Reports From the Field

Using Clinical Decision Support to Reduce Inappropriate Imaging: A Health Care Improvement Case Study



Data obtained included the percentage of pediatric patients with suspected appendicitis who received ultrasounds and CT scans each month from 1 October 2010 through 31 March 2012. Banner Health staff originally collected the data to support the implementation of health care improvement initiative; the use of these data in this paper is a secondary use [29].

This manuscript was prepared using the SQUIRE 2.0 guidelines [30]. No patient-identifiable data were used, so institutional review board approval was not sought.


The 4 steps of implementing CDS can be described as functionality planning, software customization and workflow design, training and user support, and optimization [31].


The use of computerized provider order entry (CPOE) is a precursor to using clinical decision support, since orders must be entered electronically to be subject to CDS review. Banner Health deployed CPOE to its various facilities starting in 2008. The deployment was staged in a rolling fashion with one or two facilities going live every few months so that the deployment team was available at each facility.

Phase 1: Planning

In contrast to many large health systems, the organization has a single board of directors that oversees the entire system of over 37,000 employees. Activities and relationships to promote the use of evidence-based practices are built into the organizational structure. For example, Banner Health maintains a Care Management Council, a group comprised of clinical and administrative leadership to provide executive oversight of health care improvement projects. The Council convenes on a quarterly basis to review and approve the adoption of new clinical practice guidelines, policies, and standardized standing orders that have been developed by multidisciplinary groups of physicians and other clinicians. A key focus of the Council is ensuring consistent application of evidence-based guidelines to clinical care and disseminating knowledge of clinical best practices across a large and complex enterprise.

Interdisciplinary clinical consensus groups support the Council’s work. These groups are comprised of administrative and program management staff, physicians and other clinicians, and engineers. Each clinical consensus group focuses on emerging issues and improvement opportunities within a specific clinical domain and leads the implementation of health care improvement initiatives in that domain. Providers and staff at all levels of the organization were involved in planning and implementing the health care improvement initiative in inappropriate imaging. This increased buy-in and staff support, which are associated with successful health care improvement initiatives [32]. Banner Health staff rallied around the idea of addressing inappropriate imaging as a key priority initiative. The teams that implement each initiative include an engineer that focuses on redesigning clinical workflows for each initiative. There is also an organizational unit responsible for project management that provides teams with logistical and operational support.

Phase 2: Software Customization and Workflow Redesign

Once the clinical consensus group selected inappropriate imaging as a priority, the next step was to examine the process flow for imaging ordering. In 2011 Banner Health integrated CDS functionality with CPOE into the electronic health record. Before the use of CDS, inpatient and emergency department imaging orders were simply transmitted to imaging staff after the order was entered. After CDS implementation, the process flow begins with an inpatient imaging order and entailed checking the order against clinical guidelines on the proper use of imaging. If the image order did not conform to guidelines, which in this case indicate that ultrasound should be used before CT scans as a diagnostic tool for suspected pediatric appendicitis, the CDS system triggered an alert [15].

Bringing the perspective and skill sets of engineers to the process of redesigning clinical workflows was particularly valuable [33]. While CDS has the potential to reduce inpatient inappropriate imaging, effectiveness depends on adjusting workflows to ensure that the information provided by CDS alerts and reminders is actionable. To reduce alert fatigue among the clinical staff, the team identified the appropriate level of workflow interruption for each alert and reminder (hard stop, workflow interruption, or informational) [5,6].

The design principles that were used to design the alert include intuitive system development to promote ease of use, one set of screen formats and data definitions, and a set of consistent core reports and standard system output formats across facilities. The alert’s appearance was tailored for maximal impact and covered most of the screen. Color contrast was used, but since some people are color-blind, the meaning of the alert did not depend on the color contrast. The alerts included recommendations for changing the treatment plan to encourage using ultrasound as a first-line diagnostic tool. Minimizing the number of clicks to accept the proposed treatment plan change in the alert is desirable.

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