ArticleImplementation science : IS2026
Nudging provider adoption of clinical decision support: study protocol for a stepped-wedge cluster randomized, hybrid type III trial of an electronic health record-agnostic pulmonary embolism risk tool.
Article in Implementation science : IS, 2026. The graph could read no effect estimate from its abstract, so it casts no vote on the map. It is linked to trial NCT07249385 (Nudging Provider Adoption of Clinical Decision Support), which is not on this map. Not yet cited in PubMed.
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Nudging Provider Adoption of Clinical Decision Support: Implementation of an EHR-Agnostic Pulmonary Embolism Risk Prediction Tool
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17 authors.
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Abstract
backgroundAbout 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.
methodsA 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. DISCUSSION: 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.
trial registrationNCT07249385; Registered 11/18/2025.
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