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Open Access Research article

“Reducing unnecessary testing in a CPOE system through implementation of a targeted CDS intervention”

Donald L Levick1*, Glenn Stern2, Chad D Meyerhoefer3, Aaron Levick4 and David Pucklavage5

Author Affiliations

1 Office of Chief Medical Information Officer, Lehigh Valley Health Network, Cedar Crest and I-78, PO Box 689, Allentown, PA, 18105, USA

2 Chasm Crossing Consulting, 1470 Limeport Pike, Coopersburg, PA, USA

3 Rauch Business Center, 621 Taylor Street, Bethlehem, PA, 18015, USA

4 Department of Physics, Cornell University, 109 Clark Hall, Ithaca, NY, 14853, USA

5 Information Services, Lehigh Valley Health Network, Cedar Crest and I-78, PO Box 689, Allentown, PA, 18105, USA

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BMC Medical Informatics and Decision Making 2013, 13:43  doi:10.1186/1472-6947-13-43

Published: 8 April 2013

Abstract

Background

We describe and evaluate the development and use of a Clinical Decision Support (CDS) intervention; an alert, in response to an identified medical error of overuse of a diagnostic laboratory test in a Computerized Physician Order Entry (CPOE) system. CPOE with embedded CDS has been shown to improve quality of care and reduce medical errors. CPOE can also improve resource utilization through more appropriate use of laboratory tests and diagnostic studies. Observational studies are necessary in order to understand how these technologies can be successfully employed by healthcare providers.

Methods

The error was identified by the Test Utilization Committee (TUC) in September, 2008 when they noticed critical care patients were being tested daily, and sometimes twice daily, for B-Type Natriuretic Peptide (BNP). Repeat and/or serial BNP testing is inappropriate for guiding the management of heart failure and may be clinically misleading. The CDS intervention consists of an expert rule that searches the system for a BNP lab value on the patient. If there is a value and the value is within the current hospital stay, an advisory is displayed to the ordering clinician. In order to isolate the impact of this intervention on unnecessary BNP testing we applied multiple regression analysis to the sample of 41,306 patient admissions with at least one BNP test at LVHN between January, 2008 and September, 2011.

Results

Our regression results suggest the CDS intervention reduced BNP orders by 21% relative to the mean. The financial impact of the rule was also significant. Multiplying by the direct supply cost of $28.04 per test, the intervention saved approximately $92,000 per year.

Conclusions

The use of alerts has great positive potential to improve care, but should be used judiciously and in the appropriate environment. While these savings may not be generalizable to other interventions, the experience at LVHN suggests that appropriately designed and carefully implemented CDS interventions can have a substantial impact on the efficiency of care provision.

Keywords:
Clinical decision support; Computerized physician order entry; Medical error; BNP testing; Alert fatigue; Sociotechnical; Unintended consequences; Appropriate testing