A resident-led intervention to reduce daily laboratory orders following new EMR adoption

From the 2019 HVPAA National Conference

Dr. Shannon Stockton (Vanderbilt University Medical Center), Dr. Michael Tozier (Vanderbilt University Medical Center), Dr. Pierce Trumbo (Vanderbilt University Medical Center), Dr. Vikranth Induru (Vanderbilt University Medical Center), Mr. Kinsley Ojukwu (Vanderbilt University Medical Center), Dr. Bradley Christensen (Vanderbilt University Medical Center), Dr. Jennifer Andrews (Vanderbilt University Medical Center), Dr. Kevin Flemmons (Vanderbilt University Medical Center), Dr. Donald Brady (Vanderbilt University Medical Center), Dr. Sunil Kripalani (Vanderbilt University Medical Center)

Background

Ordering daily labs on stable hospitalized patients is a common source of low-value care.1In 2014, residents at Vanderbilt University Medical Center (VUMC) led an initiative to reduce unnecessary daily CBCs and BMPs.2In 2017, our institution switched to an electronic medical record (EMR) that permitted recurring daily labs. Afterwards, we observed mean hospital-wide increases of 0.32 CBCs and 0.12 BMPs per patient per day.

Objective

We describe a multifaceted initiative by the resident-led VUMC High Value Care (HVC) Committee to reduce unnecessary daily labs following new EMR adoption.

Methods

The HVC Committee designed a three-part, evidence-based intervention to reduce daily lab ordering among internal medicine (IM) residents.3First, an attending hospitalist educated residents on the evidence for on-demand ordering, with follow-up reminders to residents in weekly program emails. In December 2018, we began providing weekly feedback on lab ordering rates to residents on general medicine teams. Most recently, we gained approval from the VUMC Lab Formulary Committee to remove standing CBC and BMP orders in the new EMR. Roll-out of the order change is planned for June 2019.

To monitor the progress of our initiative, we have compared ordering rates for all hospitalized patients and those on hospitalist-led teams to those for patients on resident-led general medicine teams. Due to changes in information systems after roll-out of the new EMR, ordering rates from November 2017 to May 2018 are unavailable.

Results

Following EMR implementation, hospital-wide CBC and BMP ordering rates increased by 0.32 and 0.12 tests per patient per day, respectively, resulting in approximately 20,000 more CBCs and 7000 more BMPs ordered over a 3-month period (Figures 1 and 2). A similar trend was observed on resident-led general IM services; CBCs increased from 0.64 to 0.91 tests per patient per day and BMPs increased from 0.94 to 1.06 tests per patient per day.

Lab ordering rates on general IM teams have decreased following education and data feedback activities, with reductions of 0.08 CBCs and 0.04 BMPs per patient per day in the eight months since the start of the initiative. During the same period, rates on hospitalist teams stayed relatively constant (0.03 fewer CBCs, 0.02 more BMPs), as did hospital-wide ordering rates (no change in CBCs, 0.01 more BMPs).

Conclusions

After previous successful initiatives at VUMC to limit daily labs, ordering rates increased after new EMR introduction and the cessation of prior education and data feedback activities. To re-address over-ordering, the HVC Committee has provided education and data feedback to IM residents, with modest decreases in ordering rates. A forthcoming change to the EMR may lead to more marked improvements. Our research is limited by the lack of ordering rates for a 6-month period following EMR implementation.

Clinical Implications

The benefits of limiting daily labs—e.g., reduced iatrogenic anemia, patient discomfort, and costs—are well recognized. Our experience suggests the need for continued interventions to maintain low ordering rates; in addition, academic medical centers implementing new EMRs should consider impact on lab utilization before implementation.

Figures

Click here to register for the 2022 Architecture of High Value Health Care National Conference!

What are academic medical centers across the country doing to improve healthcare value?

Value improvement guides: Published reviews in JAMA Internal Medicine coauthored by experienced faculty from multiple leading medical centers, with safety outcomes data and an implementation blue print.

Review article detailing 25 labs to refine for high value quality improvement | July 2020

MAVEN campaign: Free 4 year high value care curriculum online.

Join the Alliance! Membership is free with institutional approval and commitment to improving value in your medical center.

Learn more about HVPAA on Health Affairs Blog