Hospitals provide guidelines for eliminating unnecessary medical tests

Using EHRs as a vehicle, the effort aims to reduce routine laboratory testing that is wasteful and threatens the value of healthcare, researchers say.

Researchers have developed evidence-based guidelines intended to help hospitals eliminate unnecessary medical testing, and are developing an approach to deliver the guidelines to clinicians through electronic health records.

In addition to limiting unnecessary tests, the initiative intends to give providers real-time feedback on their ordering patterns with anonymized comparative data.

The guidelines, published this week in JAMA Internal Medicine, were developed by researchers at Johns Hopkins University, the University of Michigan, University of Pennsylvania, University of Toronto and the University of Virginia—all members of the High Value Practice Academic Alliance, a coalition of more than 80 academic medical centers working to improve healthcare by eliminating waste.

“Although laboratory expenditure often represents less than 5 percent of most hospital budgets, the impact is far-reaching given that laboratory tests influence nearly 60 percent to 70 percent of all medical decisions,” state the authors. “Excessive phlebotomy can lead to hospital-acquired anemia, increased costs, and unnecessary downstream testing and procedures.”

Laboratory testing of hospitalized patients is one of the largest contributors to wasteful healthcare spending, according to Andrew Parsons, MD, a co-author of the article, a hospitalist in the University of Virginia Health System and assistant professor at the University of Virginia School of Medicine.

“A number of hospitals have taken on their own initiatives to try and reduce unnecessary laboratory testing, but there really hasn’t been—until now—a united effort,” says Parsons. “What we wanted to do was review different interventions that have been instituted, see what was most effective, and then put together an implementation blueprint to guide hospital teams so they can improve their practices.”

Also See: Cedars-Sinai reduces unnecessary care using EHR alerts

Parsons notes that the evidence-based guidelines developed by him and his colleagues are based on real-world implementations with recommendations in three areas of practice relating to medical tests: educational initiatives, leveraging EHRs, and real-time clinician feedback on test ordering patterns.

“Most of the successful studies didn’t just do one of those things, they took a multi-level approach doing all three,” he contends. “It’s not standard practice to consider the cost of the test. But hospitals should educate providers on the cost of the tests they order. We also want to educate them on the negative effects of unnecessary laboratory testing, such as developing anemia in the hospital and downstream testing that comes from false positive results of the laboratory tests that they order.”

When it comes to using EHRs, Parsons urges hospitals to customize their systems to set up alerts to notify clinicians as they attempt to order tests electronically. “As soon as a provider goes to put into an order, an alert pops up that says ‘FYI, this was just ordered yesterday or this test has been done within a given period of time and here’s the result—do you still want to order this test?'” he observes.

In addition, Parsons recommends that hospitals limit the ability of physicians to order laboratory tests. “It’s a common practice to pre-order laboratory tests—when a patient comes in the hospital—out three to four days,” he says. “We’d like to restrict that and really force the provider to think each day about only the test they want to order for the following day.”

Parsons also advises that hospitals give providers real-time feedback on their ordering patterns for tests, so they can adjust those practices accordingly. This feedback should also include anonymized comparative data to show how they stack up to their peers in terms of ordering behavior.

“Keeping things anonymous, they should on a weekly basis send out a staff directive with average ordering patterns per patient per day,” he adds. “You access the EHR to pull out all that information on orders. This has been highly effective.”

Parsons laments the fact tests are often ordered in a knee-jerk fashion. However, he and his fellow researchers encourage clinicians to reconsider the use of routine daily lab tests performed on hospitalized patients, such as a complete blood count used to evaluate overall health and detect a wide range of disorders as well as a basic metabolic panel which measures glucose level, electrolyte and fluid balance, and kidney function.

“Efforts to reduce the frequency of laboratory orders can improve patient satisfaction and reduce cost without negatively affecting patient outcomes,” concludes the JAMA article. “Healthcare professionals and administrative leaders should carefully strategize and optimize efforts to reduce daily laboratory testing.”

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