Promoting improved utilization of laboratory testing through changes in an electronic medical record: experience at an academic medical center

This case study over time describes five years of experience with interventions to improve laboratory test utilization at an academic medical center. The high-frequency laboratory tests showing the biggest declines in order volume post intervention were serum albumin (36%) and erythrocyte sedimentation rate (17%). Introduction of restrictions for 170 high-cost send-out tests resulted in a 23% decline in order volume. Targeted interventions reduced mis-orders involving several “look-alike” tests: 1,25-dihydroxyvitamin D, 25-hydroxyvitamin D; manganese, magnesium; beta-2-glycoprotein, beta-2-microglobulin. Lastly, targeted alerts reduced duplicate orders of germline genetic testing and orders of hepatitis B surface antigen within 2 weeks of hepatitis B vaccination.

[1]  Valerie L. Ng,et al.  Utilization management in the core laboratory. , 2014, Clinica chimica acta; international journal of clinical chemistry.

[2]  Patrick M Sluss.  Reference laboratory utilization management. , 2014, Clinica chimica acta; international journal of clinical chemistry.

[3]  Anand S Dighe,et al.  Utilization management in a large urban academic medical center: a 10-year experience. , 2011, American journal of clinical pathology.

[4]  E. Benson,et al.  The responsible use of the clinical laboratory. , 1986, Clinical biochemistry.

[5]  C J McDonald,et al.  The effect on test ordering of informing physicians of the charges for outpatient diagnostic tests. , 1990, The New England journal of medicine.

[6]  Carolyn Shaffer,et al.  Diagnostic blood loss in mechanically ventilated patients. , 2007, Heart & lung : the journal of critical care.

[7]  M Werner,et al.  Appropriate utilization and cost control of the hospital laboratory: panel testing and repeat orders. , 1995, Clinica chimica acta; international journal of clinical chemistry.

[8]  James M O'Brien,et al.  Laboratory testing in the intensive care unit. , 2007, Critical care clinics.

[9]  I. Durand-Zaleski,et al.  Reducing unnecessary laboratory use with new test request form: example of tumour markers , 1993, The Lancet.

[10]  Michael L Astion,et al.  Improving the value of costly genetic reference laboratory testing with active utilization management. , 2014, Archives of pathology & laboratory medicine.

[11]  G. Minuk,et al.  Vaccine-induced hepatitis B surface antigen positivity in adult hemodialysis patients: incidental and surveillance data. , 1996, Journal of the American Society of Nephrology : JASN.

[12]  M. Crook,et al.  Pathology tests: is the time for demand management ripe at last? , 2003, Journal of clinical pathology.

[13]  Matthew D Krasowski,et al.  Pathology consultation on vitamin D testing. , 2011, American journal of clinical pathology.

[14]  Brian R. Jackson,et al.  Utilization and utility of clinical laboratory reports with graphical elements , 2012, Journal of pathology informatics.

[15]  Demetrios Demetriades,et al.  The increasing burden of phlebotomy in the development of anaemia and need for blood transfusion amongst trauma patients. , 2012, Injury.

[16]  Sandhya K Rao.  Utilization management in the changing health-care environment. , 2014, Clinica chimica acta; international journal of clinical chemistry.

[17]  Sammy Saab,et al.  Hepatitis B surface antigenemia in chronic hemodialysis patients: effect of hepatitis B immunization , 2002, American Journal of Gastroenterology.

[18]  J. Warren,et al.  Laboratory test utilization program: structure and impact in a large academic medical center. , 2013, American journal of clinical pathology.

[19]  Dan Greenberg,et al.  Cost-utility analyses of diagnostic laboratory tests: a systematic review. , 2011, Value in health : the journal of the International Society for Pharmacoeconomics and Outcomes Research.

[20]  Donna MacMillan,et al.  An analysis of reference laboratory (send out) testing: an 8-year experience in a large academic medical center. , 2004, Clinical leadership & management review : the journal of CLMA.

[21]  A. Fryer,et al.  Managing demand for laboratory tests: a laboratory toolkit , 2012, Journal of Clinical Pathology.

[22]  Stacy E F Melanson.  Establishing benchmarks and metrics for utilization management. , 2014, Clinica chimica acta; international journal of clinical chemistry.

[23]  C. Naylor,et al.  Do we know what inappropriate laboratory utilization is? A systematic review of laboratory clinical audits. , 1998, JAMA.

[24]  S. Miyakis,et al.  Factors contributing to inappropriate ordering of tests in an academic medical department and the effect of an educational feedback strategy , 2006, Postgraduate Medical Journal.

[25]  G Hultén,et al.  Large Differences in Laboratory Utilisation between Hospitals in Sweden , 2000, Clinical chemistry and laboratory medicine.

[26]  Peter K Lindenauer,et al.  The cost of defensive medicine on 3 hospital medicine services. , 2014, JAMA internal medicine.

[27]  Amelia E. Huck,et al.  Utilization management in the clinical laboratory: an introduction and overview of the literature. , 2014, Clinica chimica acta; international journal of clinical chemistry.

[28]  Chad D. Meyerhoefer,et al.  “Reducing unnecessary testing in a CPOE system through implementation of a targeted CDS intervention” , 2013, BMC Medical Informatics and Decision Making.

[29]  T. Oppé,et al.  Vitamin D deficiency. , 1979, British medical journal.

[30]  Alastair G. Gale,et al.  Labeling of Medicines and Patient Safety: Evaluating Methods of Reducing Drug Name Confusion , 2006, Hum. Factors.

[31]  Lothar Heilmann,et al.  Antiphospholipid Syndrome in Obstetrics , 2003, Clinical and applied thrombosis/hemostasis : official journal of the International Academy of Clinical and Applied Thrombosis/Hemostasis.

[32]  G. Lockitch,et al.  Trace elements in nutrition for premature infants. , 1995, Clinics in perinatology.

[33]  Matthew D. Krasowski,et al.  Autoverification in a core clinical chemistry laboratory at an academic medical center , 2014, Journal of pathology informatics.

[34]  W. Cook,et al.  Prolonged hepatitis B surface antigenemia after vaccination. , 2000, Pediatrics.

[35]  Brian R. Jackson,et al.  Laboratory diagnostic oversight committees and the profession of laboratory medicine. , 2013, American journal of clinical pathology.

[36]  Brian R Jackson.  Laboratory formularies. , 2014, Clinica chimica acta; international journal of clinical chemistry.

[37]  D. Yeh,et al.  A clinician's perspective on laboratory utilization management. , 2014, Clinica chimica acta; international journal of clinical chemistry.

[38]  B. Puppala,et al.  Incidence and duration of hepatitis B surface antigenemia after neonatal hepatitis B immunization. , 1994, The Journal of pediatrics.

[39]  Kent Lewandrowski,et al.  Effect of laboratory testing guidelines on the utilization of tests and order entries in a surgical intensive care unit* , 2008, Critical care medicine.

[40]  Carolyn D. Rysgaard,et al.  Positive hepatitis B surface antigen tests due to recent vaccination: a persistent problem , 2012, BMC Clinical Pathology.

[41]  Brian R Jackson,et al.  Managing laboratory test use: principles and tools. , 2007, Clinics in laboratory medicine.

[42]  H Köhler,et al.  The test for hepatitis B surface antigen is transiently positive after vaccination with recombinant vaccine. , 1997, Nephrology, dialysis, transplantation : official publication of the European Dialysis and Transplant Association - European Renal Association.

[43]  S. Mor-Yosef,et al.  An administrative intervention to improve the utilization of laboratory tests within a university hospital. , 2005, International journal for quality in health care : journal of the International Society for Quality in Health Care.

[44]  Jessie H. Conta,et al.  Genetic testing utilization and the role of the laboratory genetic counselor. , 2014, Clinica chimica acta; international journal of clinical chemistry.

[45]  Yuchiao Chang,et al.  A utilization management intervention to reduce unnecessary testing in the coronary care unit. , 2002, Archives of internal medicine.

[46]  Barry S. Levy,et al.  Neurologic Effects of Manganese in Humans: A Review , 2003, International journal of occupational and environmental health.

[47]  S. Emerson,et al.  The impact of requisition design on laboratory utilization. , 2001, American journal of clinical pathology.

[48]  James S Hernandez,et al.  Management structure: establishing a laboratory utilization program and tools for utilization management. , 2014, Clinica chimica acta; international journal of clinical chemistry.

[49]  B C Dow,et al.  Several assays show hepatitis B positivity soon after vaccination , 1998, BMJ.

[50]  Donna MacMillan.  Calculating cost savings in utilization management. , 2014, Clinica chimica acta; international journal of clinical chemistry.

[51]  Hartmut Goldschmidt,et al.  Consensus recommendations for standard investigative workup: report of the International Myeloma Workshop Consensus Panel 3. , 2011, Blood.

[52]  B L Lambert,et al.  Predicting look-alike and sound-alike medication errors. , 1997, American journal of health-system pharmacy : AJHP : official journal of the American Society of Health-System Pharmacists.

[53]  Elizabeth M. Van Cott.  Laboratory test interpretations and algorithms in utilization management. , 2014 .

[54]  Thomas C. Wilson,et al.  Analysis of vitamin D status at two academic medical centers and a national reference laboratory: result patterns vary by age, gender, season, and patient location , 2013, BMC Endocrine Disorders.

[55]  Kent Lewandrowski,et al.  Managing utilization of new diagnostic tests. , 2003, Clinical leadership & management review : the journal of CLMA.