Development of an Educational Strategy and Decision Support Tool to Enhance Appropriate Use of Stress Echocardiography at a Large Academic Medical Center: A Prospective, Pre- and Postintervention Analysis

•Inappropriate ordering of cardiac diagnostic testing remains an issue.•Little is known about rarely inappropriate stress echocardiography rates in a single-payer health system.•Methods to improve that focus solely through education have shown little success.•A novel approach incorporating education and new ordering requisition (a decision support tool) was implemented.•The 2011 AUC were able to classify the majority of studies.•Rarely appropriate testing decreased by 39% and appropriate testing increased by 17%.