Impact of nonintrusive clinical decision support systems on laboratory test utilization in a large academic centre

Abstract

Background: The near-universal prevalence of electronic health records (EHRs) has made the utilization of clinical decision support systems (CDSS) an integral strategy for improving the value of laboratory ordering. Few studies have examined the effectiveness of nonintrusive CDSS on inpatient laboratory utilization in large academic centres. Methods: Red blood cell folate, hepatitis C virus viral loads and genotypes, and type and screens were selected for study. We incorporated the appropriate indications for these labs into text that accompanied the laboratory orders in our hospital’s EHR. Providers could proceed with the order without additional clicks. An interrupted time-series analysis was performed, and the primary outcome was the rate of tests ordered on all inpatient medicine floors. Results: The rate of folate tests ordered per monthly admissions showed no significant level change at the time of the intervention with only a slight decrease in rate of 0.0109 (P = .07). There was a 43% decrease in the rate of hepatitis C virus tests per monthly admissions immediately after the intervention with a decrease of 0.0135 tests per monthly admissions (P = .02). The rate of type and screens orders per patient days each month had a significant downward trend by 0.114 before the intervention (P = .04) but no significant level change at the time of the intervention or significant change in rate after the intervention. Discussion: Our study suggests that nonintrusive CDSS should be evaluated for individual laboratory tests to ensure only effective alerts continue to be used so as to avoid increasing EHR fatigue.

Reducing red blood cell folate testing: a case study in utilisation management

“…There is little published literature on utilisation projects to reduce folate testing. Eaton et al 32 found their non-intrusive clinical decision support tool in the hospital’s electronic health record was ineffective at reducing folate testing. MacMillan et al 33 found their approach of restricting ordering of RBC folate testing in the CPOE system to haematologists or gastroenterologists reduced orders by 94%.…”

“…It is also not clear how long this decrease in ordering would have been sustained if that had been our only intervention. As demonstrated in a previous study by Eaton et al ,32 educational interventions such as email or a pop-up at the time of ordering are rarely sufficient to modify laboratory test ordering practices. In our project, while the larger decrease in RBC folate testing occurred as a result of implementing a biochemist-approval process, we believe that contacting stakeholders helped physicians to feel that they were being consulted and involved in the change process.…”

“…In 2013, Health Quality Ontario—The Ontario Health Technology Advisory Committee decided to limit eligibility for coverage of RBC folate testing at private laboratories to patient populations with a) low haemoglobin levels and a high mean corpuscular volume (MCV); or b) suspected gastrointestinal disorders causing malabsorption or suspected malnutrition of any cause 31. In 2014, Eaton et al implemented a non-intrusive clinical decision support tool in their hospital’s electronic health record stating the low frequency of folate deficiency in the American population and suggesting that folate testing not be ordered, but they saw no significant effect on ordering practices 32. MacMillan et al 33 found that by removing RBC folate from the list of tests available to order in their CPOE system for all physicians except haematologists or gastroenterologists, they were able to reduce ordering of the test by 94%.…”

Internal Medicine Residents’ Knowledge and Practice of Pulmonary Tuberculosis Diagnosis

“…Determining how to leverage health system resources to facilitate TB-related education and evaluations may be of particular value. Prior work has found that the use of prompts and clinical decision support tools in electronic medical records can assist in improving diagnostic evaluations of ID-related conditions, such as chronic hepatitis C virus and asymptomatic bacteriuria [ 19 , 20 ]. Such prompts related to both key and commonly used TB diagnostics, such as NAATs and LTBI tests, may be both educational and functional.…”

Laboratory test ordering in inpatient hospitals: a systematic review on the effects and features of clinical decision support systems

“…However it caused an overall reduction in laboratory resources consumption for transplanted patients. Eaton et al [36] performed a multifaceted intervention, in their good quality study which indicated no effect on the rate of folate tests orders, but 43% reduction in the rate of hepatitis C virus tests. Rudolf et al [43] study demonstrated that although recurrent daily laboratory tests reduced, the total tests volume remained unchanged.…”