EHR Diagnostic Stewardship Strategy Reduces Unnecessary GI Testing

Researchers were able to reduce unnecessary orders of a gastrointestinal panel by 46% and saved as much as $168,000 over 15 months after programming a hospital’s electronic health record (EHR) system to provide information on appropriate use of the panel, according to a new study published in Infection Control & Hospital Epidemiology.

Lead study author, Jasmine R. Marcelin, M.D., associate medical director of antimicrobial stewardship at University of Nebraska Medical Center, and her research team hardwired criteria into a health system’s EHR to provide best practice alerts and a “hard stop” that prevents inappropriate orders of the Gastrointestinal Pathogen Panel.

The panel is useful for new patients who could have been exposed to a wider variety of pathogens, but unnecessary for patients later in their hospital stay. It is also more rapid and sensitive than traditional stool culture and detects 22 common pathogens. But the panel is expensive to use.

In the 15 months before activating the hard stop, 21.5% of the tests ordered were considered inappropriate. After applying changes in the EHR, only 4.9% were inappropriate.

The study took place at an 830-bed Midwestern tertiary-care medical center with a large population of complex and immunocompromised patients. Participants were hospitalized patients with diarrhea who had a Gastrointestinal Pathogen Panel ordered for them between January 2016 and March 2017 — period one — and April 2017 through June 2018 — period two.

In period one, 1,587 tests were ordered over 212,212 patient days, at a rate of 7.48 per 1,000 patient days. Comparatively, in period two, after the changes to the EHR were made, 1,165 tests were ordered over 222,343 patient days at a rate of 5.24 per 1,000 patient days.

In order for the panel to be used properly, before it was implemented, an antimicrobial stewardship program was created to provide guidance on the Gastrointestinal Pathogen Panel.

The antimicrobial stewardship program suggested that testing should not be repeated or performed after a patient’s fifth day in the hospital.

Inpatient use of the panel was reviewed over the first 12 months after implementation of guidance on test use and revealed that 19.9% of tests were inappropriate and did not detect any meaningful pathogens.

Marcelin and the team reviewed baseline data on the adherence to current guidelines, set a goal to reduce the use of the test by 20% and worked with the informatics team to create decision support tools to enforce the guidelines.

The update guidelines provided information on appropriate use and alternative testing, as well as took away the possibility to order duplicate tests for patients hospitalized for more than 72 hours. It was found that stool testing in patients hospitalized for more than 72 hours — or those who have previously been tested — is unlikely to be clinically relevant.

When users of the EHR went to order a panel, a silent best practice advisory was also triggered, which allowed for measurement of the number of times the order panel was opened but not completed.

It was estimated that the diagnostic stewardship intervention, including the hard stop and best practice alert reduced the ordering rates of the panel by 30% between periods one and two.

The authors wrote that diagnostic stewardship interventions can improve patient satisfaction, reduce irrelevant or false-positive test results and save costs.

“We found that when it comes to diarrheal illnesses in the hospital, asking physicians to reconsider if the testing is appropriate through hardwired alerts saves money without compromising quality of care,” Marcelin said.

Marcelin also suggested that further research on diagnostic stewardship could include the evaluation of outcomes of the length of a hospital stay or reduction or inappropriate antibiotic use associated with hard stop.

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