Reducing Unwarranted Variation in Emergency Department Laboratory Test Ordering With a Feedback-Based Decision Support Tool: Qualitative Formative Evaluation

Background Substantial unwarranted variations exist in laboratory test ordering practices in the emergency department (ED), despite a plethora of digital health interventions to facilitate laboratory test ordering consistent with best-practice recommendations. Drivers of such variation are many and varied and deeply ingrained within organizational culture and work practices. An appreciation of the impact of contextual factors on digital health implementation is essential for achieving intended outcomes. Objective This study aimed to design, develop, and formatively evaluate a digital health tool to reduce unwarranted variation in pathology test ordering, the Emergency Department Pathology Ordering Support Tool (ED-POST), through co-design and collaboration with key stakeholders. Methods A multimethod qualitative co-design approach with formative evaluation was undertaken across 3 phases in a large Australian ED between April and December 2023. Phase 1 involved semistructured interviews with ED clinicians and observations to examine existing workflows, decision-making processes, and user requirements, informing prototype development. Phase 2 included demonstrations of the ED-POST prototype to ED clinicians, followed by semistructured interviews to explore perceived usability, utility, and impact. Phase 3 comprised a stakeholder forum with clinicians, researchers, and developers to assess scalability and refine design. Participants were selected purposively, and data were analyzed inductively to generate themes. Results The perceived use and value of ED-POST varied depending on user role. Triage nurses who ordered preliminary tests at the beginning of the patient encounter were more likely to use ED-POST for point-of-order decision-making. Junior physicians saw value in ED-POST as a form of backup to reaffirm personal impressions. Senior physicians responsible for determining a differential diagnosis at a later stage of the patient journey saw less utility in ED-POST for supporting ordering decisions but saw potential in its big-data synthesis capabilities to support reporting and quality improvement. Conclusions Understanding roles and workflows in the early developmental stages of a digital health tool and user involvement at every stage are necessary to optimize adoption, scalability, and outcomes. Future digital tool design and implementation initiatives should focus on feedback-driven mechanisms with real-time data integration to facilitate more informed ordering behaviors.