Strategies to improve test utilisation
With thousands of tests on a typical laboratory menu, optimisation of the utilisation is a need in most laboratories. The administration of the Laboratory must set a strategy to achieve better utilisation of tests. Strategies to improve test utilisation in a clinical laboratory may be:
- ordering templates
- alerts for redundant test orders
- ordering constraints to minimize recurring orders
- display of relevant prior laboratory data
- integration of practice guidelines into CPOE ordering screens
- Improving test search to permit improved test selection
- corollary test alerts
- displaying test cost on CPOE ordering screen
- unbundling CPOE test panels into their individual components
User interface modifications
One of the most basic yet effective interventions to alter test utilization is to modify CPOE test ordering screens. A modification so that the common tests is more convenient to order than tests that are only occasionally. Such modifications presumably reduce over-ordering of tests by reducing the “impulse-buy” mentality. Another strategy is to “unbundle” testing panels. In that way, physicians must select the individual tests instead of ordering the panel. In a study, found that an unbundling of metabolic panel tests decreased 51% the use of the relevant tests.
Overutilization of inpatient laboratory tests may occur due to orders for recurring or “until discontinued” tests. CPOE systems that permit recurring orders may actually facilitate the overutilization of laboratory testing. With CPOE, clinicians may place recurring orders (e.g. CBC and electrolytes every morning until discontinued) but may fail to cancel them after the test is no longer clinically necessary.
A 24% reduction in orders for metabolic panel tests was attributed to this alert. CPOE systems provide a leverage point for restricting recurrent orders, although significant leadership may be required. Once the organisation started using recurrent orders on templates and culture of the hospital is set, they can be challenging to eliminate.
Ordering templates play an important role in standardizing care and encouraging adherence to clinical guidelines. Templates typically consist of an order set including medication, laboratory and other orders. The set is appropriate for a particular clinical setting or diagnosis. For example, an admission template for myocardial infarction might include laboratory orders (e.g. serial troponin assays), medication orders (e.g. aspirin, beta blockers), specific dietary orders (e.g. low-salt diet), and nursing instructions.
Clinicians may start with the standard template and then make modifications to address the unique clinical circumstances of the patient. Another advantage of templates is that when clinical guidelines change, a simple change in the template is enough. Any change in guideline is thus made immediately apparent to all ordering providers, simply by the update of the template.
Ordering messages and practice guidelines
CPOE provides a platform for informing clinicians of practice guidelines. It also facilitates the tracking of deviations from the guideline. For example, when ordering red blood cells (RBCs), clinicians must select an indication based on the patient’s age, hematocrit, and state of stress. The software flags orders for RBCs not meeting guidelines and alerts electronically transfusion service staff. So a review of the orders with the ordering clinician will take place. In a cardiac intensive care unit setting, found that integration of practice guidelines into standard admissions order templates significantly decreases the use of laboratory tests without compromising care.
Display of test cost
Display of cost information during order entry, influences utilization. In a controlled trial in an outpatient primary care setting, display of laboratory test cost led to a 14% reduction in the number of tests. The effects of displaying cost information at a teaching hospital had a result of 4.5% reduction. There is also a significant reduce of inpatient test utilization using the diagnosis-related group (DRG) payment schema. However, reducing test utilization by simply displaying costs, is not always a solution. Vesting of Physicians in cost reduction activities is under discussion.
Search functionality exists in most laboratory CPOE implementations. With search, clinicians enter search terms and the system returns a list of corresponding tests. Clinicians then select the specific test they wish to order from the list. Search terms can include test names, corresponding synonyms and even corresponding disease states.
We may use the example of “celiac disease” where a search might return “anti-transglutaminase IgA” and “endomysial IgA antibody”. By not requiring the clinician to know the exact names of the tests, the search function is considerably more user-friendly. In contrary, free text orders cannot be electronically interfaced and the lab personnel must translate them manually into specific test names or codes. This leads to inefficiencies, errors, and ambiguity.
Add-on test management
After the processing of a specimen in the lab, clinicians may wish to order subsequent tests on the sample remaining in the laboratory. These tests are known as add-on tests and the management of add-ons often requires significant laboratory resources. Most CPOE systems do not support add-on testing. Thus, clinicians wishing to order add-on tests must call the laboratory with a verbal order. The laboratory staff must manually retrieve the sample and enter the orders for additional testing into the LIS. Such systems are often inefficient, because of the necessary multiple manual steps. In such a case the order may lack appropriate documentation. Extending CPOE systems to handle add-on testing can be logistically challenging. This is because the add-on test process does not follow the same steps as a new test order.
Laboratory Tests Ordering Platform
In conclusion the “Lab-Orders” ordering system is not a simple electronic ordering system. Based on communication with other information systems, it is provided with the patient’s current data, the admission reason and the diagnosis. It is also provided with all the info concerning tests being held in the labs, including the days and the delivery times. Having available all the information concerning the patient, the system supports cliniciens in a better way.