The path of least resistance: how computerized provider order entry can lead to (and reduce) wasteful practices

From the 2018 HVPAA National Conference

Cori Atlin (University of Toronto), Joseph Choi (University of Toronto)

Background

Computerized provider order entry (CPOE) has the potential to improve efficiency and accuracy. However, this hinges on careful planning. Poorly planned CPOE order sets can lead to undetected errors and waste. In our emergency department (ED), lactate dehydrogenase (LDH) was included in various blood panels, but had little clinical value.

Objectives

This quality improvement initiative aimed to reduce unnecessary LDH testing in the ED.

Methods

A group of ED physicians reviewed CPOE blood panels and uncoupled LDH in conditions where it was deemed not to provide any clinically useful information. We measured the daily number of LDH tests performed before and after its removal. We tracked the frequency of other serum tests as controls. We also analyzed the number of add-on LDH (i.e. to add LDH to samples already sent to the lab) as a balancing measure, since this can disrupt work flow and delay care.

Results

Through this intervention, we reduced the number of LDH tests performed by 69%, from an average of 75.1 tests per day to 23.2 (p < 0.0005) (Table 1, Figure 1). The baseline controls did not differ after the intervention (e.g. a complete blood count was performed 197.7 and 196.1 times per day pre- and post-intervention, respectively [p = 0.7663]) (Figure 2). There was less than 1 add-on LDH per day on average.

Conclusion

CPOE care templates can be powerful in shaping behaviours and reducing variability. However, close oversight of these panels is necessary to prevent errors and waste.

Implications for the Patient

Including LDH as a default order prompted wasteful, non-evidence-based test ordering practices. After this intervention, physicians were surveyed and they did not even notice its absence in the lab panels. By removing LDH, we were able to eliminate waste, improve testing stewardship, and cut costs with no apparent adverse effects.

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