دانلود رایگان مقاله انگلیسی تاثیر سیستم های پشتیبانی تصمیم گیری بالینی غیر قانونی بر استفاده آزمایش های آزمایشگاه - وایلی 2018

Abstract

Background: The near‐universal prevalence of electronic health records (EHRs) has made the utilization of clinical decision support systems (CDSS) an integral strategy for improving the value of laboratory ordering. Few studies have examined the effectiveness of nonintrusive CDSS on inpatient laboratory utilization in large academic centres. Methods: Red blood cell folate, hepatitis C virus viral loads and genotypes, and type and screens were selected for study. We incorporated the appropriate indications for these labs into text that accompanied the laboratory orders in our hospital's EHR. Providers could proceed with the order without additional clicks. An interrupted time‐series analysis was performed, and the primary outcome was the rate of tests ordered on all inpatient medicine floors. Results: The rate of folate tests ordered per monthly admissions showed no significant level change at the time of the intervention with only a slight decrease in rate of 0.0109 (P = .07). There was a 43% decrease in the rate of hepatitis C virus tests per monthly admissions immediately after the intervention with a decrease of 0.0135 tests per monthly admissions (P = .02). The rate of type and screens orders per patient days each month had a significant downward trend by 0.114 before the intervention (P = .04) but no significant level change at the time of the intervention or significant change in rate after the intervention. Discussion: Our study suggests that nonintrusive CDSS should be evaluated for individual laboratory tests to ensure only effective alerts continue to be used so as to avoid increasing EHR fatigue.

4 | DISCUSSION

This study suggests that the impact of nonintrusive CDSS should be evaluated for individual laboratory tests to ensure only effective alerts continue to be used so as to avoid increasing EHR fatigue. The CDSS can still be a low‐cost intervention for continuing educational efforts on appropriate ordering practices for selected laboratory tests. The folate results showed a significant pre‐existing trend of a decrease in the number of folate tests ordered per monthly admissions. This baseline decrease before the intervention was most likely associated with an increase in awareness from informal educational lectures within the department. The data did demonstrate a decrease in the number of HCV VL and genotype tests ordered per monthly admissions immediately after the intervention. However, given the few number of these tests being ordered, the clinical significance of this decrease is likely minimal. The pre‐existing trend of a decrease in T&S orders per patient days each month over the time period was maintained even after the intervention. The effect of the intervention on this laboratory test was diminished by the truncated postintervention time period.

Prior work has shown that noninterruptive notifications do not increase the appropriate utilization of baseline laboratory testing.12 Because we did not evaluate the appropriateness of individual patients' orders, whether the pre‐existing trends in reduction of folate and T&S orders specifically represented a reduction in unnecessary testing was outside of the scope of our analysis. The specific laboratory tests in this study were targeted at our institution, but nonintrusive messaging can continue educational efforts regarding the appropriate ordering of other tests as long as a clear message is displayed. In fact, targeting laboratory tests that have high volume and show no pre‐existing decreasing trends would be important.