EHR default order cuts unnecessary imaging in half for cancer patients

Thanks to a “nudge” introduced into electronic health records, daily imaging was reduced by about 50 percent for patients with advanced cancer during palliative radiation therapy sessions.

Despite the fact that daily imaging is often used for curative radiotherapy, national guidelines consider it unnecessary for palliative radiotherapy because it can increase treatment time and expense for patients in distress, according to a study published last week in JAMA Oncology.

The study, involving five Penn Medicine radiation oncology practices in New Jersey and Pennsylvania, showed that the implementation of a default order within the EHR that specified no daily imaging during palliative radiotherapy resulted in a decrease in daily imaging to 32 percent of treatment courses from 68 percent.

“Cutting down on lower-value healthcare is a hard nut to crack—successfully doing so through the electronic health record in a scalable way opens a whole new set of tools we can bring to bear on the problem,” says Justin Bekelman, MD, the study’s co-senior author and director of the Penn Center for Cancer Care Innovation at the Abramson Cancer Center and associate professor of radiation oncology and medical ethics and health policy. “By eliminating friction involved with ordering guideline-based cancer care, we showed that clinicians quickly adopt it.”

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In addition, because of the ability to eliminate unnecessary daily imaging, the radiotherapy session time in the study was reduced by an average of two minutes per session. This is welcome news for palliative care patients, who are often in pain or discomfort and for whom daily imaging unnecessarily extends the duration of each radiation therapy session.

“We recognized that patients were undergoing unnecessary scans due to the standard care habits, and we understood that this frequent imaging was causing more discomfort than benefit,” says lead author Sonam Sharma, MD, an assistant professor of radiation oncology at the Icahn School of Medicine at Mount Sinai, who conducted this research while in the Perelman School of Medicine at the University of Pennsylvania. “This shows that a minor adjustment can have a dramatic effect on medical practice.”

In the study, radiation oncology practices were randomly assigned to take up the EHR nudge. At the same time, however, doctors were not precluded from choosing to order daily imaging if they believed it was the best course of treatment for their patients.

“Nudges can be very powerful—most previous interventions have been focused on increasing high-value care, such as boosting flu vaccination rates,” says co-senior author Mitesh Patel, MD, MBA, director of the Penn Medicine Nudge Unit and assistant professor of medicine and health care management. “This is one of the first cases where we applied a nudge to decrease a lower-value unnecessary behavior. It not only worked, but its effect has been sustained and implemented throughout our entire health system.”