The role of a best practice alert in the electronic medical record in reducing repetitive lab tests

Abstract

Background: The recommendations of the American Board of Internal Medicine Foundation's "Choosing Wisely^®" initiative recognize the importance of improving the appropriateness of testing behavior and reducing the number of duplicate laboratory tests.

Objective: To assess the effectiveness of an electronic medical record Best Practice Alert (BPA or "pop up") intervention aimed at reducing duplicate laboratory tests and hospital costs.

Design: Comparison of the number of duplicated laboratory tests performed on inpatients before and after the intervention.

Setting: University of Florida Health Shands Hospital, Gainesville, FL, USA, during 2014-2017.

Intervention: The electronic medical record intervention was a BPA pop-up alert that informed the ordering physician if a recent identical order already existed along with the "ordering time", "collecting time", "resulting time", and the result itself.

Main outcome measures: Percentage change in the number of inpatient duplicate orders of selected clinical biochemistry tests and cost savings from reduction of the duplicates. Student's t-test and beta-binomial models were used to analyze the data.

Results: Results from the beta-binomial model indicated that the intervention reduced the overall duplicates by 18% (OR=0.82, standard error=0.016, P-value<0.000). Percent reductions in 9 of the 17 tests were statistically significant: serum hemoglobin A1C level, vitamin B12, serum erythrocyte sedimentation rate, serum folate, serum iron, lipid panel, respiratory viral panel, serum thyroid stimulating hormone level, and Vitamin D. Additionally, important cost savings were realized from the reduction of duplicates for each lab test (with the exception of CRP) with an estimated overall savings of $72,543 over 17 months in the post-intervention period.

Conclusions: The present study included all hospital inpatients and covered 17 clinical laboratory tests. This rather simple and low-cost intervention resulted in significant reductions in percentage duplicates of several tests and resulted in cost savings. The study also highlights the role of hospitalists in quality improvement.

Keywords: costs; health care; laboratory; testing.

Figure 1

Overall proportion of duplicates before and after intervention.

Figure 2

Lab test’s specific proportion of duplicates before and after intervention (tests with statistically significant decrease in the duplicates after intervention). Notes: B12, serum vitamin B12; ESR, serum erythrocyte sedimentation rate; folate, serum folate level; free T4, serum free T4 level; HbA1c, serum hemoglobin A1C level; iron, serum iron saturation level; RVP, respiratory viral panel – nasopharynx swab; TSH, serum thyroid-stimulating hormone level.

Figure 3

Lab tests’ specific proportion of duplicates before and after intervention. Notes: ammonia, serum ammonia level; ANA, serum antinuclear antibody; CBC w diff, complete blood count with differential; CRP, serum C reactive protein; ferritin, serum ferritin level; PSA, serum prostate specific antigen.