Abstract
Background Point-of-care ultrasound (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 potential medicolegal liability, may expose the patient to repetitive or potentially unnecessary imaging, and is a missed opportunity for reimbursement. Identifying effective facilitators of ED POCUS documentation completion requires additional investigation. Methods In the first part of this mixed-methods study, eligible attending physicians were stratified into levels of use ("high"/"low"/"never") based on recent POCUS documentation performance. Semi-structured interviews were conducted with high and low utilizers to explore their perceptions of the POCUS submission workflow and their receptivity to various proposed interventions. Qualitative data were analyzed using a thematic analysis that explored perceived usefulness and usability. The second part of the study consisted of two intervention phases. First, physicians achieving minimum POCUS documentation numbers were rewarded with additional shift scheduling flexibility. In the second phase, the intervention that garnered the most interview support, daily documentation reminder emails, was implemented. The primary outcome was the individual POCUS documentation rates calculated as all studies submitted divided by all studies performed (submitted plus unsubmitted) per month. Provider-level monthly data was aggregated into a departmental rate. Results Interviews were conducted with 12 physicians, six from the highest and six from the lowest documentation quartiles. Both groups supported the same two proposed interventions: reminder emails ranked first, then monetary rewards ranked second. 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, a documentation decision could be dependent on the performing resident physician's displayed confidence. Both groups voiced frustration with the need to use a separate program, Qpath (Telexy Healthcare, Inc, Maple Ridge, British Columbia, Canada), for POCUS documentation. During intervention phase one, the aggregate departmental documentation rate increased from 44.6% to 60.1% with the introduction of the schedule request incentive. This improvement was seen across all documentation quartiles. The departmental rate remained stable and did not improve further following the addition of the daily documentation reminder emails in intervention phase two. When reminder emails ceased yet the day-off request incentive continued, the departmental rate did not drop. Conclusions The implementation of a non-financial shift scheduling incentive correlated with the largest increase in departmental POCUS documentation rate. Interviewees incorrectly predicted that email reminders would be the most influential intervention highlighting a mismatch between physician perception and effective drivers of behavior change. Further investigation may focus on determining the size and longevity of the isolated impact of a schedule request incentive, as one might expect diminishing marginal utility.