EHR electronic medical record . Doctor note

Best Practice Alerts from Electronic Records Can Reduce Redundant Lab Testing Interview with:

Rohit Bishnoi, M.D. Division of Hematology and Oncology Department of Medicine University of Florida Gainesville, FL

Dr. Bishnoi

Rohit Bishnoi, M.D.
Division of Hematology and Oncology
Department of Medicine
University of Florida
Gainesville, FL What is the background for this study?

Response: National Healthcare expenditure was $3.6 trillion in 2018 and 17.7% of Gross Domestic Product. Redundant laboratory testing is one part of this problem that is more pronounced in hospitalized patients as they are often seen by multiple physicians from the time of admission till discharge. This added burden on the US health care system leads to increased costs, decreased patient satisfaction, and unnecessary phlebotomy. It also leads to iatrogenic anemia over time and unnecessary transfusions. The Choosing Wisely initiative recommendation from the Society of Hospital Medicine, Society for the Advancement of Blood Management, and the Critical Care Societies Collaborative have recommended avoiding repetitive labs.

As one of the physicians in the division of hospital medicine at the University of Florida (UF) Health Shands hospital, we encountered this problem frequently where a patient will get multiple HbA1c or lipid profiles or iron studies during the same hospital stay without any clear clinical indication. Most often these tests were ordered by different physicians seeing the same patient and not realizing that either the test has already been ordered or sometimes it is related to practice pattern of physicians. We often heard complaints about this from our nursing and laboratory staff and, most importantly by patients themselves. What are the main findings?

Response: In September 2014 we designed a quality improvement project to tackle this head-on and coordinated a team of hospitalists, statisticians, information technology and laboratory staff. We identified 17 tests and optimal time window for reordering these tests by using best practice guidelines and expert opinion form sub-specialists from different divisions in the Department of Medicine. Once we identified these tests, we created a Best Practice Alert (BPA) which alerted the ordering physicians, if the test has been ordered or is being processed or resulted recently. BPA window displayed previous ordering time, collection time, resulting time and link to the results when available. This alert could be overridden depending on ordering physician discretion as per clinical scenario.

This alert went into practice in September 2015 for all inpatient units including general, intermediate and intensive care units at the UF Health Shands hospital which is a 996-bed tertiary care facility. We collected and analyzed data for 34 months, 17 months each for pre and post-intervention.

Results of the study showed that the intervention with Best Practice Alert resulted in an average overall reduction of 15.4% for the duplicate tests, with the maximum reduction for vitamin D (−58.7%), vitamin B12 (−49.6%), and respiratory viral panel nasopharynx swab (−33.4%). This intervention also showed an estimated overall savings of $72,543 over 17 months in the post-intervention period. What should readers take away from your report?

Response: In the current scenario with rising health care costs, we should use the full functionality of electronic medical records to help our patients. With this simple but effective intervention, we were able to reduce redundant labs and produced significant cost savings. This intervention has resulted in a change that is permanent and can be applied to other tests as well. What recommendations do you have for future research as a result of this work?

Response: We believe that this simple, no-cost intervention can be applied to most of the laboratory tests in hospitalized patients. This gentle reminder can lead to change in practice patterns as well. During our study we did not receive any negative feedback of excessive BPA or workflow disruptions. Is there anything else you would like to add?

Response: Although we reviewed the available guidelines and sought expert opinion within our institution, we felt that there is a lack of consensus. There is limited data from the relevant national societies on optimal duration between laboratory tests.

No relevant financial disclosures​


Bejjanki H, Mramba LK, Beal SG, Radhakrishnan N, Bishnoi R, Shah C, Agrawal N, Harris N, Leverence R, Rand K. The role of a best practice alert in the electronic medical record in reducing repetitive lab tests. Clinicoecon Outcomes Res. 2018;10:611-618


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Mar 20, 2020 @ 12:38 pm

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