Ensuring patients receive the right test at the right time is a foundation of laboratory stewardship. Toward this goal, laboratories have tried many tactics to guide ordering practices and optimize the laboratory test menu. Laboratory directors can remove obsolete tests or introduce reflex algorithms that automatically trigger additional tests based upon initial laboratory findings.
While these approaches can be quite successful, what happens if the laboratory does not have ownership of the entire menu? Is the chance to guide stewardship through the menu lost?
The answer is no: The laboratory can still use the menu to influence ordering patterns through careful collaboration and organization.
The Origin of Order Menu Complexity
The modern laboratory menu resembles a network more than it does the closed system that the word menu implies. The complexity of the orderable menu within the electronic medical record (EMR) varies between health systems, and many include interfaces to external laboratories. A driving force is the incentive to reduce paper-based results, particularly with the federal government’s meaningful use regulations.
In addition, there are many reasons for patients to get labs drawn outside a particular provider’s system: Some insurance plans may require a different location, or patients may choose a different lab for convenience. Once a lab is interfaced to the EMR, the orders for the outside laboratory become options within the hospital’s orderable menu.
To simplify finding tests, the hospital laboratory may create submenus (preference lists, order sets, or panels) for individual providers and groups of providers. These submenus become the sources for ordering. If an order is deleted from the database, it typically does not get removed from all the downstream submenus. However, if a new order is added, it may not be visible unless it’s also included on the separate menus.
While a merged menu explains duplicate or triplicate options, why might there be even more? Depending upon how the system is established, the laboratory must build a new test in the EMR in order for providers to see results. Just as an individual laboratory makes updates to its menu, the menu in the EMR needs similar changes. If inactivated tests are not regularly removed, then the menu can quickly become clogged with old and new versions of similar sounding tests. In one system, approximately 200 tests were found for drugs of abuse (1). After reviewing these and other tests in the EMR, the laboratory consolidated 859 tests to 137.
Using the Menu Structure to Manage Utilization: Three Examples
Infliximab
We recently worked with primary users to create an in-house test for infliximab, including a reflex for anti-infliximab antibodies, to avoid sending it to a reference laboratory. After adding it to the menu, we notified all providers, including focused communication to high utilizers. Yet few orders arrived.
Upon investigation, we found that the order that linked to the reference lab also linked to an external commercial laboratory and was embedded in a panel to make it easier to find and order. We replaced the reference lab code with the in-house code for this order, so that when patients presented to the hospital laboratory for collection, the samples routed to the in-house test.
Creatine Kinase-MB (CKMB)
At a prior hospital, I worked on a utilization project to reduce the use of CKMB, given the superiority of troponin. With provider leadership agreement, we removed CKMB from the hospital menu, and orders quickly decreased as expected. However, we did not realize this order had been part of a cardiac panel that included CK. Eventually, when the laboratory reviewed CK utilization, we identified an order panel that included CK. The laboratory removed CK from the panel, and the orders decreased accordingly (2).
Antinuclear Antibodies (ANA) With Reflex
The Choosing Wisely program recommends against ordering individual serologies—such as Sjögren’s-syndrome-related antigen A or double-stranded DNA—if the ANA is normal. A review of one hospital menu revealed 80 options, including panels, individual markers, and different methods of analysis, reflecting three performing laboratories. An analysis showed that several tests were old versions of panels that were no longer available, while others were similar tests that could be co-mapped to one order.
Working with rheumatology and the EMR leadership, the laboratory identified a reflexive panel that started with ANA. The group found a similar panel for each interfaced laboratory, enabling mapping to a single orderable. They took a similar approach for each of the individual tests. They reviewed preference lists and panels and placed the orders for the ANA (with and without reflex) in each, with the more specific individual tests placed on the rheumatology preference lists. The total number of options was reduced to six (1), and ordering patterns became more reflective of published recommendations (3).
How To Avoid Tension Between the Laboratory and Clinical Providers
The experiences of laboratorians who have studied the issue of choice overload demonstrate that providers appreciate changes that make their job easier and improve patient care. Except for the CKMB example above, it’s notable that no tests were entirely removed from the menu. The efforts consolidated options and made it easier to identify recommended tests.
For the ANA example, providers could still individually order SSA, SSB, and other sub-serologies, as these were available in the full menu. The data showed that providers shifted to using the reflex, and the providers reported that it helped order all the needed sub-serology tests without having to place a lot of individual orders with the potential to miss one.
What Can Laboratorians Do?
As a first step, I would encourage clinical laboratorians to regularly look at the options providers see. If providers call with a question about ordering a specific test, ask if they can show you what they see as options. Understanding the organization and the options facing the providers can help highlight the barriers and opportunities to make it easier to select the recommended test.
As laboratory tests increase in number and complexity, identifying the right test for the right patient becomes more of a challenge. For any system, the laboratorians in the hospital are the local experts and are ideally suited to review this menu for changes and updates, even if the menus extend beyond their individual laboratory. By taking on this effort, laboratorians can continue to guide utilization.
Charlene Bierl, MD, is director of the division of laboratory medicine in the department of pathology and laboratory medicine at the Hospital of the University of Pennsylvania, and associate professor in the Perelman School of Medicine at the University of Pennsylvania. +Email: [email protected]
References
- Barry C, Edmonston TB, Gandhi S, et al. Implementation of laboratory review of test builds within the electronic health record reduces errors. Arch Pathol Lab Med 2020;144(6):742-747.
- Behling KC, Bierl C. Cost per case mix index-adjusted hospital day as a measure of effective laboratory utilization efforts in a growing academic medical center. Am J Clin Pathol 2019;151(4):371-376.
- Barry C, Kaufman S, Feinstein D, et al. Optimization of the order menu in the electronic health record facilitates test patterns consistent with recommendations in the Choosing Wisely initiative. Am J Clin Pathol 2020;153(1):94-98.