Impact of Non-interruptive Medication Laboratory Monitoring Alerts in Ambulatory Care

Lo, Helen G.; Matheny, Michael E.; Seger, Diane L.; Bates, David W.; Gandhi, Tejal K.

doi:10.1197/jamia.m2687

Cited by 70 publications

(63 citation statements)

References 29 publications

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“…Other approaches could be possible as well. For example, we rigorously avoided the forcing function approach, but that approach has shown benefit in studies of medication safety prompting systems 24,25 even though it also leads to high override rates. 26 As another example, a recent Cochrane review 1 found that computer-generated reminders delivered on paper were effective in changing practice and that providing space for physicians to respond led to greater effect size; including an explanation of the reminder, however, which we avoided, also improved effect size.…”

Section: Discussionmentioning

confidence: 99%

Clinical Reminders Designed and Implemented Using Cognitive and Organizational Science Principles Decrease Reminder Fatigue

Green¹,

Nease²,

Klinkman³

2015

The Journal of the American Board of Family Medicine

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Background:Response rates to point-of-care clinical reminders typically decrease over time. We hypothesized that this "reminder fatigue" could be prevented by (1) applying sound human factors engineering and cognitive science principles in designing the reminder system, and (2) implementing the reminders with rigorous attention to organizational science principles.Methods: This was a retrospective cohort enumeration from January 1, 2006, through July 31, 2012, in a set of 5 academically affiliated family medicine practices. We modeled the odds ratio of clinician action in response to a reminder according to the number of reminders issued during the encounter, the number of problems on the patient's problem list, patient age, and time (number of months since launch) using logistic regression with clustering by encounter.Results: There were issued 988,149 reminders at 453,537 encounters during the sampling frame. Action was taken in response to 60.1% of reminders, and discussion or consideration was documented in another 26.8%. The odds ratios for action in response to reminders over time, by number of prompts during the encounter, and by number of problems were 1.01, 1.18, and 1.02, respectively. Key design features included issuing reminders only when a service was due, allowing clinicians to attend to reminders when doing so fit their workflow (vs forcing attention at a specific time), keeping reminders very short and simple (action item only, no explicative material), and a team meeting and buy-in process before each new reminder was implemented.

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Section: Discussionmentioning

confidence: 99%

Clinical Reminders Designed and Implemented Using Cognitive and Organizational Science Principles Decrease Reminder Fatigue

Green¹,

Nease²,

Klinkman³

2015

The Journal of the American Board of Family Medicine

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“…While prior literature either evaluates only physician test ordering 5,6 or overall test completion, 8,9 rarely are both reported. 20,40 Most studies have reported only completion rates, usually determined from claims data, 41 while we have separated outcomes into test ordering and patient completion of ordered tests.…”

Section: Discussionmentioning

confidence: 99%

“…Some studies report clinician ordering only, 5,6 while others report overall test completion rates. [7][8][9][10][11] In addition, little information is available about why patients fail to complete ordered laboratory tests.…”

Section: Introductionmentioning

confidence: 99%

Patient Completion of Laboratory Tests to Monitor Medication Therapy: A Mixed-Methods Study

et al. 2012

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BACKGROUND:Little is known about the contribution of patient behavior to incomplete laboratory monitoring, and the reasons for patient non-completion of ordered laboratory tests remain unclear. OBJECTIVE: To describe factors, including patientreported reasons, associated with non-completion of ordered laboratory tests. DESIGN: Mixed-Methods study including a quantitative assessment of the frequency of patient completion of ordered monitoring tests combined with qualitative, semi-structured, patient interviews. PARTICIPANTS: Quantitative assessment included patients 18 years or older from a large multispecialty group practice, who were prescribed a medication requiring monitoring. Qualitative interviews included a subset of show and no-show patients prescribed a cardiovascular, anticonvulsant, or thyroid replacement medication. MAIN MEASURES: Proportion of recommended monitoring tests for each medication not completed, factors associated with patient non-completion, and patientreported reasons for non-completion. KEY RESULTS: Of 27,802 patients who were prescribed one of 34 medications, patient non-completion of ordered tests varied (range: 0-24 %, by drug-test pair). Factors associated with higher odds of test noncompletion included: younger patient age (< 40 years vs. ≥ 80 years, adjusted odds ratio [AOR] 1.52, 95 % confidence interval [95 % CI] 1.27-1.83); lower medication burden (one medication vs. more than one drug, AOR for non-completion 1.26, 95 % CI 1.15-1.37), and lower visit frequency (0-5 visits/year vs. ≥ 19 visits/ year, AOR 1.41, 95 % CI 1.25 to 1.59). Drug-test pairs with black box warning status were associated with greater odds of non-completion, compared to drugs without a black box warning or other guideline for testing (AOR 1.91,. Qualitative interviews, with 16 no-show and seven show patients, identified forgetting as the main cause of non-completion of ordered tests. CONCLUSIONS:Patient non-completion contributed to missed opportunities to monitor medications, and was associated with younger patient age, lower medication burden and black box warning status. Interventions to improve laboratory monitoring should target patients as well as physicians.

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“…23,[38][39][40][41][42][43][44][45] One study (4%) was conducted in Europe and Australia. 46,47 Thirteen studies (57%) evaluated CCDSSs in primary care,* 5 (22%) in hospital outpatient ambulatory care, 26,31,33,36,44 and 5 (22%) in hospital inpatient care. 22,25,32,34 Intervention.-Fifteen different CCDSSs were studied, of which 6 (40%) were focused solely on laboratory testing, † 5 (33%) also included other reminders such as treatment options, [27][28][29]31,39,[41][42][43] and 4 (27%) were not stand-alone systems, but were developed by an EHR software vendor.…”

Section: Included Studiesmentioning

confidence: 99%

“…[20][21][22][24][25][26][27][28][29][30][31][32][33][34][35][36][37] Eight studies (35%) were conducted in Europe. 23,[38][39][40][41][42][43][44][45] One study (4%) was conducted in Europe and Australia.…”

Section: Included Studiesmentioning

confidence: 99%

The Effects of Computerized Clinical Decision Support Systems on Laboratory Test Ordering: A Systematic Review

Delvaux¹,

Thienen²,

Heselmans³

et al. 2017

Archives of Pathology &Amp; Laboratory Medicine

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Context.-Inappropriate laboratory test ordering has been shown to be as high as 30%. This can have an important impact on quality of care and costs because of downstream consequences such as additional diagnostics, repeat testing, imaging, prescriptions, surgeries, or hospital stays.Objective.-To evaluate the effect of computerized clinical decision support systems on appropriateness of laboratory test ordering.Data Sources.-We used MEDLINE, Embase, CINAHL, MEDLINE In-Process and Other Non-Indexed Citations, Clinicaltrials.gov, Cochrane Library, and Inspec through December 2015. Investigators independently screened articles to identify randomized trials that assessed a computerized clinical decision support system aimed at improving laboratory test ordering by providing patientspecific information, delivered in the form of an on-screen management option, reminder, or suggestion through a computerized physician order entry using a rule-based or algorithm-based system relying on an evidence-based knowledge resource. Investigators extracted data from 30 papers about study design, various study characteristics, study setting, various intervention characteristics, involvement of the software developers in the evaluation of the computerized clinical decision support system, outcome types, and various outcome characteristics.Conclusions.-Because of heterogeneity of systems and settings, pooled estimates of effect could not be made. Data showed that computerized clinical decision support systems had little or no effect on clinical outcomes but some effect on compliance. Computerized clinical decision support systems targeted at laboratory test ordering for multiple conditions appear to be more effective than those targeted at a single condition.(Arch Pathol Lab Med. 2017;141:585-595; doi: 10.5858/ arpa.2016-0115-RA) A fter years of persistent increase, laboratory test ordering has become the highest-volume medical act. In the United States 1 and Europe, 55 the annual increase in the use of laboratory tests averaged around 5% during the last decade. Medicare 2 spending for clinical laboratory testing has peaked at almost $10 billion, accounting for 1.7% of the total health care budget. However, it has been estimated that when including non-Medicare spending, the figures for the United States are up to 7 times higher.3 In Europe, laboratory spending accounted for 1.8% of total health care spending in 2012, totaling E17 billion. Overuse of laboratory test ordering has been shown to be at 20%. 4 Even though reducing the overuse of laboratory testing may not seem very important in relation to the whole of health care spending, the true benefits are to be found in reducing downstream costs.5 These downstream activities include additional diagnostics such as repeat testing or imaging, prescriptions, surgeries, and hospital stays. Besides reducing costs, improving appropriate laboratory test ordering improves the quality of care by avoiding false-positive results and accidental findings of unknown significance, 6 and is not ass...

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Impact of Non-interruptive Medication Laboratory Monitoring Alerts in Ambulatory Care

Abstract: We found that non-interruptive medication laboratory monitoring alerts were not effective in improving receipt of recommended baseline laboratory test monitoring for medications. Further work is necessary to optimize compliance with non-critical recommendations.

Cited by 70 publications

References 29 publications

Clinical Reminders Designed and Implemented Using Cognitive and Organizational Science Principles Decrease Reminder Fatigue

Clinical Reminders Designed and Implemented Using Cognitive and Organizational Science Principles Decrease Reminder Fatigue

Patient Completion of Laboratory Tests to Monitor Medication Therapy: A Mixed-Methods Study

The Effects of Computerized Clinical Decision Support Systems on Laboratory Test Ordering: A Systematic Review

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