From the 2018 HVPAA National Conference
Rachna Rawal (St. Louis University), Oluwasayo Adeyemo (St. Louis University), Paul Kunnath (St. Louis University), Hala Saad (St. Louis University), Alex Lane (St. Louis University), Ara Vartanyan (St. Louis University), Jennifer Schmidt (St. Louis University)
Repetitive laboratory ordering for hospitalized patients is a known cause of unnecessary healthcare spending. The EMR often utilizes order sets to facilitate efficiency. Internal Medicine residents identified our EMR as a barrier to cost-conscious care. Changes were made to the EMR to facilitate cost-conscious care.
- Understand how the EMR can promote cost-conscious care
- Utilize the EMR to change ordering habits and generate culture change
Internal Medicine residents identified limited lab frequency options (including “daily”, “AM draw”) in the admission order set as a barrier to cost conscious lab ordering. The study team worked with IT to implement additional lab frequency options including: “Q48H”, “MWF”, and “TuThSa”. Additionally, the order set listing of labs was altered—BMP was listed before CMP and CBC without differential was listed prior to CBC with differential. Data was collected for 50 weeks (16 week control; 34 week intervention).
Subjects were residents rotating on the General Medicine inpatient service. In post-intervention weeks 1-16 residents were not notified of the EMR changes. In weeks 17-32, study team provided regular reminders of EMR changes via email, posters, and oral presentations. Residents completed pre, 16-week post-intervention and 32-weeks post-intervention surveys (developed by the survey team) assessing order set use, perception. Resident use of each frequency option was gathered from the EMR.
Pre-intervention baseline data, 92% of residents reported reliance on the Medicine admission order set to order labs. Post-intervention, 28% of residents reported that additional order set options were more helpful reminders to practice cost-conscious care compared to emails, presentations and team room posters. 50% of residents reported placing CBC without differential higher than CBC with differential and BMP higher than CMP affected how they ordered. 85% of residents used the new EMR ordering options “sometimes” to “always”.
EMR data showed a after 32 weeks (p<0.05).
After 32 weeks, 0% of residents identified the EMR as the major barrier to cost-conscious care compared to 40% pre-intervention. Based on aggregate EMR data, there was a statistically significant (p<0.05) increase in the use of the “AM draw” from 3.15% (baseline) to 8% (16 weeks post-intervention) to 21% (32 weeks post-intervention).
The increased use of “AM draw” order demonstrates a clear change in resident ordering practice. Additionally, choosing a lab option that requires daily re-ordering shows a shift toward actively deciding if labs are appropriate rather than defaulting to everyday labs. Our data suggests residents were inappropriately using the “daily” option—the AM draw option was not a new option, but its use significantly increased once residents were educated on high-value lab ordering. This implies lack of resident awareness of mindful lab ordering as a cause. These results show that optimizing the EMR can be a tool to promote high-value care. We believe that these EMR changes are generating a cultural change in our program towards more cost-conscious care.
Implications for the Patient
The EMR can be successfully be optimized to facilitate high-value care. Easing the accessibility of varied lab frequency options and educating physicians on the available options, promotes mindful care and can lead to a cultural shift.