Promoting improved utilization of laboratory testing through changes in an electronic medical record: experience at an academic medical center

Abstract

This case study over time describes five years of experience with interventions to improve laboratory test utilization at an academic medical center. The high-frequency laboratory tests showing the biggest declines in order volume post intervention were serum albumin (36%) and erythrocyte sedimentation rate (17%). Introduction of restrictions for 170 high-cost send-out tests resulted in a 23% decline in order volume. Targeted interventions reduced mis-orders involving several "look-alike" tests: 1,25-dihydroxyvitamin D, 25-hydroxyvitamin D; manganese, magnesium; beta-2-glycoprotein, beta-2-microglobulin. Lastly, targeted alerts reduced duplicate orders of germline genetic testing and orders of hepatitis B surface antigen within 2 weeks of hepatitis B vaccination.

Figure 1

Changes in laboratory test ordering. Data is broken down into high frequency tests (core laboratory chemistry and hematology testing excluding CBC with differential), CBC with differential, erythrocyte sedimentation rate (ESR), and restricted send-out testing with effects on (A) frequency of ordering (adjusted for patient days) and (B) average annual savings. The pre-intervention period was two years leading up to interventions (changes in ordering frequency options; institution of restricted send-out testing) in July 2012. The post-intervention period is two years following that into July 2014. *P < 0.005, **P < 0.001.

Figure 2

Ordering patterns of 1,25-dihydroxyvitamin D and 25-hydroxyvitamin D. (A) Annual test volumes for 1,25-dihydroxyvitamin D from 2000 to 2014 (annual volume for 2014 estimated based on data through 7/22/2014); (B) Annual test volumes for 1,25-dihydroxyvitamin D from 2007 to 2014 (annual volume for 2014 estimated based on data through 7/22/2014), broken down by location of order – inpatient unit or outpatient clinics; (C) Annual test volumes for 25-dihydroxyvitamin D from 2000 to 2014 (annual volume for 2014 estimated based on data through 7/22/2014). Subset of data for 25-dihydroxyvitamin D up to October 2012 has been previously published [53]. The arrows indicate date that new EMR was introduced.