Emergency Physicians' Knowledge and Attitudes of Clinical Decision Support in the Electronic Health Record: A Survey-based Study

Objectives The objective was to investigate clinician knowledge of and attitudes toward clinical decision support (CDS) and its incorporation into the electronic health record (EHR). Methods This was an electronic survey of emergency physicians (EPs) within an integrated health care delivery system that uses a complete EHR. Randomly assigned respondents completed one of two questionnaires, both including a hypothetical vignette and self-reported knowledge of and attitudes about CDS. One vignette version included CDS, and the other did not (NCDS). The vignette described a scenario in which a cranial computed tomography (CCT) is not recommended by validated prediction rules (the Pediatric Emergency Care Applied Research Network [PECARN] rules). In both survey versions, subjects responded first with their likely approach to evaluation and then again after receiving either CDS (the PECARN prediction rules) or no additional support. Descriptive statistics were used for self-reported responses and multivariate logistic regression was used to identify predictors of self-reported knowledge and use of the PECARN rules, as well as use of vignette responses. Results There were 339 respondents (68% response rate), with 172 of 339 (51%) randomized to the CDS version. Initially, 25% of respondents to each version indicated they would order CCTs. After CDS, 30 of 43 (70%) of respondents who initially would order CCTs changed their management decisions to no CCT versus two of 41 (5%) with the NCDS version (chi-square, p=0.003). In response to self-report questions, 81 of 338 respondents (24%) reported having never heard of the PECARN prediction rules, 122 of 338 (36%) were aware of the rules but not their specifics, and 135 of 338 (40%) reported knowing the rules and their specifics. Respondents agreed with favorable statements about CDS (75% to 96% agreement across seven statements) and approaches to its implementation into the EHR (60% to 93% agreement across seven statements). In multivariable analyses, EPs with tenure of 5 to 14years (odds ratio [AOR]=0.51, 95% confidence interval [CI]=0.30 to 0.86) and for 15years or more (AOR=0.37, 95% CI=0.20 to 0.70) were significantly less likely to report knowing the specifics of the PECARN prediction rules compared with EPs who practiced for fewer than 5years. In addition, in the initial vignette responses (across both versions), physicians with 15years of ED tenure compared to those with fewer than 5years of experience (AOR=0.30, 95% CI=0.13 to 0.69), and those reporting knowing the specifics of the PECARN prediction rules were less likely to order CCTs (AOR=0.53, 95% CI=0.30 to 0.92). Conclusions EPs incorporated pediatric head trauma CDS via the EHR into their clinical judgment in a hypothetical scenario and reported favorable opinions of CDS in general and their inclusion into the EHR. ACADEMIC EMERGENCY MEDICINE 2013; 20: 352-360 (C) 2013 by the Society for Academic Emergency Medicine