P2.073: Improving Follow-Up in Primary Care for Children with Elevated Blood Lead Levels: A Novel Telephone Encounter Nudge

Purpose/Objectives: Childhood lead exposure harms development and growth. Since October 28, 2021, the CDC has defined an elevated blood lead level (EBLL) as ≥ 3.5 µg/dL, identifying children at highest risk. In Philadelphia, 11% of children had documented EBLLs in 2022. Variations in clinical workflows and regional guidelines prompted development of an institutional pathway and highlighted the need for electronic health record (EHR) tools to assist providers with follow-up. This project aimed to increase timely follow-up testing for children with EBLLs in primary care.

Design/Methods: Guided by the institutional pathway, we evaluated existing workflows to develop clinical decision support (CDS) tools, aiming to reduce unintentional care variations. Stakeholder focus groups identified preselected orders and guided note templates as impactful interventions. Pathway recommendations were translated into cascading logic statements within the EHR rules engine to determine appropriate follow-up intervals, labs, and orders. To improve adherence and simplify documentation, we created an order set and automated note template that preselected recommended actions and documentation based on lead levels. These tools were deployed across our large network of 33 primary care offices in urban, suburban, and semi-rural settings on October 3, 2024.

Building on this foundation, we recently leveraged the same logic to control a documentation “nudge” within the universal telephone encounter note for patients overdue for EBLL follow-up. The nudge prompted an optional intervention, displayed the most recent EBLL and result date, linked to the order set and template, and disappeared upon signing the note. Nudge data collection at our pilot site began March 6, 2025. To assess CDS impact, we developed a dashboard to track the primary outcome measure of lead level normalization and process measures, including overdue follow-up of elevated lead levels, nudge triggering, and order set usage.

Results: Our dashboard showed that 52% of 8,948 encounters since October 2021 were overdue for follow-up (Figure 1). Lead levels normalized in 29% of encounters, remained elevated in 45%, and were not followed-up in the remaining cases. Over six months, the order set was used 193 times, with lead level (75%), multivitamin/iron supplementation (54%), and complete blood count/hemoglobin (20%) among the most common orders, reflecting promising user engagement. The ongoing nudge pilot triggered nudges 31 times, affecting 26 patients (Figure 2). Since most patients with EBLLs have not met recommended follow-up, continued monitoring of lead level normalization and follow-up rates is ongoing.

Conclusion/Discussion: Regional EBLL management guidelines were adapted into a standardized pathway and CDS toolset to reduce care variations. Baseline data revealed low compliance with EBLL follow-up. Early post-implementation data show promise in order set engagement and patient identification through nudges. Continuous monitoring using real-time dashboards will evaluate the long-term impact of these interventions on lead level normalization and follow-up adherence.