A cross-disciplinary team at Cooper University Health Care in Camden, New Jersey used their electronic health record to reduce the inappropriate use of thyroid testing and antinuclear antibody (ANA) testing, following Choosing Wisely recommendations from the American Society for Clinical Pathology and the American College of Rheumatology, respectively.
“I have watched a lot of the Choosing Wisely initiative, and these areas had surfaced as opportunities,” said Charlene Bierl, MD, who now is the Division Director of Lab Medicine at the Hospital of the University of Pennsylvania and who worked on the Cooper project while she was with the affiliated Children’s Hospital of Philadelphia. “With the ANA test, we noticed trouble where patients came in with referrals but did not have the tests that the rheumatologist would want and additional testing had to be added, or patients had results from suspected false positive results from specialized tests that may have been avoided with different initial testing. There was interest in creating a more standardized menu to help assist with the initial ordering process.”
The Cooper team—including representatives from information technology, endocrinology, rheumatology, informatics and pathology—collaborated to create standardized choices in the EHR. Wherever possible, the EHR guided primary care physicians toward a single screening test, the results of which would automatically trigger any appropriate additional specialized testing. This type of test is known as a “reflex” test. The team also renamed some tests in the system to clarify clinicians’ options. These changes spared physicians from sorting through a number of different and confusing options, and ensured that physicians would be far less likely to order multiple potentially unnecessary tests.
Once the project was instituted, almost all orders for ANA testing used the reflex test, meaning that subsequent tests would only be conducted if the ANA test was positive. As a result, orders for two of these specialized subsequent tests fell by 22.5 and 87 percent, respectively. Orders for two specialized thyroid tests decreased by 27.4 and 30.7 percent as a result of the implementation of that reflex test.
According to Dr. Bierl, the major challenges were in optimizing the lists. “We had good partnerships with endocrinology and rheumatology,” she said. “It took a little while to determine what tests should be on the menus and to identify names that would be easily understood by all physicians.”
This challenge was further complicated because the outside companies that patients use for testing, such as LabCorp and Quest, have different names for similar tests. “How do you name a test in your system so that when a patient brings a requisition for one lab to a different location, they get the test that the physician originally intended?” Dr. Bierl said. “You want a name where the doctors know what they’re getting, and phlebotomists know what they’re drawing regardless of the performing lab.”
Overall, Dr. Bierl said that the project built bridges between different entities within the Cooper system. “It was welcomed by everyone, including primary care,” she said. “Physicians are grasping with how complex the order menu has become. We can make it easier to order the right test at the right time.”
Readers who would like to learn more about the project can read an article that the project team published in the American Journal of Clinical Pathology.