Hardwiring diagnostic stewardship using electronic ordering restrictions for gastrointestinal pathogen testing

Abstract

Objective:To evaluate the impact of a hard stop in the electronic health record (EHR) on inappropriate gastrointestinal pathogen panel testing (GIPP).Design:We used a quasi-experimental study to evaluate testing before and after the implementation of an EHR alert to stop inappropriate GIPP ordering.Setting:Midwest academic medical center.Participants:Hospitalized patients with diarrhea for which GIPP testing was ordered, between January 2016 through March 2017 (period 1) and April 2017 through June 2018 (period 2).Intervention:A hard stop in the EHR prevented clinicians from ordering a GIPP more than once per admission or in patients hospitalized for >72 hours.Results:During period 1, 1,587 GIPP tests were ordered over 212,212 patient days, at a rate of 7.48 per 1,000 patient days. In period 2, 1,165 GIPP tests were ordered over 222,343 patient days, at a rate of 5.24 per 1,000 patient days. The Poisson model estimated a 30% reduction in total GIPP ordering rates between the 2 periods (relative risk, 0.70; 95% confidence interval [CI], 0.63–0.78; P < .001). The rate of inappropriate tests ordered decreased from 21.5% to 4.9% between the 2 periods (P < .001). The total savings calculated factoring only GIPP orders that triggered the hard stop was ∼$67,000, with potential savings of $168,000 when factoring silent best-practice alert data.Conclusions:A simple hard stop alert in the EHR resulted in significant reduction of inappropriate GIPP testing, which was associated with significant cost savings. Clinicians can practice diagnostic stewardship by avoiding ordering this test more than once per admission or in patients hospitalized >72 hours.

Economic impact of clinical decision support interventions based on electronic health records

“…Medication dosing support, relevant information display, and expert systems (categories 1, 4, and 5) were each reported only once from an economic perspective (11%) [18,19,24]. In eight studies (30%) [14,16,25,28,30,31,33,35], interventions from two different categories were explored in combination. Moreover, we found three studies (11%) [21,29,32] in which the option to place a certain order or test, e.g., a laboratory test, was removed from the EHR CPOE system or the clinician's laboratory ordering preference list.…”

“…The removal of an order option ultimately resulted in fewer laboratory tests and reduced healthcare expenditure in all studies [14,28,31]. Finally, we identified two different types of implemented hard-stops [40]: an interruptive alert [30] and a restrictive hard-stop [14]. An interruptive alert requires a clicking response from the physician before being able to move forward.…”

Incorporating preauthorization into antimicrobial stewardship pharmacist workflow reduces Clostridioides difficile and gastrointestinal panel testing

“…The University of Nebraska previously reported a similar intervention for GIPAN testing, which resulted in a 30% reduction in GIPAN ordering rates and a yearly cost savings of $168,000. 15 Despite our center having a large population of highly immunosuppressed patients which mandated several exceptions to our approval criteria (Table 1), we found even more substantial reductions in GIPAN use.…”

Economic impact of clinical decision support interventions based on electronic health records

“…An overview of the characteristics of the included studies is listed in Table 2. Generally, twenty-two studies (81%) [5,[13][14][15][16]18,[20][21][22][23][24][25][28][29][30][31]32,[34][35][36][37][38] out of the included twenty-seven studies report cost savings after implementing an EHR based CDS intervention. Four studies (15%) [17,26,27,33] report a rise in cost expenditure.…”

“…Restriction of choice [39] The removal of an order option ultimately resulted in fewer laboratory tests and reduced healthcare expenditure in all studies. [14,28,31] Finally, we identi ed two different types of implemented hard-stops: [40] an interruptive alert [30] and a restrictive hard-stop [14]. An interruptive alert requires a clicking response from the physician before being able to move forward.…”