Electronic medical record (EMR) dashboards do little to encourage judicious ordering of routine laboratory tests. Researchers made this finding after conducting an intervention on cost-effective care that was published in the Journal of Hospital Medicine. “The advantage of an EMR-based dashboard is that it’s transparent and automated. However, we found that providers didn’t use it as much as we expected,” senior study author Kira Ryskina, MD, MS, an assistant professor with the University of Pennsylvania’s Division of General Internal Medicine, told CLN Stat.
Routine labs don’t always lead to better patient outcomes, but clinicians frequently overuse them in inpatient settings. To assess internal medicine residents’ ordering habits for routine lab tests, investigators in a mixed methods study decided to track resident utilization of the EMR dashboard over a designated time period. Through focus groups, they also gathered resident feedback about using the dashboards. Investigators randomized 80 residents to participate in the intervention portion of the study over a period of 6 months. Each of the residents received a snapshot and a link to their own personalized dashboard, and summaries of their utilization averages in comparison with service averages. The web-based dashboard through interactive graphs tracked resident orders of routine tests such as basic and complete metabolic panels, complete blood count, coagulation, and liver function panels.
Residents could use the dashboard to review the tests they ordered or look up a patient’s medical record. Researchers via web-based tracking and email-read receipts measured the rate of engagement in the EMR tool. They also analyzed the transcripts of the focus groups to assess common themes on dashboard usability and barriers to using this technology. Most of the residents (74%) took the initiative to open the email link to the dashboard. However, just 21% took the additional step to access the EMR tool. “In absolute terms, 21% seems low although there’s little data about physician engagement with dashboards, so we don’t have accurate expectations of what might be an ‘appropriate’ or ‘high’ rate of engagement,” Ryskina said, offering some perspective on the results.
Dashboard use didn’t seem to greatly affect lab ordering behaviors either although investigators reported that residents who did open the dashboard link ordered 0.26 fewer tests per doctor-patient day than those who didn’t. The drop in lab orders by dashboard users was especially prominent on the second day of the intervention, when orders dropped by 0.59 labs per doctor-patient-day, compared with nonusers.
Participants for the most part liked the idea of getting personalized, real-time feedback about their ordering behaviors. This suggests that young doctors are aware of the lab test overuse problem. “However, many residents questioned several aspects of the specific intervention used in this study and suggested that significant improvements would need to be made to future dashboards to increase their utility,” the authors acknowledged.
According to Ryskina, physicians reported a number of barriers to engaging with the dashboards, including time constraints on busy inpatient service, a lack of concrete directions to change behavior, and concerns about the data (e.g., short measurement time frame and lack of risk adjustment for differences in case mix). The study’s small sample size also limited its findings.
The results suggest that optimizing laboratory ordering through utilization dashboards may require stronger incentives to achieve high participation rates among physicians, Ryskina said. There are reports of widespread efforts by medical centers to encourage more judicious use of laboratory tests, she said. “These range from educational interventions to EMR-based dashboards to displaying costs in the EMR, for instance. However, there’s not a lot of empirical evidence suggesting an optimal approach,” Ryskina added. Engaging the senior attending physicians on the service may be one way to improve uptake of this intervention. “There’s definitely a lot of interest and research in this area, but the findings are mixed so far,” she said.