CEO SUMMARY: Systems for computerized physician order entry (CPOE) and clinical decision support can contribute to better utilization of laboratory tests while achieving improvements in patient outcomes. At Decatur Memorial Hospital, use of CPOE helped physicians slash the volume of blood products used by one-third, even as the risk of adverse patient events declined by a similar amount. Growing numbers of hospitals and health systems are implementing CPOE and clinical decision support systems.
OPTIMAL UTILIZATION OF LABORATORY TESTS BY PHYSICIANS is an ideal that is seldom realized. However, some hospitals are achieving noteworthy improvements in lab test utilization, lower costs, and improved patient outcomes through the use of both computerized physician order entry (CPOE) and evidence-based medicine rules.
At Decatur Memorial Hospital in Decatur, Illinois, a special program to improve physician utilization of blood products is showing impressive results. The laboratory worked with physicians to develop the ordering guidelines for blood products. The hospital uses the CPOE and clinical decision support system known as McKesson Horizon Expert Orders, along with the HorizonLab LIS.
Since this program was initiated in 2007, the 365-bed hospital has reduced usage of blood from a monthly average of 290 units to about 200 units per month. “This use of CPOE saves our hospital more than $200,000 per year,” stated John Little, Administrative Director of the lab- oratory. “It has measurably improved patient care and also decreased the risk of adverse events. Both our laboratory and the physicians consider this use of CPOE to be a win-win outcome.”
Little explained that use of the CPOE assists physicians in determining the appropriate amount of blood to transfuse, based upon the laboratory values and other criteria. In turn, this has reduced the number of incidents where a patient was over-transfused.
Changing the Philosophy
“Historically the rule of thumb used by physicians at our hospital was that, when ordering a transfusion, good practice was to order two units,” said Little. “The thinking was that, if a patient needed one unit, it was likely the patient would need more than one unit. On the other hand, if there were indications that a patient needed only one unit, there was the possibility that perhaps the patient did not need to be transfused at all.
“We wanted to add clinical precision to the process of evaluating the patient and ordering blood products,” he continued. “CPOE was a positive way to improve utilization of blood products. The physician is more involved in evaluating the patient.
“In each case where the CPOE and evidence-based rules help the physician either transfuse less blood, or avoid the need for a transfusion, there is a direct reduction in the patient risk of infectious disease,” added Little. “This is supported by many studies that conclude that transfusing blood—even if it’s the patient’s own blood—is risky. Therefore, each time the volume of blood transfused is reduced, risk to the patient is reduced as well.
“As a solution to inappropriate utilization of blood products or laboratory tests, use of CPOE is appealing because it requires the physicians to assess the patient against the appropriate evidence-based medicine guidelines at the time they are considering the transfusion,” he noted.
“For example, the CPOE system might help the physician realize that he or she was looking at yesterday’s hemoglobin levels,” said Little. “In this situation, the CPOE will prompt the physician to review or to order hemoglobin levels for today.”
Little offered another example of how the CPOE can guide the physician. “Every time a patient’s hemoglobin is low and the need for a transfusion is indicated, the CPOE and evidence-based rules have the physician re-evaluate that patient’s oxygen-carrying capacity and the patient’s vital signs before the system allows a first, second, or third unit of blood,” he added.
“This was a primary goal of implementing the CPOE,” stated Little. “Having the physician re-evaluate the patient at this point during treatment was expected to avoid some of the second- and third-unit transfusions that were actually clinically unneeded. In turn, the physician could achieve the desired patient outcome even as fewer blood products were used.”
“We know from the clinical literature that a patient does better and length of stay can shorten if the patient can avoid being transfused,” observed Little. “Overall, it is a positive thing for the patient, for the hospital, and for the physicians when blood products are transfused only in the appropriate amount and in the appropriate situations.”
Decatur Memorial Hospital is using CPOE and clinical care algorithms that include laboratory values to better manage physicians’ utilization of blood products. It is important to note that these care pathways were developed in collaboration with the laboratory and the physicians. That means the CPOE system presents physicians with patient care algorithms that were developed by their colleagues in the hospital and reflect the current published evidence.
If Horizon Expert Orders has a familiar ring to long-time readers of THE DARK REPORT, that should be no surprise. This is the expert system developed by the University of Vanderbilt Medical Center in Nashville, Tennessee, early last decade. Called “WizOrder” by Vanderbilt, the software system was licensed by McKesson. Laboratory Administrators at Vanderbilt told THE DARK REPORT that, in each department where WizOrder was implemented, utilization of laboratory tests declined by an average of 35% to 40%.
Vanderbilt’s lab leaders attributed this decline in lab test utilization to a variety of factors. Since the CPOE showed pending lab test orders, physicians didn’t order duplicate tests, for example. Also, the care algorithms in the clinical decision support function helped physicians avoid ordering tests that were clinically unnecessary.
The experience of the laboratory at Decatur Memorial Hospital at improving utilization of blood products demonstrates that today’s generation of CPOE systems and clinical decision support tools are effective ways to improve patient care while controlling the cost of care.