Path of least resistance: how computerised provider order entry can lead to (and reduce) wasteful practices

UHN-JC-Wasteful Computerized Orders

University Health Network (ED)

Background: Computerised provider order entry (CPOE) is rapidly becoming the mainstay   in clinical care and has the potential to improve provider efficiency and   accuracy. However, this hinges on careful planning and implementation. Poorly   planned CPOE order sets can lead to undetected errors and waste. In our   emergency department (ED), lactate dehydrogenase (LDH) was bundled into   various blood work panels but had little clinical value.
Objectives: This quality improvement initiative aimed to reduce unnecessary LDH testing   in the ED.

Methods: A group of ED physicians reviewed CPOE blood work panels and uncoupled LDH   in conditions where it was deemed not to provide any clinically useful   information. We measured the daily number of LDH tests performed before and   after its removal. We tracked the frequency of other serum tests as controls.   We also analysed the number of add-on LDH (ie, to add LDH to samples already   sent to the lab) as a balancing measure, since this can disrupt work flow and   delay care.
Results: Through this intervention, we reduced the number of LDH tests performed by   69%, from an average of 75.1 tests per day to 23.2 (P<0.0005). The   baseline controls did not differ after the intervention (eg, a complete blood   count was performed 197.7 and 196.1 times per day preintervention and   postintervention, respectively (P=0.7663)). There was less than one add-on   LDH per day on average.

Conclusions: CPOE care templates can be powerful in shaping behaviours and reducing   variability. However, close oversight of these panels is necessary to prevent   errors and waste.

Authors: Joseph Choi and Cori Rebecca Atlin

Project complete