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Changing Electronic Formats Is Associated With Changes in Number of Laboratory Tests Ordered
Gari Blumberg, MD; Eliezer Kitai, MD; Shlomo Vinker, MD; and Avivit Golan-Cohen, MD
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Changing Electronic Formats Is Associated With Changes in Number of Laboratory Tests Ordered

Gari Blumberg, MD; Eliezer Kitai, MD; Shlomo Vinker, MD; and Avivit Golan-Cohen, MD
A slight decrease in the convenience of ordering a laboratory test led to a dramatic decrease in test utilization.
RESULTS

A dramatic decrease in orders occurred when GGT tests could be ordered only via the search engine function. The number of orders fell from about 36,000 to just over 1000 per month (a 97.3% reduction). When, a few months later, GGT was returned to 1 place on the main screen, the numbers jumped back to 18,000; they then increased to more than 35,000 when GGT returned to both places on the main screen. Since July 2015, GGT has been available only in the group of liver tests (and the search function). To see if changes in patient population had caused the changes in GGT, we compared the number of tests at each period with the population of the HMO during the same period (Figure).

Since July 2015, the numbers of test orders have slowly increased but are still (as of 2018) about 25 to 34 per 1000 HMO members and not the 51 per 1000 seen prior to the intervention.

DISCUSSION

A slight decrease in the convenience of ordering a laboratory test that is not indicated for routine screening led to a dramatic decrease in the number of tests sent. A decrease from 3 options to 2 showed a decrease in orders of about 50%, and a decrease to 1 option further decreased orders to 3% of the original levels. Although it was not studied in parallel, no reports were made of diagnoses being missed or delayed due to these changes in the ordering of laboratory tests. It is indeed more likely that costs of imaging tests and second-line laboratory tests were much higher when the test was easier to order. It seems clear that the patients—who will not have to undergo protracted work-ups and increased anxiety due to a false-positive GGT test—will benefit, as well as the doctors who will be able to use their own medical acumen in choosing tests. Because the doctors are still able to choose the test should they feel it is necessary by actively searching for it, it follows that the increased convenience was the most likely cause of the overordering, facilitated by the use of shortcuts.

The other side of the coin is also important: Does making the choice of laboratory tests more difficult increase the risk of missing an important finding? To see if we had inadvertently caused undertesting, we looked at the tests of alkaline phosphatase during the study period. We found that the number of alkaline phosphatase tests were steady whereas the numbers of GGT tests changed in accordance with presentation on the laboratory page. This does not allow us to ascertain what the optimal level of GGT testing is but shows the difference between 2 tests usually given in the same clinical circumstances.

We also looked at the total numbers of HMO members over the study period to see if the changes in GGT testing could be connected to changes in total population served. We found that the total number of insured patients in the HMO ranged from 716,000 to 732,000 over the study period and since. Contrary to a possible connection, the times of higher total populations were those when lower numbers of GGT tests were ordered. By comparing the total population with the numbers of orders for a similar test, such as alkaline phosphatase, we can conclude that the main influence on the number of GGT tests ordered was the changes in presentation on the laboratory page.

In another HMO in Israel, senior doctors reduced a checklist of 51 commonly ordered tests by removing 27 tests and adding 2. Orders of those that were deleted were reduced by 27%, the unchanged ones were reduced by 18%, and the added tests increased by 60%.7 These findings show that making tests easier to order increased the numbers of orders in a more significant fashion than deleting tests decreased the numbers of orders. This would be an interesting topic for a further study.

Limitations

This study has some limitations. For one, we looked only at the numbers of tests ordered by the various ways of presentation but were not able to ascertain whether the decrease in testing caused a decrease in detection of disease. Such a study would require more resources in order to read so many medical records. That is a challenge we would like to take on in the future. We were also not able to ascertain what the “ideal” level of GGT tests should be. Another limitation is that the attitudes of the physicians toward these changes were not elicited. Because it is important that the physician’s work not be made more difficult, this would be a good topic for a further study. In the future, we would like to see if the trend continues over longer periods of time.

CONCLUSIONS

Utilizing a change to the EHR, we demonstrated that a slight decrease in the convenience of ordering a laboratory test that is not indicated for routine screening—the measurement of GGT level—led to a dramatic decrease in the number of test orders sent by physicians. We were able to demonstrate that the computer rather than the physician had an influence on GGT laboratory test utilization patterns. Convenience is a positive thing when it saves precious time, but if it leads to overtesting, we shall not have gained much.

Author Affiliations: Leumit Health Services, Givat Shmuel (GB), and Tel Aviv (EK, SV, AG-C), Israel; Department of Family Medicine, Tel Aviv University (GB, EK, SV, AG-C), Tel Aviv, Israel.

Source of Funding: None.

Author Disclosures: The authors report no relationship or financial interest with any entity that would pose a conflict of interest with the subject matter of this article.

Authorship Information: Concept and design (GB, EK, SV, AG-C); acquisition of data (GB, EK); analysis and interpretation of data (EK, SV, AG-C); drafting of the manuscript (GB); and critical revision of the manuscript for important intellectual content (EK, SV, AG-C).

Address Correspondence to: Gari Blumberg, MD, Leumit Health Services, ​18 Ben Gurion St, Givat Shmuel, Israel. Email: gblumberg@leumit.co.il.
REFERENCES

1. Carey WD. How should a patient with an isolated GGT elevation be evaluated? Cleve Clin J Med. 2000;67(5):315-316.

2. Murali AR, Carey WD. Liver test interpretation—approach to the patient with liver disease: a guide to commonly used liver tests. Cleveland Clinic website. clevelandclinicmeded.com/medicalpubs/diseasemanagement/hepatology/guide-to-common-liver-tests. Published April 2014. Accessed May 1, 2018

3. Sela BA. Gamma glutamyl transferase. Israel Family Physicians Association website. wikirefua.org.il/w/index.php/גמא-גלוטאמיל_טרנספראזה_-_Gamma_glutamyl_transferase. Updated October 21, 2015. Accessed May 1, 2018.

4. Seppänen K, Kauppila T, Pitkälä K, et al. Altering a computerized laboratory test order form rationalizes ordering of laboratory tests in primary care physicians. Int J Med Inform. 2016;86:49-53. doi: 10.1016/j.ijmedinf.2015.11.013.

5. Kahan NR, Waitman DA, Vardy DA. Curtailing laboratory test ordering in a managed care setting through redesign of a computerized order form. Am J Manag Care. 2009;15(3):173-176.

6. Vardy DA, Simon T, Limoni Y, et al. The impact of structured laboratory routines in computerized medical records in a primary care service setting. J Med Sys. 2005;29(6):619-626.

7. Shalev V, Chodick G, Heymann AD. Format change of a laboratory test order form affects physician behavior. Int J Med Inform. 2009;78(10):639-644. doi: 10.1016/j.ijmedinf.2009.04.011.
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