Journal:The effect of a test ordering software intervention on the prescription of unnecessary laboratory tests - A randomized controlled trial

Full article title	The effect of a test ordering software intervention on the prescription of unnecessary laboratory tests - A randomized controlled trial
Journal	BMC Medical Informatics and Decision Making
Author(s)	Martins, C.M.; da Costa Teixeira, A.S.; de Azevedo. L.F.; Sá, L.M.; Santos, P.A.; do Couto, M.L.; da Costa Pereira, A.M.; Hespanhol, A.A.; da Costa Santos, C.M.
Author affiliation(s)	University of Porto
Primary contact	E-mail: carlosmartins20 at gmail dot com
Year published	2017
Volume and issue	17 (1)
Page(s)	20
DOI	10.1186/s12911-017-0416-6
ISSN	1472-6947
Distribution license	Creative Commons Attribution 4.0 International
Website	https://bmcmedinformdecismak.biomedcentral.com/articles/10.1186/s12911-017-0416-6
Download	https://bmcmedinformdecismak.biomedcentral.com/track/pdf/10.1186/s12911-017-0416-6 (PDF)

Abstract

Background: The way electronic health record and laboratory test ordering system software is designed may influence physicians’ prescription. A randomized controlled trial was performed to measure the impact of a diagnostic and laboratory tests ordering system software modification.

Methods: Participants were family physicians working and prescribing diagnostic and laboratory tests.

The intervention group had modified software with basic shortcut menu changes, where some tests were withdrawn or added, and with the implementation of an evidence-based clinical decision support system based on United States Preventive Services Task Force (USPSTF) recommendations. This intervention group was compared with typically used software (control group).

The outcomes were the number of tests prescribed from those: withdrawn from the basic menu; added to the basic menu; marked with green dots (USPSTF’s grade A and B); and marked with red dots (USPSTF’s grade D).

Results: Comparing the monthly average number of tests prescribed before and after the software modification, from those tests that were withdrawn from the basic menu, the control group prescribed 33.8 tests per 100 consultations before and 30.8 after (p = 0075); the intervention group prescribed 31.3 before and 13.9 after (p < 0001). Comparing the tests prescribed between both groups during the intervention, from those tests that were withdrawn from the basic menu, the intervention group prescribed a monthly average of 14.0 vs. 29.3 tests per 100 consultations in the control group (p < 0.001). From those tests that are USPSTF’s grade A and B, the intervention group prescribed 66.8 vs. 74.1 tests per 100 consultations in the control group (p = 0.070). From those tests categorized as USPSTF grade D, the intervention group prescribed an average of 9.8 vs. 11.8 tests per 100 consultations in the control group (p = 0.003).

Conclusions: Removing unnecessary tests from a quick shortcut menu of the diagnosis and laboratory tests ordering system had a significant impact and reduced unnecessary prescription of tests.

The fact that it was not possible to perform the randomization at the family physicians’ level, but only on the computer servers is a limitation of our study. Future research should assess the impact of different test ordering systems during longer periods.

Trial registration: ISRCTN45427977, May 1st 2014 (retrospectively registered).

Keywords: Preventive health services, primary health care, evidence-based practice, decision support systems, clinical decision making, computer-assisted

Background

Informatics has undoubtedly changed the way societies live, socialize, learn, work, and deal with healthcare. We now live in a period of increasing concern about the excessive presence of medicine in our lives. When inefficient software is combined with a non-evidence-based medical practice, there is the risk of patient harm, significant impact to quality of life, and damage to the healthcare system due to unnecessary costs.

The implementation of electronic health records (EHRs) has both potential benefits and drawbacks. Among the benefits, the prevention of medical errors and the promotion of patient safety has often been mentioned and confirmed in clinical practice. Despite the positive effects of EHR implementation in clinical practice, a range of barriers faced by physicians has been identified. These barriers may include technical and financial aspects, time, psychological, social, legal, and organizational changes to the process. After having removed the first barriers to EHR implementation, it is now time to implement continuing improvement and development of the available tools and to incorporate the scientific evidence obtained to this point.

To achieve better patient safety standards and improve healthcare system cost-effectiveness, there has been a worldwide effort to implement an integrated EHR system with diagnostic and laboratory test ordering communication systems. There have also been attempts to incorporate clinical decision support systems to further improve the quality of medicine. Prescribing diagnostic and laboratory tests is a key component of medical consultation. In the primary health care setting, tests are often ordered with preventive intentions and fulfillment of patient expectations. There is also great uncertainty and variability among family physicians’ ordering routines. The effects of test ordering communication systems integrated with clinical decision support systems have been reported in various clinical practice settings. Main et al. have performed a systematic review of this topic and reported that integration of clinical decision support systems resulted in significant benefits to the prescribing process and practitioner performance outcomes in nearly two-thirds of the 24 studies that met the inclusion criteria.

In Portugal, the use of EHR software with a diagnostic and laboratory test order communication system has been mandatory since September 2011. Most of the primary healthcare centers use software called Sistema de Apoio ao Médico (Physician’s Support System [SAM]). In the module used to order diagnostic and laboratory tests, physicians access a searchable test menu by two possible strategies: 1) typing the test name in a search box or 2) browsing by a shortcut menu structure (Fig. 1). Different menus are available for most areas of medicine, including basic, allergology, andrology, cardiovascular, central nervous system, digestive, dosing, endocrinology, gynecology, hematology, infectious diseases, nephrology, obstetrics, oncology, otorhinolaryngology, osteoarticular, preoperative, respiratory, rheumatology, and urology. Under each menu there is a set of specific lab tests. Physicians can choose one or more tests by double-clicking each test or can choose the entire set by double-clicking on the shortcut menu’s title. For example, the basic menu is composed of uric acid, total cholesterol, creatinine, gamma-glutamyl transferase, glucose, hemogram, serum protein electrophoresis, aspartate aminotransferase, urine type 2, sedimentation rate, electrocardiogram, and lung x-ray tests.

Figure 1. Usual ordering communication system: the basic shortcut menu

If a physician would like to choose only hemogram and glucose, they must double-click on each test. However, if they would like the entire basic set of tests, they must double-click on the basic menu title. Our research team suspected that this basic shortcut menu is often selected during routine consultations in which patients ask for routine check-ups without specific reason. As we have shown in a previous study, there is a high prevalence of Portuguese adults (99.2%) that believe they should have routine blood and urine tests annually. This statistic demonstrates the importance of examining the effectiveness and efficiency of this basic sub-menu.

Through a randomized controlled trial, the primary aim of the present study was to compare the effects of modifying the EHR ordering communication system (modified SAM) by changing the basic shortcut menu and adding a clinical decision support system based on the integration of the United States Preventive Services Task Force (USPSTF) recommendations. After the last primary healthcare reform in Portugal, primary healthcare centers have been divided into healthcare center groups. In a healthcare center group, the informatics network is linked through servers that may serve more than one healthcare center. Creating a modified version of the SAM software requires it to be installed at a server level, which determines that all physicians at all healthcare centers served by that server will receive the same version of the software. For this reason, it was not possible to randomize the study at the physician level. Rather, we had to randomize the servers at the healthcare center group level.

Methods

Trial design

All servers of the Western Oporto grouping of health centers counted for randomization, except that serving the center where study authors worked (to avoid possible bias). The remaining nine servers were randomized into two groups: 1) five servers were randomly allocated to the intervention group and 2) four servers to the control group.

Participants

All family physicians working and prescribing diagnostic and laboratory tests in the Western Oporto group of health centers (except in those where the authors worked) participated in this study.

Data of the diagnostic and laboratory tests prescriptions were centrally collected by informatics staff belonging to the Ministry of Health and sent to the research team without patients’ or physicians’ identifications.

Interventions

The control group continued to use the standard version of the EHR software (SAM) as presented in Fig. 1. The intervention group used a modified version of the software (SAM modified) installed in each server (Fig. 2). Software modifications consisted of two principal changes:

1. Basic shortcut menu changes: The composition of the basic menu set of diagnostic laboratory tests was changed. Some tests were removed, including uric acid, serum protein electrophoresis, sedimentation rate, electrocardiogram, and lung x-ray. Other tests were added, including HDL cholesterol, fecal occult blood test, triglycerides, Pap smear, and mammography. Although some tests were removed from the basic menu, physicians were still able to request them by typing their names in the search for tests box.

2. Addition of an evidence-based decision support: For the tests listed in Table 1, we added traffic light-based colored dots according to the USPSTF recommendations and an additional information box containing the summary of the USPSTF recommendation and a link to the integral recommendation at the USPSTF website (Fig. 2).

Figure 2. Modified ordering communication system: the basic shortcut menu. Red numbers: 1 - Traffic lights colored dots according to United States Preventive Services Task Force recommendations grades. 2 - Text box with the summary of the recommendation for each selected test. 3 - Link to the original recommendation at the USPSTF’s website. 4 - Search for tests box, where any test, including those removed from the basic menu, can be searched and requested by typing the test’s name. 5 - Legend of the colored dots

Table 1. United States Preventives Services Task Force (USPSTF) recommendations (March, 2012) a USPSTF grades A and B: the USPSTF recommends the service, marked with green dots. Grade D: the USPSTF recommends against the service, marked with red dots. Grade I: the USPSTF concludes that the current evidence is insufficient to assess the balance of benefits and harms of the service, marked with yellow dots. b DXA Dual-energy X-ray absorptiometry Colored dots Gradea Test Summary of the recommendations Red D Pelvic ultrasound Not recommended as routine screening for ovarian cancer Red D Cancer antigen 19-9 Not recommended as routine screening for pancreatic cancer Red D Rest electrocardiography Not recommended in asymptomatic adults at low risk for coronary heart disease events Red D Exercise electrocardiography Not recommended in asymptomatic adults at low risk for coronary heart disease events Red D Carotid artery ultrasound Not recommended as screening for asymptomatic carotid artery stenosis in the general adult population Red D Spirometry Not recommended as screening adults for chronic obstructive pulmonary disease Red D Hepatitis B surface antigen Not recommended as routine screening Red D Hepatitis C antibodies Not recommended as routine screening Yellow I Triglycerides There is currently insufficient evidence of the benefit of including triglycerides as a part of the initial tests used to screen routinely for dyslipidemia. Yellow I Prostate-specific antigen The evidence is insufficient to recommend for or against routine screening for prostate cancer in men younger than 75. Yellow I Lung computed tomography The evidence is insufficient to recommend for or against routine screening for lung cancer. Yellow I Lung x-ray The evidence is insufficient to recommend for or against routine screening for lung cancer. Yellow I Thyroid-stimulating hormone The evidence is insufficient to recommend for or against routine screening. Green B Glucose Screening for type 2 diabetes recommended in asymptomatic adults with sustained blood pressure (either treated or untreated) greater than 135/80 mm Hg Green A/B Total cholesterol Recommended every 5 years, for men aged 35 and older and women 45 and older if they are at increased risk for coronary heart disease, at younger ages if they are at increased risk for coronary heart disease. Green B Mammography Biennial screening recommended for women aged 50 to 74 years Green A Cervicovaginal cytology Every 3 years screening recommended for women who have cervix, 21 to 65 years old Green A Fecal occult blood test Recommended annually as a possible method of screening for colorectal cancer, 50 to 75 years Green A Colonoscopy Recommended every 10 years as a possible method of screening for colorectal cancer, 50 to 75 years Green A Flexible sigmoidoscopy Recommended every 5 years as a possible method of screening for colorectal cancer, 50 to 75 years Green A/B HDL cholesterol Recommended every 5 years, for men aged 35 and older and women 45 and older if they are at increased risk for coronary heart disease, at younger ages if they are at increased risk for coronary heart disease. Green B DXAb of the hip and lumbar spine Screening recommended for osteoporosis in women aged 65 years or older and in younger women whose fracture risk is equal to or greater than that of a 65-year-old Green A Venereal Disease Research Laboratory Recommended for persons at increased risk for syphilis infection

Notes

This presentation is faithful to the original, with only a few minor changes to presentation. In some cases important information was missing from the references, and that information was added. A significant amount of grammar edits were made to make the document more readable.