Boston Medical Center trims unneeded tests with EHR-based prompts

Electronic health record-based interventions enabled clinicians at Boston Medical Center to reduce unnecessary diagnostic tests and increase the use of postoperative order sets, through the use of Choosing Wisely recommendations.

In a study, published in the Joint Commission Journal on Quality and Patient Safety, the hospital evaluated Choosing Wisely recommendations integrated into its Epic EHR to alert providers to the best practice information.

The American Board of Internal Medicine Foundation’s Choosing Wisely initiative is based on guidance from medical specialty societies and has identified nearly 500 common diagnostic tests and procedures that may not have clear benefit for patients and sometimes should be avoided.

Specifically, Boston Medical Center’s study focused on five areas—the overutilization of chest X-rays, routine daily labs, red blood cell transfusions, urinary catheters, and the underutilization of pain and pneumonia prevention orders for patients after surgery.

“At six months following the intervention, the proportion of patients receiving preadmission chest X-rays showed a significant decrease of 3.1 percent,” found the study’s authors. “The proportion of labs ordered at routine times also improved significantly, with a decrease of 4 percent. Total lab utilization also declined, with a post-implementation decrease of 1,009.6 orders per month.”

“We found no significant difference at six months in estimated red blood cell transfusion utilization rate or the number of non-ICU urinary catheter days,” added the authors. “The proportion of postoperative patients receiving appropriate pain and pneumonia prevention orders showed a statistically significant, absolute increase of 20 percent.”

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“The results from our interventions suggest that they alone show promise in improving high-value care, but using only an electronic medical record intervention may not be adequate to achieve optimal outcomes emphasized by Choosing Wisely,” says Nicholas Cordella, MD, corresponding author, a fellow in quality improvement and patient safety at BMC, and an assistant professor at Boston University School of Medicine.

While the study demonstrated the impact of deploying multiple interventions simultaneously within the EHR as a way to deliver high-value care, Cordella and his co-authors recommend that future efforts aimed at increasing high-value care—defined as delivering the best possible care while simultaneously reducing unnecessary healthcare costs—should consider other elements such as clinician education, audits and feedback and peer comparison.

“To move the needle on reducing unnecessary healthcare costs, we need to consider multi-pronged approaches in order to engage providers in ways that can truly make a difference in how we deliver exceptional, high-value care to every patient,” adds Cordella.

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