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

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.