Centre for Quality Improvement and Patient Safety, University of Toronto, 19.105-600 University Avenue, Toronto, Ontario M5G 1X5, Canada.
Division of General Internal Medicine, Dalhousie University, 436 Bethune Building, 1276 South Park Street, Halifax, Nova Scotia B3H 2Y9, Canada.
Int J Med Inform. 2021 Sep;153:104546. doi: 10.1016/j.ijmedinf.2021.104546. Epub 2021 Aug 4.
Reducing inappropriate blood tests has been highlighted by Choosing Wisely as a key area of focus. Computer physician order entry is one modifiable contributor, but little is known about how computer ordering compares to paper methods when it comes to low-value laboratory testing.
To determine which method of order entry is associated with a greater amount of appropriate lab testing. Furthermore, to identify ordering patterns for more targeted interventions in future.
We conducted a retrospective observational cohort study of inpatients discharged at two hospitals (one site uses paper order sets, while the other uses electronic order sets).
General internal medicine wards at two Canadian teaching hospitals.
At site 1 (electronic orders), all general internal medicine discharges from May 2015 and February 2016. At site 2 (paper orders), all general internal medicine discharges from April 15, 2015 to May 26, 2015.
MAIN OUTCOME(S) AND MEASURE(S): Main outcome was the percentage of inpatient discharges at each site with orders for daily laboratory tests for three days on admission. Secondary measures include proportion of tests with appropriate indications and rates of discontinuation of daily laboratory tests.
We reviewed 395 discharges with a mean patient age of 69.5 ± 18.9 years and mean length of stay of 12.1 days. Daily laboratory tests were more common with paper orders (site 2) compared to electronic order sets (site 1) for complete blood count (CBC) (90.8% vs. 68.5%, p < 0.001), electrolytes (93.8% vs 71.5%, p < 0.001), and creatinine (93.8% vs 70.0%, p < 0.001) testing. However, paper orders for daily laboratory tests were more often appropriate, both in CBC (76.3% vs. 38.9%, p < 0.001) and electrolyte/creatinine (80.3% vs 44.2%, p < 0.001) testing. Discontinuation of daily labs occurred more often with paper orders (35.4% vs. 6.7%, p < 0.001).
Compared to written orders, daily laboratory testing using electronic ordering was associated with higher rates of inappropriate indications and lower rates of discontinuation. Our results support interventions aimed at ensuring electronic order sets incorporate appropriate indications and a mechanism for discontinuation of daily lab orders. Further studies aimed at understanding how the process of completing paper or electronic orders influence appropriateness of daily laboratory orders are needed to further minimize inappropriate testing.
明智选择将减少不必要的血液检测作为重点关注领域之一。计算机医嘱录入是一个可改变的因素，但对于实验室低值检测来说，计算机医嘱与纸质医嘱相比哪种方法更合适，目前知之甚少。
确定哪种医嘱录入方法与更多适当的实验室检测相关。此外，还确定了未来更有针对性的干预措施的医嘱模式。
我们对两家医院（一家使用纸质医嘱集，另一家使用电子医嘱集）的普通内科住院患者进行了回顾性观察队列研究。
加拿大两家教学医院的普通内科病房。
Site1（电子医嘱）为 2015 年 5 月至 2016 年 2 月所有普通内科出院患者；Site2（纸质医嘱）为 2015 年 4 月 15 日至 2015 年 5 月 26 日所有普通内科出院患者。
主要结果是每个站点的住院患者出院时，入院后三天内每天实验室检测的医嘱比例。次要测量指标包括具有适当适应证的检测比例和每天实验室检测的停药率。
我们共回顾了 395 例患者，患者平均年龄为 69.5±18.9 岁，平均住院时间为 12.1 天。与电子医嘱集相比，纸质医嘱集（Site2）更常开具全血细胞计数（CBC）（90.8%比 68.5%，p<0.001）、电解质（93.8%比 71.5%，p<0.001）和肌酐（93.8%比 70.0%，p<0.001）的检测医嘱。然而，纸质医嘱集开具的每日实验室检测医嘱更常具有适当的适应证，CBC（76.3%比 38.9%，p<0.001）和电解质/肌酐（80.3%比 44.2%，p<0.001）的检测均如此。纸质医嘱集开具的每日实验室检测医嘱停药的比例更高（35.4%比 6.7%，p<0.001）。
与书面医嘱相比，使用电子医嘱录入的每日实验室检测与更高的不适当适应证和更低的停药率相关。我们的研究结果支持旨在确保电子医嘱集包含适当适应证和每日实验室医嘱停药机制的干预措施。需要进一步的研究来了解完成纸质或电子医嘱的过程如何影响每日实验室医嘱的适当性，以进一步减少不必要的检测。
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