International Journal of Medical Informatics 102 (2017) 29–34

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International Journal of Medical Informatics

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Changing the electronic request form proves to be an effective tool for

optimizing laboratory test utilization in the emergency department
Ivana Lapić ∗ , Gordana Fressl Juroš, Ivana Rako, Dunja Rogić
Department of Laboratory Diagnostics, University Hospital Center Zagreb, Kišpatićeva 12, 10 000 Zagreb, Croatia

a r t i c l e i n f o a b s t r a c t

Article history: Objectives: Appropriate laboratory utilization more often than not needs to be initiated by the laboratory.
Received 6 January 2017 This study was performed to analyze the impact on test ordering patterns in the emergency department
Received in revised form 3 March 2017 obtained by omitting certain tests from the electronic tick box request form. The tests could still be
Accepted 5 March 2017
ordered by writing the full name of the test or by a phone call.
Methods: Erythrocyte sedimentation rate (ESR), fibrinogen, aspartate aminotransferase (AST), calcium
Keywords:
and lipase were omitted from the electronic request form and could subsequently be ordered either by
Laboratory utilization
phone or a typed-in request. A reflex testing protocol was elaborated for reduction of creatine kinase
Electronic request form
Emergency department
(CK) and CK-MB analyses. All interventions were introduced with prior consultation with clinical staff
and according to current guidelines. The reduction of test orders and costs in the post-intervention period
was assessed. All data were retrieved retrospectively from the laboratory information system (LIS).
Results: Disappearance from the tick box request form resulted in a significant decrease in the number
of requests for targeted tests in the post-intervention year, mostly affecting AST and fibrinogen (83%
and 79% reduction of ordering, respectively), followed by a 58% reduction in calcium orders, and 54%
and 43% reductions in ESR and lipase requests, respectively. A substantial reduction in CK requests was
also observed, while CK-MB requests almost disappeared. Annual cost savings that emerged from all
implemented interventions were estimated to be 19,445D .
Conclusion: Significant reduction in ordering of selected tests was achieved simply by limiting their avail-
ability in hospital computerized order entry (COE) system. The present data suggest that removal of
laboratory tests from the electronic request form can be an effective tool for changing physicians’ test
ordering behavior.
© 2017 Elsevier B.V. All rights reserved.

1. Introduction laboratory experts [2]. Although overutilization is most common,

optimization of laboratory testing does not necessarily mean reduc-
Appropriate utilization of laboratory testing is considered to be tion in the number of tests ordered but rather orientation toward
the key issue of the pre-preanalytical phase [1]. Due to increas- justified and adequate test requisition [3,4]. Selective and patient-
ing pressure on reducing healthcare costs while continuously oriented laboratory testing is the prerequisite not only for efficient
improving the quality of service and patient management, optimal patient management but also laboratory cost-effectiveness [4–6].
laboratory utilization is becoming an ever-growing concern among It is clear that involvement of laboratory experts in this process
is essential. In the so called ‘volume to value’ transition era, lab-
oratories no longer serve just as a nameless silent service but are
Abbreviations: ESR, erythrocyte sedimentation rate; AST, aspartate aminotrans- becoming increasingly involved in the proper selection of labora-
ferase; CK, creatine kinase; CK-MB, creatine-kinase MB; LIS, laboratory information tory tests, thus contributing to the quality of patient care [7–9].
system; COE, computerized order entry; IT, information technology; ED, emergency In an effort to rationalize, it is of upmost importance to get
department; ALT, alanine aminotransferase; GGT, gammaglutamyl transferase; LD, active real time insight into physicians’ ordering practices and
lactate dehydrogenase; CRP, C-reactive protein; CBC, complete blood count; PT,
identify the key problems. This information serves as the corner-
prothrombin time; aPTT, activated partial thromboplastin time; NTproBNP, N-
terminal pro-brain natriuretic peptide; HIS, hospital information system; hs-Tn, stone for implementation of demand management strategies which
high-sensitive troponin; ULRR, upper limit of the reference range; TAT, turnaround might include various educational and administrative interven-
time. tions [3,9,10]. These tools are classified as weak, moderate and
∗ Corresponding author.
strong, depending on the strength of their impact on the reduc-
E-mail address: [email protected] (I. Lapić).

http://dx.doi.org/10.1016/j.ijmedinf.2017.03.002
1386-5056/© 2017 Elsevier B.V. All rights reserved.
30 I. Lapić et al. / International Journal of Medical Informatics 102 (2017) 29–34

tion of inappropriate testing [3]. Education-based approach, which ordering those tests by phone or by writing the name of the test in
includes informative lectures referring to relevant and evidence- the field for comments at the bottom of the request form will signif-
based guidelines, is considered a weak but crucial tool in an ongoing icantly reduce their utilization. This type of soft approach appeared
maintenance of a successful laboratory-clinician cooperation. How- feasible both from our point of view and after discussing it with lead
ever, it inevitably needs to be coupled with other interventions. On physicians in charge of the ED. It was jointly assumed that it might
the other hand, interventions of moderate and strong effectiveness be an efficient way of discouraging mindless test requesting but
imply a more rigorous approach and are usually incorporated in still obtaining all the test results if necessary.
the laboratory and/or hospital information system. Possibilities are The aim of the present study was to assess the impact of restric-
different and depend on the nature of the problem. They include tive changes in the electronic request form on ordering selected
various restrictions in the test ordering process such as order- tests and the appropriate cost reductions achieved.
ing algorithms and reflex testing, privilege ordering principles and
limitation or complete removal of test availability. Despite the vari- 2. Materials and methods
ability of intervention principles, they all have the same ultimate
goal of systematic guidance toward a more appropriate laboratory 2.1. Setting
patient management [3,4,6,11,12]. There is evidence that applica-
tion of various interventions simultaneously is more effective than This study was conducted at the emergency laboratory of the
a single one [3]. Department of Laboratory Diagnostics, University Hospital Center
Emergency laboratory is a unique entity in the laboratory set- Zagreb. This emergency laboratory operates within the premises
ting where a selection of urgent tests is available for fast, reliable of the Department of Emergency Medicine and provides laboratory
and accurate management of critically ill patients. According to diagnostics for outpatients admitted to the ED. The laboratory oper-
available data, inapropriate and excessive laboratory ordering prac- ates on 24/7 basis, performing approximately 0.5 million tests/year,
tices are especially common in the emergency department (ED) which corresponds to about 200 patients per day. The laboratory
[1,13–15]. The underlying causes mostly speculated are defensive test panel includes routine biochemistry (glucose, creatinine, urea,
medicine, scarce knowledge of diagnostic accuracy of laboratory aspartate aminotransferase (AST), alanine aminotransferase (ALT),
tests and lack of cost-awareness among physicians [1,3,6,13,15,16]. gamma glutamyltransferase (GGT), lactate dehydrogenase (LD),
Due to all these factors, it seems well worth the effort to introduce total and direct bilirubin, sodium, potassium, chlorides, calcium,
utilization restrictions in the emergency laboratory. ethanol, creatine kinase (CK), CK-MB, C-reactive protein (CRP),
We hypothesized that ready availability of all tests on the alpha amylase in plasma and urine, lipase), hematology (complete
request form at our institution enhances the use of laboratory blood count (CBC), erythrocyte sedimentation rate (ESR)), coagula-
testing, both in routine and in emergencies. We identified the emer- tion (prothrombin time (PT), activated partial thromboplastin time
gency laboratory setting as an area for optimizing laboratory test (aPTT), fibrinogen, D-dimers), immunochemistry tests (troponin T
utilization given the persistent, rather uniform traditional ordering and NTproBNP) and urinalysis.
habits present among physicians in our ED. Laboratory tests are ordered through an electronic tick box
The focus of our intervention were mainly obsolete tests that request form in the hospital information system (HIS). After sample
are nowadays replaced by more specific ones and/or the ones that delivery to the laboratory, the request is transferred to the labora-
are crucial only in a limited number of conditions in critically ill tory information system (LIS).
patient management.
To specify, erythrocyte sedimentation rate (ESR) is a test of 2.2. Study design
limited utility nowadays according to published data, remaining
helpful in the diagnosis and management of a few specific condi- This study represents a retrospective analysis of test requests
tions usually not being treated within the ED [17]. Similarly, CK in the emergency laboratory over a period of three years (from
and CK-MB are severely outdated tests in the management of sus- 2013 to 2015), compared to the year before interventions were
pected acute coronary syndrome, especially since the introduction made (2012). IT-based interventions were, as explained previously,
of high-sensitive troponin tests [18]. implemented in the computerized order entry (COE) form. The tests
Alanine aminotransferase (ALT) and aspartate aminotransferase that were omitted from the electronic request form were ESR, AST,
(AST) are traditionally and de facto incorrectly called ‘liver function calcium, lipase, fibrinogen, CK and its cardiac isoenzyme (CK-MB).
tests’ and are usually ordered together [19]. Although their utility All interventions were introduced after thorough discussion and in
is often intertwined, ALT is known to be a more specific indicator agreement with key physicians in charge of the ED. An informative
of liver disease [19–21]. Therefore, we deemed it justified to limit notification was disseminated to the entire clinical staff prior to
AST availability on the request form. introduction of each intervention.
Fibrinogen analysis in the ED is important in a few specific clin- The course of implementation of interventions and the type of
ical conditions, the most significant being management of trauma interventions are outlined in Table 1.
hemorrhage. Its widespread determination in the ED is, therefore, Specifically, the ready availability on the electronic request form
of questionable clinical utility and not recommended [22,23]. was limited for ESR, fibrinogen, AST, lipase and calcium but all
Calcium is another test we believed reasonable to focus our these tests remained available by phone call from physicians to
efforts on. Although hypocalcemia is known to be a common finding the laboratory staff or by writing the name of the test in the field
in critically ill patients [24,25], it was demonstrated that its levels for comments at the bottom of the request form. Furthermore, an
rarely affect treatment in the ED [26]. Furthermore, replacement automatic IT-based reflex testing protocol within the laboratory
therapy has not demonstrated to improve patient outcome [24]. was elaborated for reduction of CK and CK-MB testing, as shown in
Finally, although lipase appears to be a more specific test than Fig. 1. Nevertheless, these tests could also be requested regardless
amylase for diagnosis of acute pancreatitis [27], we considered it of the reflex testing protocol if urged by physician.
justifiable to reduce its tick box availability in our laboratory setting
due to almost uniformly coupled ordering with amylase and its 2.3. Data collection and analysis
higher price.
In this study, we presumed that omitting selected tests in the The following data were obtained for the studied years (2012,
electronic request form and thus introducing the obligation of 2013, 2014, 2015): the number of patients admitted to the emer-
 I. Lapić et al. / International Journal of Medical Informatics 102 (2017) 29–34 31

Table 1 Table 2
Interventions performed from 2013 to 2015. The number of patients, tests performed and the average number of tests per patient
in the studied period (2012–2015).
Time implemented Test Intervention
Year 2012 2013 2014 2015
January 2013 • ESR, fibrinogen • omission from the electronic
• CK, CK-MB request form (available by Number of patients 59,790 57,498 63,085 69,852
phone call or writing the test Number of tests performed 526,923 491,541 509,961 468,545
name in the field for Average number of tests/patient 8,8 8,5 8,1 6,7
comments)
• IT-based reflex testing
protocol

February 2015 • AST, lipase • omission from the electronic

• calcium (adult request form (available by
population phone call or writing the test
onlya ) name in the field for
comments)

a
Calcium was removed from the request form for adult population only, accom-
modating the attending physicians’ request.

Tests requested together

Fig. 2. Change in the percentage (%) of AST orders in the total number of patients
during 2015.

hs-Tn + CK + CK-MB CK + CK-MB

intervention and post-intervention year for each targeted test
together with percentage reduction in the number of orders. Analy-
Eliminaon of sis showed that there was a statistically significant difference in the
CK and CK-MB
number of test orders of all targeted tests in the post-intervention
year compared to the pre-intervention year (p < 0.001).
Analyze hs-Tn only Analyze CK
Significant reduction of fibrinogen requests was noted in 2013
(from 32% orders in the total number of patients to 7%), while a
further drastic reduction occurred in 2014 (4/63,085 patients) and
2015 (3/69,852 patients).
CK < ULRR2 CK > ULRR The most significant fall in test ordering in the second phase of
intervention period was achieved for AST. Monthly change in the
Reflex tesng
number of AST orders following the elimination from the electronic
Do not analyze CK-MB Analyze CK-MB request form and application of the rule of ordering exclusively by
physicians’ call or specific written remark is shown in Fig. 2.
Fig. 3 shows subsequent decrease in CK determinations over
Fig. 1. Flow-chart of the IT-based protocol for CK and CK-MB analysis.
2
ULRR (male) < 177 U/L, ULRR (female) < 153 U/L. years after the introduction of laboratory reflex protocol for auto-
matic elimination of CK analysis when requested together with
high-sensitive troponin in 2013.
gency laboratory, the number of tests performed and the number Moreover, with the introduction of the reflex protocol, CK-
of ordered target tests in the pre- and post-intervention years. All MB was almost completely eradicated. The analysis showed that
data were drawn from the hospital and laboratory IT-system (IN2 in 2014 only 14 CK-MB requests in the total number of 63,085
d.o.o., Zagreb, Croatia). patients were processed, while in 2015 CK-MB was analyzed for
Chi- square test was used to assess differences in the number only 6/69,852 patients.
of ordered tests in the pre- and post-intervention year, p < 0.05 Finally, the implementation of the interventions resulted in a
was considered statistically significant. Statistical analysis was notable reduction in costs, as shown in Table 4.
performed using the Medcalc statistical software, version 14.12.0
(MedCalc, Ostend, Belgium). 4. Discussion
We also retrospectively calculated the additional costs that
would have been generated in 2015 for each test included in the This study shows the results of laboratory initiated endeav-
study if not restricted, based on their approximate ordering fre- ors toward rationalizing laboratory utilization in the ED through
quency in 2012. The data for the year 2012 served as a reference request form interventions. In order to curb habit-driven test order-
(as a year when all tests were available on the request form with- ing, it was of foremost importance to get actively involved in
out restrictions) while 2015 represents the reference period after pre-preanalytical phase, i.e. in the process of requesting laboratory
all interventions included in the study were implemented. tests. First step was to establish active, trustworthy and ongoing
communication with clinicians which involved discussing their
3. Results needs, getting acquainted with published guidelines and recom-
mendations and identifying the areas for improvement. Based on
Table 2 displays the number of patients and tests processed in these consultations, and considering the possibilities of interven-
the emergency laboratory in the observed years. tion into our hospital and laboratory IT-system, a joint decision
Table 3 summarizes the total number of targeted test requests was made on which tests could be omitted from readily available
compared to the total number of patients in the specific pre- tick box panel. Thus, ESR, fibrinogen, AST, lipase and calcium were
32 I. Lapić et al. / International Journal of Medical Informatics 102 (2017) 29–34

Table 3
Reduction in the number of targeted tests per years before and after intervention.

Requests in the pre-intervention year 2012 Requests in the post-intervention year 2013 Percentage reduction (%)
(N/patients) (N/patients)

ESR 1563/59,790 717/57,498 54%

Fibrinogen 19,393/59,790 3861/57,498 79%

Requests in the pre-intervention year 2014 Requests in the post-intervention year 2015 Percentage reduction (%)
(N/patients) (N/patients)

AST 23741/63,085 4568/69,852 83%

Calcium (all requests) 6077/63,085 2867/69,852 58%
Calcium(adult population) 4255/63,085 1077/69,852 77%
Lipase 2687/63,085 1658/69,852 43%

Fig. 3. The absolute number of CK tests performed from 2012 to 2015, compared to the absolute number of hs-Tn tests.

Table 4
Reagent cost savings in 2015 compared to those in 2012, when all tests were available on the tick box request form without restrictions.

Requests in 2012 N/59790 (%) Requests in 2015 N/69852 (%) Annual reagent cost savings (D )

ESR 1563 (3) 620 (1) 61

Fibrinogen 19393 (32) 3 (<0.1) 8292
CK 19749 (33) 5295 (8) 6998
CK-MB 379 (1) 6 (<0.1) 366
AST 24908 (42) 4568 (7) 2199
Calcium 5577 (9) 2867 (4) 390
Lipase 2687 (5) 994 (1) 1139
Total 19,445

removed, together with introduction of in-laboratory reflex testing tion also successfully reduced the number of CK and CK-MB tests
rule for CK and CK-MB analysis, making ordering of these tests pos- performed.
sible only by phone call or a typed-in request. The implementation The results of our study show the effectiveness of this simple
of these restrictions yielded an immediate and substantial reduc- limiting approach which consisted of requiring minimal additional
tion in test ordering. Significant drop in ordering was achieved for effort when ordering selected tests. It confirmed our hypothesis
all tests included in the study but the most notable reduction in that easy hands-on availability of laboratory tests on the request
the post-intervention year was the decrease in AST and fibrinogen form is the strongest predictor of testing frequency and that it
testing. These tests were previously ordered regularly as respective therefore favors non-selective and often excessive ordering. This
parts of the metabolic or coagulation panel. Furthermore, there was assumption is in accordance with published data about variables
a noted decrease in ESR requests after the corresponding tick box affecting physicians’ test ordering habits [3,29,30]. Studies dealing
had been removed, which could easily be explained by the fact that with similar approaches of altering the laboratory test request form
its significance is nowadays limited to a small number of clinical in primary care also demonstrated its effectiveness in rationalizing
conditions and its clinical utility is replaced by more specific tests laboratory test requesting [31,32].
[17]. Similarly, the within-laboratory cancellation of CK and/or CK- Moreover, the implemented interventions had a significant
MB when requested together with high-sensitive troponin (thus impact on reducing laboratory reagent costs, resulting in a total
presuming clinical question involving cardiac damage) is an exam- of 19,445D annual savings for calendar year 2015, calculated on
ple of elimination of obsolete and unnecessary testing according the basis of ordering frequency of targeted tests in 2012 when all
to relevant guidelines and published data [18,28]. This interven- tests were available on the request form. It is important to empha-
 I. Lapić et al. / International Journal of Medical Informatics 102 (2017) 29–34 33

size that those notable savings have been achieved by reducing

exclusively the tests classified as low-cost. Summary table
Inappropriate laboratory utilization clearly is a widespread phe- What was already known on the topic
nomenon and deserves our continuous consideration. Growing • Appropriate laboratory utilization is considered a key for effi-
cient patient management and reducing laboratory costs.
demand for laboratory testing is among other known reasons, such
• Information-technology based strategies prove to be an
as aging population, prevalence of chronic diseases, etc., at least
effective tool for optimizing laboratory utilization in different
partly also the consequence of the easy availability and lack of settings.
feedback measures [4]. Introduction of automated tests with short • The introduction of changes in the electronic request form
turnaround times (TAT), the appearance of new tests without omit- can affect physicans’ ordering habits and rationalize the use
ting the old ones and the development of predictive medicine are of laboratory testing.
some of the strongly contributing factors to the boost of labora- What this study added to our knowledge
tory testing [3,7]. This trend is, however, contrary to the continuous • The instant availability of laboratory tests on the request
need for reducing costs. This apparently unsolvable paradox should form enhances overutilization of laboratory testing and a sig-
be at least partly dealt with and diminished through proactive nificant decrease in ordering can be achieved if additional
minimal effort is required.
involvement of laboratory experts in demand monitoring and man-
• Changing the electronic request form is a simple, but highly
agement [30]. This is a challenging task since it is not easy for effective limiting approach, even in a sensitive environment
non-clinical staff to get involved in the process of clinical decision- such as the emergency department, if introduced in close
making. Therefore a number of different approaches and tools are cooperation with physicians and following relevant guide-
available [3]. If successful, such interventions prove to be benefi- lines and recommendations.
cial not solely in the context of saving limited laboratory resources • IT-driven approach proved to be very effective and satisfy-
but also of providing patient-oriented care and contributing to a ing both for the laboratory and clinicians in the emergency
more efficient workflow, not to mention making laboratory activi- department in terms of enhancing laboratory service quality.
ties more meaningful [7]. Utilization management is a vivid process
that requires continuous monitoring, adapting and assessing. In 5. Conclusion
this process, a close ongoing cooperation between laboratory and
clinical staff is mandatory and should never be put aside [3]. Changing the availability of selected tests on the electronic
In this study, we present how simple interventions in com- request form significantly reduced their use in the ED and
puterized order entry system which limit the instant availability a substantial reduction of laboratory costs was achieved. We
of certain laboratory tests and require minimal additional effort believe that this represents a small but significant step away
can dramatically influence ordering habits and subsequently lead from absent-minded schematic laboratory testing toward more
to savings within tight laboratory budget. Our study proved that evidence-based approach. Utilization management remains an
routine testing habits are hard to change and therefore can be open and challenging area with great potential not only for improv-
influenced most successfully by using interventions that operate ing appropriateness in test requesting but also for contributing to
at the same level. If request form changes are introduced carefully the overall quality of the testing process and patient management
and according to current guidelines, the shift toward slightly more [7].
evidence-based testing can be attained. However, it is hard to gen-
eralize the achieved results since the success of the interventions Authors’ contributions
also depends on the setting [11].
At our institution, changing the electronic request form proved IL designed the study, collected the data, performed data anal-
to be an effective tool in reducing laboratory utilization in the ED ysis and wrote the manuscript. GFJ and IR planned and performed
and improving laboratory cost-effectiveness. Our results might be the interventions, designed the study and wrote the manuscript.
regarded as valuable considering that the ED is a very challenging DR gave the original idea to study these interventions, planned and
and sensitive environment for such restrictive interventions since performed the interventions and wrote the manuscript. All authors
it requires timely and accurate results for effective care [13]. The participated in drafting the manuscript, revised the final version
smooth implementation was due to careful test selection and good and approved it.
communication between clinical and laboratory staff.
The study has several limitations: the first one pertains to lack Funding
of data on patients’ diagnosis, which makes it impossible to clearly
define the inappropriateness of laboratory testing; however, the This research did not receive any specific grant from funding
case mix of patients in our ED is fairly constant from one year agencies in the public, commercial, or not-for-profit sectors.
to the next. Secondly, we are not aware if any of the restrictions
caused underutilization and subsequently led to delayed diagno- Conflict of interests
sis or misdiagnosis. It is important to emphasize once again that
all the targeted tests were not discontinued and could have been The authors declare no conflict of interest.
requested any time either by writing the name of the test on the
request form or by phone. There were no official complaints made Acknowledgement
to the laboratory about these changes, either from physicians or
patients. All these limitations are in concordance with a large num- None.
ber of published papers that state the difficulties in choosing the
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