Simple visual aid in EHR reduces duplicate imaging orders by 40%

Placing simple, passive prompts in the electronic health record at one emergency department helped reduce duplicate orders of imaging tests by more than 40%, according to a new study.

Researchers with Beth Israel Deaconess Medical Center, in Boston, recently made that discovery through a years-long experiment involving tens of thousands of patients. Their study results—highlighted this month in JAMA Network Open—present a means to eliminate healthcare waste without overburdening busy physicians, the authors concluded.

“This type of EHR-based reminder may be a useful alternative to interruptive, post-order alerts for reducing duplicate order entry,” wrote Steven Horng, MD, with the Department of Emergency Medicine at BIDMC, and colleagues. “We believe guiding clinicians to a right action is better than telling the clinician they have made an error. This approach may help reduce alert fatigue and lessen clinician stress and burnout associated with EHRs.”

The analysis included more than 111,000 patients who visited the ED between 2013 and 2015. After tracking test ordering patterns for one first year, Horng et al. inserted a “just-in-time” prompt into the EHR, with a red highlight appearing around the checkbox if a clinician had already ordered that same imaging test during the ED visit.

Adding this “noninterruptive nudge” into the EHR led to a roughly 40% decrease in unintentional, duplicate orders of radiology tests, defined as when a provider requested a second scan, but subsequently cancelled the call. Duplicate lab tests dropped by another 49%, while there was no notable change in redundant medication orders, investigators noted.

In addition to conserving resources and adding value for the patient, the intervention also saved time to busy providers’ days. BIDMC’s records system requires password entry and at least nine clicks to cancel an order. The prompts helped providers avoid making nearly 18,000 mouse clicks, adding about 16 hours and 36 minutes back into each individual’s schedule.

The study comes with a few limitations, including only tracking duplicate orders that were subsequently canceled in the system, and not those that were carried out. But Horng and colleagues have found early promise in using such just-in-time alerts, and plan to further explore their use in other care settings.

EHR nudges are becoming an increasingly popular tool to help guide providers change behaviors in a less harsh fashion. Another JAMA Network Open study published last month found that placing virtual reminders in the EHR helped propel providers to order more cancer screenings. That analysis was performed by Penn Medicine, which has its own dedicated “Nudge Unit” designed to use behavioral science to influence behavior without restricting choices.