Effect of a Clinical Decision Support Tool for Identifying Patients Benefiting from End-of-Life Discussions on Emergency Department Clinician Behavior

Abstract

Background

Electronic health records (EHRs) are intended to improve clinical practice, but excessive alerts can be counterproductive, leading to workarounds. The Mortality Surprise Question (MSQ), a tool for identifying patients who might benefit from early end-of-life discussions, was integrated into the Emergency Department (ED) EHR admission process.

Objectives

This study investigated how the staged implementation of a clinical decision support tool at the point of admission order entry affected ED clinician admission order practices.

Methods

This retrospective cohort study examined ED admission orders from 2023 across three EDs. Clinicians used either the Quicklist or Disposition tab in the Epic EHR for admissions. The MSQ was introduced in two phases, first to the Quicklist on May 31, 2023, and then to the Disposition tab on September 11, 2023. Admissions from both tabs were analyzed pre- and post-MSQ implementation. Statistical analysis included chi-square testing to compare the admission source in the EHR after each phase of implementation of the MSQ to examine changes in the clinicians' admission workflow, with further categorization based on clinician EHR experience.

Results

Overall, 53,897 patients were admitted from the ED, with 29,542 (55%) admissions via the Quicklist and 24,355 (45%) via the Disposition tab. A statistically significant difference was found in Quicklist admission proportions before and after MSQ implementation in both workflows. As compared with clinicians with less than 2 years of experience with the EHR, clinicians with 2 to 4 years of EHR use were less likely to use the Quicklist after MSQ implementation, whereas those with over 4 years of use were more likely to use it.

Conclusion

The MSQ disrupted established workflows, prompting clinicians to initially adopt more effortful alternatives to avoid the new cognitive task. Embedding the MSQ into these alternatives reduced resistance, highlighting that removing optionality promotes adoption. Accounting for clinician habits and potential workarounds can enhance the integration and efficiency of new quality improvement measures.

Keywords

workaround - EHR - health record - workflow - Mortality Surprise Question

Protection of Human and Animal Subjects

This study was reviewed by the Yale University Institutional Review Board and did not include any interventions on human or animal subjects.

^* These authors made equal contributions as senior authors.

Publikationsverlauf

Eingereicht: 09. Januar 2025

Angenommen: 17. Juni 2025

Artikel online veröffentlicht:
14. November 2025

• References

• 1 Guo U, Chen L, Mehta PH. Electronic health record innovations: Helping physicians - One less click at a time. HIM J 2017; 46 (03) 140-144
• 2 Boonstra A, Jonker TL, van Offenbeek MAG, Vos JFJ. Persisting workarounds in electronic health record system use: types, risks and benefits. BMC Med Inform Decis Mak 2021; 21 (01) 183
• 3 Haydar SA, Strout TD, Bond AG, Han PK. Prognostic value of a modified surprise question designed for use in the emergency department setting. Clin Exp Emerg Med 2019; 6 (01) 70-76
• 4 Herskovits AZ, Newman T, Nicholas K. et al. Comparing clinician estimates versus a statistical tool for predicting risk of death within 45 days of admission for cancer patients. Appl Clin Inform 2024; 15 (03) 489-500
• 5 Murphy B. The do's and don'ts of EHR use for new resident physicians. American Medical Association. Published August 6, 2024. Accessed June 23, 2025 at: https://www.ama-assn.org/practice-management/digital-health/do-s-and-don-ts-ehr-use-new-resident-physicians#:~:text=The%20way%20you%20interact%20with%20the%20EHR,and%20group%20vice%20president%20of%20medical%20education
• 6 Mishra V, Liebovitz D, Quinn M, Kang L, Yackel T, Hoyt R. Factors that influence clinician experience with electronic health records. Perspect Health Inf Manag 2022; 19 (01) 1f
• 7 Chishtie J, Sapiro N, Wiebe N. et al. Use of Epic electronic health record system for health care research: Scoping review. J Med Internet Res 2023; 25: e51003
• 8 Wu DTY, Xu C, Kim A, Bindhu S, Mah KE, Eckman MH. A scoping review of health information technology in clinician burnout. Appl Clin Inform 2021; 12 (03) 597-620