Changing Behaviors By Pressing ‘Send’
After reading the Choosing Wisely® recommendations related to lab ordering from the Society of Hospital Medicine and Critical Care Societies Collaborative, Adam Corson, MD, a hospitalist at Seattle-area Swedish Medical Center, suspected his team was ordering labs that were potentially unnecessary and was inspired to take action.
First, he needed to determine if his suspicion was correct. He worked with his organization’s IT department to access data in the electronic health records (EHR) and created a data set that looked at ordering frequency (i.e., “daily,” “daily a.m.” and “now”) around common lab tests.
Dr. Corson found that certain members of the 60-person team ordered more daily labs than others. In fact, there were five or six people responsible for ordering about 50 percent of daily labs.
“Some physicians think of those labs as vital signs—something you just need to get,” Dr. Corson said. “That’s not always the case.”
EHRs also provided information on patients’ charts, which helped Dr. Corson determine that the labs ordered were not being analyzed and the values of the labs were often static—signaling that a patient’s condition wasn’t changing.
“It appeared that someone had flipped the switch, and physicians were just ordering labs daily—almost on autopilot,” Corson said. “You get 10 days of labs that no one uses, and the patient got poked in the arm 10 times. That was a big problem.”
His intervention was simple: He began emailing team members in August 2013 with a message asking them to stop selecting “daily” in the EHRs when ordering labs. Instead, they were encouraged to align with the Choosing Wisely recommendation to only order labs in response to specific clinical questions. The email also explained why daily lab ordering often didn’t add value to patient care and evidence that excessive testing can harm patients.
Dr. Corson then sent the physicians with the highest ordering rates an email to let them know their behavior might be wasteful.
“It was a non-threatening approach: These are the facts. This is what the literature shows. This is what we’re doing,” Dr. Corson said. “There wasn’t an overt, ‘you’re doing this wrong,’ message.”
After that, he sent monthly emails to the team to report the number of labs ordered as daily per physician. These prompted physicians with high ordering rates to examine their stats and change their behavior.
One challenge Dr. Corson encountered was that physicians taking over for colleauges who ordered daily labs were hesitant to change the original selection. He continued his email campaign to the team, which staffs four hospitals with a combined 1,420 beds, and added people when necessary.
The messages proved to be effective. When Dr. Corson compared 2013-2014 EHR data with levels from the previous year, he found that all 60 providers, in aggregate, ordered 20 percent fewer labs and that daily lab ordering fell 80 percent. For the health system, that worked out to 14,000 fewer labs a year.
“The motivation for providers to change their ordering patterns was the transparent data,” Dr. Corson said. “If you can get the data from an EHR, the project can be replicated in the confines of any hospitalist team.”
