Mixed-method Study of Point-of-care Ultrasound Documentation Compliance

Objectives: Phase One of this mixed-method study aimed to illuminate emergency physicians’ perceptions of the point-of-care ultrasound (POCUS) submission workflow and their receptivity to various proposed interventions. Phase Two then analyzed the efficacy of the implemented intervention that had garnered the most support in the initial qualitative portion.

Background: POCUS has been disruptive to many experienced emergency physicians as it requires competence in a new physical skill, real-time image interpretation, and navigation of novel software for submission to the electronic health record (EHR). Incomplete documentation of a performed POCUS study used for clinical decision-making represents a medicolegal liability and uncapturable reimbursement while potentially exposing the patient to avoidable ionizing radiation and unnecessary cost. This research group previously explored the effect of financial incentives and penalties on the use and subsequent documentation of emergency department (ED) POCUS (1). The most effective facilitator of POCUS submission requires additional investigation.

Methods: The study took place at a tertiary-care, academic, Level I trauma center which utilized Epic (Epic Systems, Verona, WI, USA) for its EHR and Qpath “Classic” (Telexy Healthcare, Maple Ridge, BC, Canada) for POCUS archiving. Participants included 68 emergency medicine attending physicians clinically active for the entire study period: July 2020 – July 2021. During the initial study phase, eligible physicians were stratified into “high,” “low,” and “never” utilizers based on recent POCUS documentation performance. Subsets of high and low utilizers participated in recorded, semi-structured, audiovisual interviews. Thematic analysis was performed on interview transcriptions using the Technology Acceptance Model, a proven theoretical framework (2,3) that explores “usefulness” and “ease of use” as perceived by end users considering adoption. Just prior to the start of the interviews, the ED administration introduced an ongoing incentive program: minimum POCUS documentation numbers were rewarded with additional shift scheduling flexibility. The second phase of the study involved implementation of the proposed intervention that received the most support from both high and low utilizers during Phase One interviews – daily documentation reminder emails. The efficacy of the schedule request incentive and our email intervention in augmenting POCUS documentation was assessed through retrospective data analysis.

Results: Of 68 eligible faculty, only 47 documented a POCUS study during control period July – December 2020. Individual POCUS documentation rate was calculated as studies submitted divided by studies performed (submitted plus unsubmitted) per month. Between 2/12/21 and 3/5/21, interviews were conducted with six physicians in the highest and six in the lowest documentation quartiles. Quantitative interview data has been summarized in [Table 1]. In Phase One, high utilizers emphasized the clinical utility of POCUS, whereas low utilizers expressed concerns over “double billing” and exposure to medicolegal liability with uncertain scan interpretations. For low utilizers, documentation decisions could depend on the performing resident physician’s displayed confidence. Both groups were frustrated by separation between Epic and Qpath. The monthly departmental documentation rate – total studies submitted divided by total performed for all physicians – is shown in [Figure 1]. In Phase Two, this aggregate rate increased appreciably with introduction of schedule requests (Incentive). The rate remained stable, but did not improve further, with addition of reminder emails (Intervention). When reminder emails ceased, but the day-off request incentive continued (Washout), the departmental rate did not drop. [Table 2] splits the department into quartiles based on individual performance over the entire study period.

Conclusions: The implementation of a shift scheduling incentive – additional flexibility through day-off requests – was associated with the largest increase in the departmental POCUS documentation rate. Interviewed physicians incorrectly predicted that email reminders would be the most influential administrative intervention. Departments hoping to improve their POCUS submission rate should identify similar low-cost, motivating incentives to yield a positive return on investment. The study was performed at a single academic site, so its generalizability is somewhat limited to community or county emergency departments, especially those without training programs.

References:
1. Melton M, Rupp JD, Blatt MI, Boyd JS, Barrett TW, Swarm M, Ward MJ: Description of the use of incentives and penalties for point-of-care ultrasound documentation compliance in an academic emergency department. Cureus. 2021, 13:e16199. doi.org/10.7759/cureus.16199.
2. King, WR, He J: A meta-analysis of the technology acceptance model. Inf Manag. 2006, 43:740-55. doi.org/10.1016/j.im.2006.05.003.
3. Nguyen, M, Fujioka, J, Wentlandt, K, Onabajo, N, Wong, I, Bhatia, RS, Bhattacharyya O, Stamenova, V: Using the technology acceptance model to explore health provider and administrator perceptions of the usefulness and ease of using technology in palliative care. BMC Palliat Care. 2020, 19:138. doi.org/10.1186/s12904-020-00644-8.

Funding: This research did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors.