Study Objectives: Overuse of health care services is a major contributor to rising health care costs. As part of an institutional affordability initiative, we created an emergency medicine (EM) “top 5” list consisting of tests, treatments, and disposition decisions that are of little value to patients. Each item had to be evidence-based, amenable to standardization, and actionable. Methods: Design: Three-phase consensus and survey process. Setting and Participants: An integrated delivery system with 2 academic and 4 community EDs. The technical expert panel included ED leadership and content experts in imaging, admissions and transfers. The provider survey was administered to all physicians, physician assistants and nurse practitioners who practice in the 6 EDs (N=286). Measurement: In phase I, the technical expert panel used a modified Delphi process with 2 rounds of surveys to rank a list of low-value clinical actions. The initial list was generated by TEP brainstorming and email solicitation of providers. Technical expert panel members ranked each item on 3 domains: contribution to cost, benefit to patients, and actionability by emergency medicine providers. In phase II, all providers were surveyed to assess distinct dimensions of each item using 2 5-point Likert scales: (a) potential benefit or harm to the patient and (b) actionable by the provider. In phase III, the technical expert panel voted for a final “Top Five” list based on survey results and discussion. Pearson correlation was used to assess inter-domain correlation. Results: The initial solicitation yielded 64 low-value clinical actions. The phase I ranking process narrowed this to 7 lab tests, 3 medications, 4 imaging studies and 3 disposition decisions, which were included in an provider survey that had a 78% response rate. All 17 items had a median score of “very” or “somewhat” beneficial and actionable. For all items, there was significant positive correlation between scores on benefit and actionability (ρ = 0.19-0.37, P-value = 0.09-0.001). Composite scores were similar when stratified by provider type (attending/resident versus nurse practitioners/physician assistants), setting (academic versus community), and experience (1-2 years, 3-9y versus >10y). In phase III, 1 action received unanimous technical expert panel support, 5 received majority support, and 12 received at least 1 vote. The final “Top Five” list included: 1) Don't order CT of the cervical spine for patients after trauma who do not meet the NEXUS or Canadian C-Spine Rule, 2) Don't order CT to diagnose pulmonary embolism without first risk stratifying, 3) Don't order MRI of the lumbar spine for patients with low back pain without “red flags,” 4) Don't order CT of the head for patients with mild traumatic head injury who do not meet New Orleans Criteria or Canadian CT Head Rule, 5) Don't order coagulation studies for patients without hemorrhage or suspected coagulopathy. Conclusion: We identified, through a consensus process, clinical actions that were of low value and within provider control. While organized emergency medicine is absent from the 17 medical specialties involved in the “Choosing Wisely” campaign, our project has piloted a methodology that emergency medicine providers can use to identify actionable targets of overuse.