From the 2019 HVPAA National Conference
Dr. Rachna Rawal (Saint Louis University), Dr. Paul Kunnath (Saint Louis University), Mr. Ara Vartanyan (Saint Louis University), Dr. Alex Lane (Saint Louis University), Dr. Hala Saad (Saint Louis University), Dr. Oluwasayo Adeyemo (Mount Sinai Baltimore), Dr. Jennifer Schmidt (Saint Louis University)
Background
A previous project targeting Internal Medicine residents’ high-value care practices prompted evaluation of the non-resident hospitalist teams ordering practices. Would exposure to residents (eceiving education on high-value care translate to changes in attending physician ordering on hospitalist-only teams?
Objective
1.Assess hospitalist lab ordering practices
2. Assess trickle down effect of resident-focused education on hospitalist-only teams
Methods
Participants included Medicine physicians attending on the non-resident and resident inpatient services. Data collected from the electronic medical record (EMR) included labs ordered (CBC without differential, CBC with differential, BMP, CMP) and patient census. Pre and post-project surveys created by the project team assessed lab-ordering practices and cost-conscious care barriers. Initial interventions, targeting residents, occurred over 80 weeks and included education, electronic medical record (EMR) changes, and a hospitalist physician champion. Prior to the resident interventions, there was a 15 week control and after the interventions a 32 week period to assess sustainability.
Results
The non-resident service census increased through the course of the project, as did the total labs/week. Additionally, attending physicians ordered more specific laboratory panels (Figure 1)–increased BMP with decreased CMP, no change to hepatic panels (balancing measure)(p<0.05). CBC with differential also decreased while CBC without differential increased (p<0.05). Figure 2 shows that the frequency of standing orders (Daily) decreased with increased use of one-time orders (Am Draw) (p<0.05). These ordering habits sustained from weeks 96-127.
55% of attending physicians reported awareness of labs’ costs. 83% of attendings feel they order labs mindfully on the non-resident services and 50% report that the resident-focused high-value care project has influenced their own ordering behaviors, which sustained at 127 weeks. 67% report using the new EMR lab frequency options instead of the “daily” option. 15% reported that the EMR ordering default change from “daily” to “AM draw” made them more mindful of laboratory orders.
Conclusion
While our initial project focused on residents, its effects have been wider reaching. Residents received initial education, however mindful lab ordering has spread to the non-resident services. We believe that the high-value care practices encountered by the attendings on the resident teams continue to impact the ordering practices of the attendings when they rotate on the non-resident hospitalist service. Our residency initiative did not only trigger this change in the hospitalist service, but the lab-ordering cultural change has sustained in the hospitalist group as well. This unintentional leakage demonstrates a true cultural shift toward high-value patient care.
Clinical Implications
An internal medicine residency culture can also impact a hospitalist service in promoting mindful laboratory habits and a high-value care culture.
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