Electronic Health Record Alert to Promote Adoption of Limited Transthoracic Echocardiograms in Primary Care and Cardiology Clinics: A Mixed Methods Evaluation.

Background: A limited transthoracic echocardiogram (TTE) can be an appropriate, lower-cost substitute for a full TTE. We assessed the impact of an electronic health record alternative alert promoting the adoption of limited TTEs on the ordering practices of cardiology clinicians and primary care providers and captured their perspectives on the initiative.

Methods: The alert was deployed in a cardiology clinic and 4 primary care clinics at an academic medical center. The alert provided clinical guidance on the appropriate use of limited TTEs when a clinician selected a full TTE order. We used logistic regression to estimate the change in the proportion of limited versus full TTEs ordered between the baseline and intervention periods in clinics with and without the alert. We also conducted interviews with 24 clinicians (5 cardiologists and 19 primary care providers) to identify implementation barriers and facilitators.

Results: Cardiology clinicians ordered 10 654 and 3761 TTEs during the baseline and intervention periods, respectively, for 9100 patients. Primary care providers ordered 723 and 617 TTEs during the baseline and intervention periods for 1273 patients. The model estimated that the percentage of limited TTEs ordered increased by 16.1±2.3 percentage points (P<0.0001) in the cardiology clinic with the alert and by 13.2±1.5 percentage points (P<0.0001) in the primary care clinics with the alert from baseline to post-intervention. Ordering practices did not change in the cardiology (0.7±0.6 percentage points; P=0.24) or primary care (0.7±1.0 percentage points; P=0.52) clinics without the alert. Clinicians viewed the alert as acceptable. Cardiologists appreciated that the alert was concise, whereas primary care providers wanted more information from the alert.

Conclusions: An alternative alert providing clinical guidance on the use of limited TTEs at the point of care increased the selection of this lower-cost test in cardiology and primary care clinics. Perspectives on the alert differed between specialists and nonspecialists, highlighting the importance of tailoring intervention design to clinical expertise.