E-iatrogenesis and Physician Burnout: Unnecessary Ordering of Urine Creatine

From the 2018 HVPAA National Conference

NEIL KESHVANI (University of Texas Southwestern Medical Center), Arjun Gupta (University of Texas Southwestern Medical Center, Dallas, TX;), Timothy J. Brown (University of Texas Southwestern Medical Center, Dallas, TX;), Brett Moran (Parkland Health and Hospital System)


E-iatrogenesis is defined as patient harm caused by the application of health information technology. Use of Computerized Provider Order Entry (CPOE) has been associated with introduction of unique medication errors and may also contribute to the ordering of unnecessary, incorrect, and costly tests, leading to low-value care.


We describe our institutional experience of ‘e-iatrogenesis’ with the improper and over-ordering of urine creatine.


At our urban safety-net hospital, the laboratory test for urine creatinINE is performed in house, while urine creatine is a send-out test to a referral laboratory. We analyzed the trends in the ‘urine creatine’ laboratory order every quarter from 2006 to 2017. We assessed for changes made to the CPOE to explain variations in urine creatine lab order placement. We studied the role of the information system end-user, the ordering clinician, in preventing e-iatrogenesis.


At our institute from 2006 to 2012, the baseline level of urine creatine ordering was 1-5 tests per quarter. After October, 2012, the levels of urine creatine exploded, to a range of 45-116 per quarter, until June, 2017 (Figure 1). During the same period, rates of ordering of urine creatinINE remained relatively stable at 2500- 3200 tests per quarter. In October, 2012, the laboratory test for urinary creatine was accidentally introduced on the preference list for internal medicine providers, which functions as a collection of commonly ordered lab tests. Urinary creatinINE was mistakenly placed on the facilities list, a list that contains orders that are used more rarely and are accessed by clicking on a different tab. Seeing urine creatine as a first choice, providers may mistakenly select that test, even though they were truly looking for the urine creatinINE, which was hidden, a tab away, under the facilities list. Providers did not bring this to the attention of the information technology teams to remediate for more than 4 years. The issue was not identified until an informatics-lab team began to investigate high cost send-out tests. In June of 2017, the name of urine creatine was changed to “metabolic creatINE random urine” and was moved to the facility list. Rates returned to the typical quarterly range of 1-3 tests (Figure 1).


This improper “display” or “cueing” of an order fooled providers into ordering an incorrect and much more expensive test and may have delayed the results of a clinically useful test.

Implications for the Patient

Institutions and providers must be aware and vigilant of e-iatrogenesis and fight provider burnout which can lead to learned helplessness and apathy in reporting important adverse programming changes which may have direct patient impact.

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