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Electronic Health Record–Based Interventions for Improving Appropriate Diagnostic Imaging: A Systematic Review and Meta-analysisEHR-Based Interventions for Improving Appropriate Diagnostic Imaging

Caroline Lubick Goldzweig, MD, MS; Greg Orshansky, MD; Neil M. Paige, MD, MSHS; Isomi M. Miake-Lye, BA; Jessica M. Beroes, BS; Brett A. Ewing, MS; and Paul G. Shekelle, MD, PhD
[+] Article, Author, and Disclosure Information

From West Los Angeles Veterans Affairs Medical Center and University of California, Los Angeles, Fielding School of Public Health, Los Angeles, and RAND Corporation, Southern California Evidence-based Practice Center, Santa Monica, California.

Disclaimer: The findings and conclusions in this article are those of the authors, who are responsible for its contents. The findings and conclusions do not necessarily represent the views of the U.S. Department of Veterans Affairs or the U.S. government; therefore, no statement in this article should be construed as an official position of the U.S. Department of Veterans Affairs.

Acknowledgment: The authors thank David Atkins, Charles Anderson, Hardeep Singh, and David Douglas for their input as technical experts or operational partners for this report.

Grant Support: By the Veterans Affairs Quality Enhancement Research Initiative (Veterans Affairs Evidence Synthesis Program Project 05-226).

Disclosures: Disclosures can be viewed at www.acponline.org/authors/icmje/ConflictOfInterestForms.do?msNum=M14-2600.

Requests for Single Reprints: Caroline Lubick Goldzweig, MD, MS, Veterans Affairs West Los Angeles Healthcare Center, 11301 Wilshire Boulevard, 111-G, Los Angeles, CA 90073; e-mail, caroline.goldzweig@va.gov.

Current Author Addresses: Drs. Goldzweig, Orshansky, Paige, and Shekelle; Ms. Miake-Lye; and Ms. Beroes: Veterans Affairs West Los Angeles Healthcare Center, 11301 Wilshire Boulevard, 111-G, Los Angeles, CA 90073.

Ms. Ewing: RAND Corporation, 1776 Main Street, Santa Monica, CA 90401.

Author Contributions: Conception and design: C.L. Goldzweig, P.G. Shekelle.

Analysis and interpretation of the data: C.L. Goldzweig, G. Orshansky, N.M. Paige, B.A. Ewing, P.G. Shekelle.

Drafting of the article: C.L. Goldzweig, G. Orshansky, N.M. Paige, I.M. Miake-Lye, P.G. Shekelle.

Critical revision of the article for important intellectual content: G. Orshansky, N.M. Paige, I.M. Miake-Lye, C.L. Goldzweig, P.G. Shekelle.

Final approval of the article: C.L. Goldzweig, G. Orshansky, N.M. Paige, I.M. Miake-Lye, J.M. Beroes, B.A. Ewing, P.G. Shekelle.

Statistical expertise: B.A. Ewing.

Obtaining of funding: P.G. Shekelle.

Administrative, technical, or logistic support: I.M. Miake-Lye, J.M. Beroes.

Collection and assembly of data: C.L. Goldzweig, G. Orshansky, N.M. Paige, I.M. Miake-Lye, J.M. Beroes, B.A. Ewing, P.G. Shekelle.


Ann Intern Med. 2015;162(8):557-565. doi:10.7326/M14-2600
Text Size: A A A

Background: One driver of increasing health care costs is the use of radiologic imaging procedures. More appropriate use could improve quality and reduce costs.

Purpose: To review interventions that use the computerized clinical decision-support (CCDS) capabilities of electronic health records to improve appropriate use of diagnostic radiologic test ordering.

Data Sources: English-language articles in PubMed from 1995 to September 2014 and searches in Web of Science and PubMed of citations related to key articles.

Study Selection: 23 studies, including 3 randomized trials, 7 time-series studies, and 13 pre–post studies that assessed the effect of CCDS on diagnostic radiologic test ordering in adults.

Data Extraction: 2 independent reviewers extracted data on functionality, study outcomes, and context and assessed the quality of included studies.

Data Synthesis: Thirteen studies provided moderate-level evidence that CCDS improves appropriateness (effect size, −0.49 [95% CI, −0.71 to −0.26]) and reduces use (effect size, −0.13 [CI, −0.23 to −0.04]). Interventions with a “hard stop” that prevents a clinician from overriding the CCDS without outside consultation, as well as interventions in integrated care delivery systems, may be more effective. Harms have rarely been assessed but include decreased ordering of appropriate tests and physician dissatisfaction.

Limitation: Potential for publication bias, insufficient reporting of harms, and poor description of context and implementation.

Conclusion: Computerized clinical decision support integrated with the electronic health record can improve appropriate use of diagnostic radiology by a moderate amount and decrease use by a small amount. Before widespread adoption can be recommended, more data are needed on potential harms.

Primary Funding Source: U.S. Department of Veterans Affairs. (PROSPERO registration number: CRD42014007469)

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Appendix Figure 1.

Summary of evidence search and selection.

CCDS = computerized clinical decision support; EHR = electronic health record.

* Results from previous systematic reviews (n = 152), the Agency for Healthcare Research and Quality database (n = 226), the update searches (n = 793), and articles identified during reference mining (n = 24) were deduplicated to reach this number.

† Manuscript reference list includes additional references cited for background and methods plus Web sites relevant to key questions.

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Appendix Figure 2.

Studies reporting both appropriateness and use outcomes.

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Figure 1.

Effect of EHR-based interventions on the appropriateness of diagnostic radiologic test ordering.

EHR = electronic health record; RE = random effects.

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Figure 2.

Effect of EHR-based interventions on the use of diagnostic radiologic test ordering.

EHR = electronic health record; RE = random effects.

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Figure 3.

Effect of EHR-based interventions on the appropriateness of diagnostic radiologic test ordering, stratified by intervention type and setting.

EHR = electronic health record; IT = information technology.

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Appendix Figure 3.

Effect of EHR-based intervention on the appropriateness of diagnostic radiologic test ordering, stratified by implementation characteristic and target.

CT = computed tomography; EHR = electronic health record.

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