Key result
Trial tests if a CDS tool with behavioral nudges improves guideline-concordant CT ordering for PE.
Why the study?
Many CT scans for pulmonary embolism in emergency departments are avoidable, and provider adoption of guideline-recommended prediction rules remains low.
Does an EHR-agnostic clinical decision support tool with behavioral nudges improve guideline-concordant CT ordering for pulmonary embolism among emergency department providers?
RCT
stepped-wedge cluster randomized
Yes
Does an EHR-agnostic clinical decision support tool with behavioral nudges improve guideline-concordant CT ordering for pulmonary embolism among emergency department providers?
This study protocol outlines a stepped-wedge cluster randomized trial to evaluate whether behavioral nudges integrated into an EHR-agnostic clinical decision support tool can improve guideline-concordant CT ordering for pulmonary embolism in the emergency department.
If effective, nudges may boost appropriate PE CT ordering in EDs; this RCT will confirm impact on guideline concordance.
About one-third of the computed tomography (CT) scans ordered yearly to evaluate for pulmonary embolism (PE) in emergency departments (ED) in the U.S. are avoidable. Clinical guidelines recommend the use of validated PE prediction rules which reduce CT scan ordering without an increase in missed PEs, but there is low provider adoption. Clinical decision support (CDS) that incorporates these rules along with nudges (subtle, non-coercive influences on decision-making) may improve provider adoption. In our pilot trial of a PE risk CDS tool with a nudge at order entry, adoption was significantly higher (39.1%) than for the tool without nudges (20.7%). The tool was developed on an EHR-agnostic web-based platform, designed for dissemination to work with any EHR. The objective of this study is to evaluate the tool with a nudge in a multi-site, randomized trial. A hybrid type III, stepped-wedge, ED-level, cluster randomized trial will be conducted. Study settings include 12 EDs in three geographically diverse health care systems. The EDs will be randomized over 9 steps over 30 months, ensuring at least 3 months of intervention exposure for all EDs. We will randomize matched pairs of EDs based on patient volume in each stratum to early intervention or late intervention. All providers ordering CTs for the evaluation of PE in adult patients at the site EDs will be included. Our study will be guided by two complementary frameworks: Behavioral Change Wheel Framework and Proctor’s Implementation Outcomes Framework. Nudge implementation strategies in the CDS user interface will be a peer comparison of providers’ hit rates for CTs ordered for PE and salient messaging. We will use an EHR-agnostic, web-based platform to implement the tool. The primary outcome will be guideline-concordant CT ordering for PE. This trial will advance our understanding of the impact of behavioral strategies on improving provider adoption of CDS. Additionally, the trial will confirm the impact of guideline-concordant CT ordering on CT yield rates across a diverse patient population. The use of an EHR-agnostic platform helps maximize the dissemination potential of the core evidence-based practices it facilitates. NCT07249385; Registered 11/18/2025.
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Khan et al. (2026) conducted an RCT in Pulmonary embolism. Clinical decision support (CDS) tool with nudge implementation strategies vs. Usual care was evaluated on Guideline-concordant CT ordering for PE. A clinical decision support tool with behavioral nudges will be evaluated in a stepped-wedge cluster randomized trial to determine its impact on guideline-concordant CT ordering for pulmonary embolism.
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