EHR-Integrated Tool Shows Promise in Reducing Headache Referrals, Referral Rates, and Institutional Economic Burden
In a 3-month trial at two primary care sites, neurology referrals decreased by 77%, and brain MRI scans dropped by 35%.
Scott Friedenberg, MD
A collaborative effort between multiple stakeholders led to the development of an electronic health record (EHR) headache tool that aimed to enhance headache diagnosis and management in primary care. Published in Neurology, findings using this Best Practice Alert (BPA) approach led to reductions in neurology referrals and MRI ordering, as well as cost savings, in a 3-month period.1
Prior to the development of this BPA, a multidisciplinary group, including primary care providers (PCPs), neurologists, pharmacists, administrators, and informaticians, analyzed the headache referral process at their institution. In their evaluation, PCPs cited diagnostic and management support, patient requests, and lack of time as key reasons for referrals. In addition, there were noted concerns about communication gaps with neurologists.
During the design thinking (DT) process, the team realized that it was the neurologist’s knowledge, not their physical presence, needed in primary care. The team, which included senior author Scott Friedenberg, MD, a neurologist at Geisinger Health, then designed the BPA, which included a diagnostic questionnaire for common primary headache disorders, reminders for identifying red flags, quick-access links to commonly prescribed medications and imaging, and a tool for electronic provider-to-provider consultations.
The BPA was developed through a paper prototype and refined over three months with PCP feedback, culminating in a tool designed to streamline headache management and improve insurance approvals and lab test orders.It was then tested in 2 primary care sites, featuring 10 physicians and 6 advanced practitioners. In the testing, the BPA automatically appeared whenever a headache diagnosis was entered as a chief complaint or problem for an encounter. Providers included were not given headache education, but rather were trained to use the tool and given a “headache tips” sheet that mirrored the BPA and Express Lane data.
Comparing 3 months before and after the integration of the EHR tool, results showed a 77% decline in neurology referrals, from 332 to 76. In addition, providers entered primary or generic headache diagnoses in the EHR 986 times before the BPA release and 874 after its release. Notably, tests and medications through the Express Lane were used only 5% by providers, with most orders placed predominantly outside of the tool.
"While the numerical results are powerful, what makes this approach more intriguing is the innovative DT methods used to create change," the study authors wrote.1 "The phrase inappropriate referral was stricken from our vocabulary, opting instead to create a strong multidepartmental collaboration allowing for multiple perspectives and a solution that benefitted all stakeholders. An ongoing partnership and feedback ensured effective communication as we worked through our improvement process."
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Prior to the BPA release, 77 brain MRI scans and 31 head CT scans were ordered. After BPA release, there was a 35% reduction in brain MRI scans (n = 50) and around the same number of head CT scans (n = 33). The implementation of the headache tool did not change the number of prescriptions for migraine preventive medications (153 before and 154 after), narcotics (28 before and 22 after), and triptans (95 before and 90 after). Notably, the number of steroid (33 before and 69 after) and NSAID prescriptions (9 before and 40 after) increased after the implementation of the BPA.
In addition to benefits on neurology referrals and imaging scans, there were cost benefits to the EHR headache tool. When multiplying the average number of patients served by PCPs used in the study over a 3-month period (930) by the reduction in consultations (232 patients at $550 per visit) and MRI scans (40 images at $2000 per test), the investigators identified a reduction in spending of $207,600 over the 3-month period, totaling a yearly savings of $830,400.
This was a study that was smaller in structure from a validation standpoint, with only 2 primary care sites; however, the study authors noted they are evaluating new ways to obtain and document patient symptoms and improve the quality of neurologists’ recommendations, to better use electronic consultations. The next iteration will assess the effectiveness of the tool on a system-wide level using a cluster randomized trial.
"Our design thinking approach has shown effective first steps toward improving the mismatch between limited access to neurology expertise and demand for access within our integrated health system,” Friedenberg et al concluded.1 “Future innovations that improve PCP's prescribing habits and include patient outcome monitoring will lead to better use of time-tested medications and measurable effect on value-based care."
