC), and you pulled up the app to review the Canadian CT Head Injury Rule with your resident. The second patient is an elderly woman presenting via EMS after a ground level fall in c-spine precautions. This time, you review the NEXUS Criteria for c-spine imaging with your resident. The third patient just got off a long flight and is short of breath. Once again, you find yourself on MDCalc, this time teaching the Well’s Criteria for pulmonary embolism and the PERC Rule.
Your resident is very grateful for all the teaching, but asks, “we seem to spend a lot of time looking up decision instruments. Wouldn’t it be easier if these tools were just part of the electronic health record (EHR), since we are already inputting all the patient data into the EHR anyway?” You think to yourself, “interesting, I wonder what impact integration of these rules into the EHR would have on CT ordering in my group?”
Background: Use of CT scanning has increased more than 20-fold since 1980[1],[2]. Although the CT is certainly a valuable tool, it is likely overused in emergency medicine.[3] CT has downstream harms, including radiation, incidental findings, over-diagnosis, financial costs, and negative impacts on emergency department throughput.[4][5]
Numerous clinical decision rules, such as the Canadian CT Head Rule[6], the NEXUS c-spine tool[7], the PERC Rule[8], and the Well’s Criteria[9], have been developed to help guide appropriate imagining.
However, uptake and appropriate use of these tools is not universal.[10] These authors question whether integration of a clinical decision support tool into the ordering system of the EHR would influence CT usage rates.
Clinical Question: Does deploying a novel, evidence-based, electronic health record (EHR) integrated clinical decision support (CDS) tool influence overall utilization of three specific high cost CT imaging studies: head, c-spine and PE?
Reference: Bookman K et al. Embedded Clinical Decision Support in Electronic Health Record Decreases Use of High-cost Imaging in the Emergency Department: EmbED study. AEM July 2017.
* Population: 163 attending-level emergency physicians at five emergency departments (one academic and four community sites – two large urban sites, two smaller urban sites and one rural site).
* Excluded: Community sites in which both an attending and advanced practice provider both saw the patient
* Intervention: A new clinical decision support (CDS) tool was integra...
