Electronic Pop-Up Message Can Cut Nondirected Testing for Rare Conditions

A simple electronic decision support tool can reduce unnecessary testing conducted as part of nondirected assessments. A pop-up screen in electronic ordering systems significantly reduced testing for rare conditions commonly included with nondirected testing for liver disease, according to a research letter published June 1 in JAMA Internal Medicine. The researchers say this intervention is likely applicable in other clinical scenarios.

Elevated liver enzymes are estimated to affect nearly eight percent of the U.S. population. Resulting workups often test for viral hepatitis as well as Wilson disease, an inborn error of copper metabolism that affects 0.003 percent of the U.S. population and rarely presents with late onset. Initial Wilson disease diagnosis occurs based on ceruloplasmin blood levels.

In the current study, researchers evaluated the effect of a decision support tool on ceruloplasmin test utilization by measuring use rates seven months before and after implementing an electronic pop-up in the electronic medical record system at Beth Israel Deaconess Medical Center (October 1, 2013 through November 27, 2014).

Ceruloplasmin was ordered 448 times (mean times per day, 2.12) before implementation of the electronic pop-up. The researchers found that after implementation orders significantly dropped to 219 (mean times per day, 1.04). For comparison sake, the researchers assessed test orders for α1-antitrypsin, which is also commonly ordered to assess liver disease. Over the same time period there was no significant change in the rate of α1-antitrypsin orders (449 before and 418 after). The researchers also noted significant drops in simultaneous testing of ceruloplasmin and viral hepatitis (407 before versus 185 after implementation), as well as a significant reduction in ceruloplasmin testing in patients older than 55 years (158 tests ordered versus 61). Similarly the control rate of α1-antitrypsin test orders did not change in older patients. No cases of Wilson disease were identified.

“Further study is needed to extend this intervention into systematic changes including reflex testing of rare conditions after common diseases have been excluded or restricting testing options for clinicians,” write the authors led by Elliot Tapper, M.D., from Beth Israel Deaconess Medical Center in Boston. “The findings from our study could inform programs to reduce the number of orders for nondirected tests in other common clinical scenarios, including antibody tests for [rheumatic] or infectious diseases or routine blood tests for routine daily blood tests for inpatients.”