Reports From the Field

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



These results can help guide the implementation of health care improvement initiatives that use CDS functionality to address inappropriate imaging. The adoption of electronic health records with CDS functionality was incentivized and supported by the Medicare and Medicaid Electronic Health Record Incentive Programs; the Medicare program now exists as part of MACRA. Using CDS to reduce inappropriate imaging is required for Medicare fee-for-service patients in the 2014 Protecting Access to Medicare Act (PAMA), highlighting the critical nature of these results, which can guide implementation of CDS to reduce inappropriate imaging [41].

As noted above, the optimization phase is continuous. Banner Health still encourages use of ultrasounds as a first-line diagnostic tool for pediatric appendicitis. Identifying which patients should immediately receive CT scans is difficult, and sometimes the decision depends on the availability of staff to conduct the ultrasound scans. Ways to maximize the productivity of ultrasound technicians have been explored. Another focus area since the original implementation of this health care improvement initiative has been health information exchange, to ensure that complete, up-to-date information is available for each patient.

Banner Health often implements CDS in conjunction with other health IT functionalities. For example, CDS and telehealth are used together to improve care in the intensive care unit (ICU) for patients with sepsis and delirium. An offsite hub of experienced ICU physicians and nurses remotely monitors ICU patients in facilities across Banner Health, using cameras with zoom capability. The intensive care specialists in the tele-hub act as part of the care team; in addition to receiving video feed, they communicate verbally with patients and ICU staff members. Predictive analytics are used to generate clinical decision support alerts and reminders, with a special focus on early intervention if a patient’s clinical indicators are trending downward. The 4 lessons described in this study were also used in the ICU sepsis and delirium initiative; staff were involved in the planning process, alerts and reminders were thoroughly tested, the workflow was adjusted to accommodate the physicians in the tele-ICU hub, and up-to-date and complete clinical information for each patient is maintained. In addition, the design principles for alerts described in this study, such as covering most of the screen and providing recommendations for changing the treatment plan within the alert itself, were also used in the ICU sepsis and delirium initiative.

One limitation of this study is that it was conducted at a single health system. Thus, the findings might not be generalizable to other health systems, particularly if a robust health IT infrastructure is not in place. The culture of Banner Health values quality and involved providers and staff at all levels in selecting and implementing health care improvement initiatives. In addition, engineers assisted with implementation. Finally, the study design does not permit conclusions about the causality of the decline in CT scans and the increase in ultrasounds for suspected pediatric appendicitis cases; unobserved factors might have contributed to the changes in CT and ultrasound use.

Future research should focus on ways to improve the implementation and organization learning process, particularly through engagement of frontline staff by leadership [36] and explore how to operationalize previous findings indicating that innovations in hospital settings are more likely to be sustained when intrinsically rewarding to staff, either by making clinician and staff jobs easier to perform or more gratifying [37]. Future research should focus on facilitating health information exchange between providers in different health systems.

Disclaimer: The views expressed in the article are solely the views of the authors and do not represent those of the National Institutes of Health or the U.S. Government.

Acknowledgments: The authors wish to thank the Banner Health team for taking time to share their insights on how health information technology can be used for health care improvement initiatives, especially John Hensing. We also thank Michael Furukawa of the Agency for Healthcare Research and Quality, formerly of the Office of the National Coordinator for Health Information Technology, who played a key role in the conceptualization of this study and data collection.

Corresponding author: Emily Jones, PhD, MPP, National Institutes of Health, 6001 Executive Blvd., #5232 Rockville, MD 20852,

Financial disclosures: None

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