Weihan Chen1, David T Saxon2, Michael P Henry3, John R Herald4, Rob Holleman5, Debbie Zawol6, Stacy Sivils7, Mohamad A Kenaan8, Theodore J Kolias9, Hitinder S Gurm10, Nicole M Bhave11. 1. Department of Internal Medicine, Michigan Medicine, University of Michigan, Ann Arbor, Michigan; Department of Internal Medicine, Veterans Affairs Ann Arbor Healthcare System, Ann Arbor, Michigan. 2. Department of Internal Medicine, Michigan Medicine, University of Michigan, Ann Arbor, Michigan; Department of Internal Medicine, Veterans Affairs Ann Arbor Healthcare System, Ann Arbor, Michigan; Division of Cardiology, Department of Internal Medicine, University of North Carolina Medical Center, Chapel Hill, North Carolina. 3. Department of Internal Medicine, Michigan Medicine, University of Michigan, Ann Arbor, Michigan; Department of Internal Medicine, Veterans Affairs Ann Arbor Healthcare System, Ann Arbor, Michigan; Section of Cardiology, Department of Internal Medicine, UChicago Medicine, Chicago, Illinois. 4. Department of Internal Medicine, Michigan Medicine, University of Michigan, Ann Arbor, Michigan; Department of Internal Medicine, Veterans Affairs Ann Arbor Healthcare System, Ann Arbor, Michigan; Department of Cardiology, Kaiser Permanente Los Angeles Medical Center, Los Angeles, California. 5. Veterans Affairs Center for Clinical Management Research, Ann Arbor, Michigan. 6. Department of Internal Medicine, Veterans Affairs Ann Arbor Healthcare System, Ann Arbor, Michigan. 7. Section of Cardiology, Department of Internal Medicine, Veterans Affairs Ann Arbor Healthcare System, Ann Arbor, Michigan. 8. Division of Cardiovascular Medicine, Department of Internal Medicine, Michigan Medicine, University of Michigan, Ann Arbor, Michigan; Section of Cardiology, Department of Internal Medicine, Veterans Affairs Ann Arbor Healthcare System, Ann Arbor, Michigan; Spectrum Health Cardiovascular Medicine, Grand Rapids, Michigan. 9. Division of Cardiovascular Medicine, Department of Internal Medicine, Michigan Medicine, University of Michigan, Ann Arbor, Michigan. 10. Division of Cardiovascular Medicine, Department of Internal Medicine, Michigan Medicine, University of Michigan, Ann Arbor, Michigan; Section of Cardiology, Department of Internal Medicine, Veterans Affairs Ann Arbor Healthcare System, Ann Arbor, Michigan. 11. Division of Cardiovascular Medicine, Department of Internal Medicine, Michigan Medicine, University of Michigan, Ann Arbor, Michigan; Section of Cardiology, Department of Internal Medicine, Veterans Affairs Ann Arbor Healthcare System, Ann Arbor, Michigan. Electronic address: nbhave@umich.edu.
Abstract
BACKGROUND: Transthoracic echocardiograms (TTEs) account for approximately half of U.S. spending on cardiac imaging. We developed an electronic medical record (EMR)-based decision-support algorithm for TTE ordering and hypothesized that it would increase the appropriateness of TTE orders. METHODS: This prospective observational study was performed at the Veterans Affairs Ann Arbor Healthcare System. From October to December 2016 (preintervention), consecutive TTEs ordered in the inpatient, outpatient, and emergency department settings were included. In May 2017, a decision-support algorithm was incorporated into the EMR, giving immediate feedback to providers. Chart review was performed for TTEs ordered from June to August 2017 (early intervention) and from June to August 2018 (late intervention). Appropriateness was determined based on the 2011 appropriate use criteria for echocardiography. RESULTS: Appropriate TTE orders increased from 87.6% preintervention to 94.5% at early intervention (z = 0.00018) but decreased to 90.0% at late intervention (z = 0.51, compared with preintervention). Among patients with no previous TTEs in our system, 95.3% of TTEs were appropriate, compared with 87.7% of TTEs for patients with prior TTEs within 30 days prior (odds ratio = 2.85; 95% CI, 1.18-6.31; P = .005). CONCLUSIONS: The EMR algorithm initially increased the percentage of appropriate TTEs, but this effect decayed over time. Further study is needed to develop EMR-based interventions that will have lasting impacts on provider ordering patterns.
BACKGROUND: Transthoracic echocardiograms (TTEs) account for approximately half of U.S. spending on cardiac imaging. We developed an electronic medical record (EMR)-based decision-support algorithm for TTE ordering and hypothesized that it would increase the appropriateness of TTE orders. METHODS: This prospective observational study was performed at the Veterans Affairs Ann Arbor Healthcare System. From October to December 2016 (preintervention), consecutive TTEs ordered in the inpatient, outpatient, and emergency department settings were included. In May 2017, a decision-support algorithm was incorporated into the EMR, giving immediate feedback to providers. Chart review was performed for TTEs ordered from June to August 2017 (early intervention) and from June to August 2018 (late intervention). Appropriateness was determined based on the 2011 appropriate use criteria for echocardiography. RESULTS: Appropriate TTE orders increased from 87.6% preintervention to 94.5% at early intervention (z = 0.00018) but decreased to 90.0% at late intervention (z = 0.51, compared with preintervention). Among patients with no previous TTEs in our system, 95.3% of TTEs were appropriate, compared with 87.7% of TTEs for patients with prior TTEs within 30 days prior (odds ratio = 2.85; 95% CI, 1.18-6.31; P = .005). CONCLUSIONS: The EMR algorithm initially increased the percentage of appropriate TTEs, but this effect decayed over time. Further study is needed to develop EMR-based interventions that will have lasting impacts on provider ordering patterns.
Authors: Fay Y Lin; Allison M Dunning; Jagat Narula; Leslee J Shaw; Heidi Gransar; Daniel S Berman; James K Min Journal: J Am Coll Cardiol Date: 2013-05-22 Impact factor: 24.094
Authors: Niti R Aggarwal; Punsak Wuthiwaropas; Barry L Karon; Fletcher A Miller; Patricia A Pellikka Journal: J Am Soc Echocardiogr Date: 2010-01-18 Impact factor: 5.251
Authors: Nicole M Bhave; Ibrahim N Mansour; Federico Veronesi; Rabia R Razi; Roberto M Lang; R Parker Ward Journal: J Am Soc Echocardiogr Date: 2011-03 Impact factor: 5.251
Authors: Rajan Sacha Bhatia; David M Dudzinski; Creagh E Milford; Michael H Picard; Rory B Weiner Journal: Echocardiography Date: 2014-01-22 Impact factor: 1.724
Authors: Saul Blecker; R Sacha Bhatia; John J You; Douglas S Lee; David A Alter; Julie T Wang; Hannah J Wong; Jack V Tu Journal: JACC Cardiovasc Imaging Date: 2013-04