- A nationwide initiative to cut down on test ordering in hospitals has recently proven to cut costs and reduce instances of patient harm through simple modifications to physician EHR use.
The Choosing Wisely campaign, launched by the American Board of Internal Medicine (ABIM) foundation and Consumer Reports in 2012, aimed to reduce medical test ordering by prompting providers to identify and cut back on five tests or procedures that are frequently ineffectual.
According to the National Academy of Medicine, over $200 billion is spent annually on excessive medical testing and treatment. Additionally, patient harm occurring as a result of excessive medical testing and treatment accounts for 30,000 deaths a year.
Several California hospitals took part in the initiative and attempted to cut costs and instances of patient harm through slight changes to their EHRs.
Cedars-Sinai Medical Center in Los Angeles reduced test ordering through an alert built into the physician EHR workflow.
The hospital alerts doctors electronically when ordering tests or drugs that do not align with 18 Choosing Wisely recommendations embedded into the software.
In a study, Cedars-Sinai analyzed alerts from 26,424 patient encounters between 2013 and 2016. All Choosing Widely guidelines were followed in 6 percent of those cases, or 1,591 encounters.
In groups that did not comply with Choosing Wisely guidelines, patients had a 14 percent higher rate of readmission and a 29 percent higher risk of complications, increasing costs by 7 percent.
Additionally, in the first year after implementing the electronic alert system, Cedars-Sinai saved 6 million in spending.
Sutter Health in Northern California similarly attempted to mitigate problems caused by excessive test ordering through a modification to its EHR.
The hospital deleted the button in physician EHRs used to order repetitive blood tests.
“We took it out and couldn’t wait to see the data,” said Sutter Health executive Ann Marie Giusto.
However, this modification only marginally affected physician test ordering due to a ‘favorites’ feature built into the hospital’s EHR.
“It had become a habit,” said Giusto.
Physicians were ordering tests so frequently EHRs saved a shortcut to the functionality in the software’s ‘favorites’ tab.
While this initial attempt proved unsuccessful, Sutter Health has since incorporated more than 130 Choosing Wisely recommendations into its test ordering procedures and saved $66 million in costs as a result.
Improvements are noticeable but gradual.
Since the initiative began, physicians and healthcare organizations have voiced frustrations over the slow rate of progress to solve what looks like a simple problem.
“The changes that need to be made don’t appear unrealistic, yet they seem to take an awful lot of time,” said executive of the Integrated Healthcare Association Dr. Jeff Rideout. “We’ve been patient for too long.”
The industry-wide urgency to see real improvement stems from the sometimes permanent consequences of excessive test ordering.
Galen Gunther, a colorectal cancer patient from Oakland, told Fox News he received permanent scarring as a result of overexposure to radiation caused by repeated blood draws and delayed tests.
“Every doctor I saw wanted to run the same tests, over and over again,” Gunther said. “Nobody wanted to take responsibility for that.”
Despite some stagnation, a few hospitals like Cedars-Sinai have managed to make considerable progress as part of the initiative.
Sharp Rees-Stealy Medical Group in San Diego, for example, has cut excessive test ordering by over 10 percent.
Additionally, Lost Angeles County-University of Southern California Medical Center achieved positive results by eliminating needless preoperative testing before routine cataract surgery.
This minor change allowed patients to get into surgery an average of 6 months sooner than when preoperative testing was still common practice at the organization.
The focus on modifying hospital EHRs to discourage excessive test ordering may combat evidence suggesting the technology may be part of the problem.
Earlier this year, a study linked higher rates of blood and imaging test ordering to physician EHR use.