Noninterruptive Clinical Decision Support Decreases Ordering of Respiratory Viral Panels during Influenza Season

Abstract

Objective A growing body of evidence suggests that testing for influenza virus alone is more appropriate than multiplex respiratory viral panel (RVP) testing for general populations of patients with respiratory tract infections. We aimed to decrease the proportion of RVPs out of total respiratory viral testing ordered during influenza season. Methods We implemented two consecutive interventions: reflex testing for RVPs only after a negative influenza test, and noninterruptive clinical decision support (CDS) including modifications of the computerized physician order entry search behavior and cost display. We conducted an interrupted time series of RVPs and influenza polymerase chain reaction tests pre- and postintervention, and performed a mixed-effects logistic regression analysis with a primary outcome of proportion of RVPs out of total respiratory viral tests. The primary predictor was the intervention period, and covariates included the provider, clinical setting, associated diagnoses, and influenza incidence. Results From March 2013 to April 2019, there were 24,294 RVPs and 26,012 influenza tests (n = 50,306). Odds of ordering an RVP decreased during the reflex testing period (odds ratio: 0.432, 95% confidence interval: 0.397–0.469), and decreased more dramatically during the noninterruptive CDS period (odds ratio: 0.291, 95% confidence interval: 0.259–0.327). Discussion The odds of ordering an RVP were 71% less with the noninterruptive CDS intervention, which projected 4,773 fewer RVPs compared with baseline. Assuming a cost equal to Medicare reimbursement rates for RVPs and influenza tests, this would generate an estimated averted cost of $1,259,474 per year. Conclusion Noninterruptive CDS interventions are effective in reducing unnecessary and expensive testing, and avoid typical pitfalls such as alert fatigue.

Displaying Cost and Completion Time for Reference Laboratory Test Orders—A Randomized Controlled Trial

“…On the contrary, multiple sources have demonstrated the superiority of noninterruptive design because it prevents “alert fatigue” that leads to overriding. 23 24 Escovedo et al implemented a silent CDS tool that reduced unnecessary ordering of respiratory viral panel for general populations of patients with respiratory tract infections. The number of orders significantly decreased after removing select synonyms and appending appropriate indications to the test display in the CPOE search window.…”

“…The number of orders significantly decreased after removing select synonyms and appending appropriate indications to the test display in the CPOE search window. 24 These independent observations support that an effective CDS tool requires a directive or action-oriented element. The timing of CDS activation is also critical to achieving the intended result.…”

The Application of Dental Fluoride Varnish in Children: A Low Cost, High-Value Implementation Aided by Passive Clinical Decision Support

“…Nevertheless, both types have proven effective in achieving desired behaviors or outcomes across multiple healthcare domains, including limiting unnecessary testing and treatment 13,14 , controlling costs 13,15 , and improving compliance with preventive services and standards of care 16,17 .…”

Clinical Decision Support Stewardship: Best Practices and Techniques to Monitor and Improve Interruptive Alerts

“…4 Fundamentally, we risk increasing provider burnout with the cumulative effect of interruptive alerts 5 ; thus, interruptive alerts should be used only when other less intrusive options have been thoroughly considered. 6 In this review, we discuss our institutional experiences and best practices to preserve the value of the interruptive alert, whether via EHR, physiologic monitor, or mobile device. We often perform tasks analogous to antimicrobial stewards; we educate clinicians about other tools that may work better with narrower coverage, optimize CDS strategies to reduce side effects, and, when necessary, discourage or even prevent the implementation of interruptive alerts when they may cause more harm than good.…”

“…4 Fundamentally, we risk increasing provider burnout with the cumulative effect of interruptive alerts 5 ; thus, interruptive alerts should be used only when other less intrusive options have been thoroughly considered. 6…”