EMR Helps Reduce Unnecessary CT Scans in ER Patients with Abdominal Pain

The new study demonstrated that when the application is utilized, patients are 10% less apt to undergo a CT scan, without increasing the number of patients who are admitted to the hospital.

Abdominal pain is the most typical complaint why people seek care in emergency rooms in the United States, accounting for 10 million visits each year. But the symptoms may be caused by myriad problems, from those that can be fixed with a single dose of an over-the-counter drug to those that could prove life-threatening within hours: from an attack of gastrointestinal (GI) distress to an ectopic pregnancy; from constipation to an appendix about to burst; from a hernia to signs of a chronic disorder such as Crohn’s disease.

This complex diagnostic face-off plays a huge role in why emergency physicians tend to lean heavily on tests like CT scans, even though they expose patients to radiation and there are few clear guidelines on which patients should get them. Since the mid-1990s, the use of CT scans to diagnose ER patients has surged, increasing ten-fold. Currently, 14% of all emergency room patients are scanned--as statistic experts frequently refer to as a contributor to expanding health care costs.

“Most patients with abdominal pain aren’t in major danger, but some of the conditions that are on the list of things we consider as causes can be fatal within a short amount of time,” said Angela M. Mills, MD, an assistant professor of emergency medicine and medical director of the emergency department at the Hospital of the University of Pennsylvania. “We need to be sure about our diagnosis in order to keep patients safe, but we need to balance the risks of giving a test like a CT scan with the chance that the test will truly provide us with information we could not get in some other way with less risk to the patient.”

The Penn researchers investigated a new tool embedded within patients’ EMRs that walked physicians through a series of questions that served as checks and balances for their decision to order a CT scan to investigate a patient’s abdominal pain. They were questioned, for instance, on what diagnosis they were striving for (from appendicitis to colitis to an ovarian cyst or tumor), and how likely they thought it was that the patient really had that problem. Moreover, if a medical resident ordered the test, it had to be approved by an attending physician before the patient could receive the scan. Those steps, the researchers said, appeared to play a role in prompting the care team to rethink their choice of tests.

The authors examined 11,176 patients seen in two Penn Medicine emergency rooms between July 2011 and March 2012. Before implementing the new accountability tool, 32.3% of patients seen received CT scans. After its use was adopted, the number dropped to 28%. After adjusting for various confounding factors, the researchers determined that patients were 10% less likely to undergo a CT scan after the tool was built into the electronic medical record. The patients were no more likely to be admitted to the hospital--a typical event when a diagnosis remains uncertain--after implementation of the approach.

An enhanced version of the program, launched since the new study was completed, also provides data on how many different abdominal imaging tests the patient has previously had at Penn, and tallies their total radiation exposure from previous CT scans. Dr. Mills hopes that additional data will help cut down on unnecessary tests even more. “For many patients, like those who are older or have cancer, this tool might not make a difference,” Dr. Mills said, “but there are many abdominal patients who are younger, healthier, and who have things that are usually not life-threatening like kidney stones, for whom we are hoping this will reduce their exposure to unnecessary radiation.”

In the future, as EMRs become more effective and accessible between different hospitals, she hopes a similar tool can be used to obtain data about the past CT scans of a larger number of patients.

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University of Pennsylvania’s Perelman School of Medicine