A clinical reminder order check (CROC) intervention to improve guideline-concordant imaging practices for men with prostate cancer: A pilot study

INTRODUCTION AND OBJECTIVE: Almost half of US Veterans with low-risk prostate cancer undergo a wasteful imaging workup after diagnosis. EMR-based Clinical Reminder Order Checks (CROC) have been implemented as interventions in other health settings with a moderate amount of success in changing ordering behaviors among providers. We used National Comprehensive Cancer Network's (NCCN) guidelines to design and implement a CROC that alerts ordering providers of potentially inappropriate imaging orders in real-time based on patient features of men diagnosed with low-risk prostate cancer. METHODS: We implemented the CROC at VA New York Harbor Healthcare System (VANYHHS) from April 2, 2015 to November 15, 2017 in the local Electronic Medical Record (EMR) system. The notification appeared in a pop-up window when an imaging test was ordered for a patient with prostate cancer and PSA < 20 ng/ml. We then used VA administrative claims from the VA's Corporate Data Warehouse to analyze imaging rates among men with low-risk prostate cancer at VHANYHHS before and after CROC implementation. We also performed a content analysis of the freeform text justifications entered by ordering providers for each override of the notification. RESULTS: 57% (117/205) of Veterans prior to CROC installation and 73% (61/83) of Veterans post-intervention with low-risk prostate cancer were appropriately not imaged. Men with low-risk prostate cancer treated in the post-intervention period were 1.3 times as likely to avoid imaging (thereby receiving guideline-concordant care) compared to those treated prior to the intervention. The most frequent override justification cited by providers were Unclear/None (67%) and Imaging for Non-Prostate Cancer Staging Concern (14.3%). CONCLUSIONS: The EMR-based CROC intervention is associated with moderate improvement in guideline-concordant imaging practices for Veterans with low-risk prostate cancer. Results of this pilot study will help inform intervention implementation across VA Medical Center systems in a national-level trial. Guidelineconcordant imaging practices at the VA promote cost-effectiveness and quality of care for Veterans by reducing unnecessary testing.