Environmental Interventions to Reduce Unnecessary Lab Test Orders

Below is a list of environmental interventions that have been proven to reduce the number of unnecessary laboratory tests.

Test requisition redesign – electronic and paper

• Restrict lab menu on inpatient order entry system
• Preferred tests & cascades emphasized
• Outmoded tests less obvious or deleted
• Minimize bundles of tests for ordering convenience
• Limit inclusion of esoteric tests on general requisitions
• Review test naming conventions and order of appearance
• Provide useful for information with name of test such as hCG pregnancy vs tumor marker
• Organize tests by ordering pattern or disease state, not alphabetically

Order entry prompts

• Clinical indications at time of ordering
• Warning of overlapping test orders such as CMP and liver profile
• Limit test order frequency per admission
• Notify physician of previous results
• Tailor ordering by physician specialty
• Prohibit automatic ordering of daily test orders
• Notify of tests restricted to outpatients, thrombophilia, genetics
• Prohibit reordering of once in a lifetime test & show previous result
• Notification that Test X only orderable by specialist
• Require clinical information such as symptoms or exposure history
• Display cost or relative cost of tests in electronic order entry

Algorithms & test ordering guidelines

• Work best if lab driven since physicians will not follow results and order tests sequentially
• Lab driven where initial results drive subsequent selection. Examples include test cascades such as thrombophilia, celiac, HCV and HIV
• Pathologist driven where path review determines next steps. Examples include flow cytometry and  bone marrow examination
• Genetic counselor driven when a consult is required before a genetic test can be ordered
• List diseases and recommended tests in ordering system

Lab Performance

• Review lab tests included in order sets and clinical guidelines
• Optimized testing and reporting
• Rapid TAT
• Minimal number of laboratory errors
• Clear, concise integrated reports with interpretive comments
• Immediate and easy access to test results
• Merged inpatient and outpatient test results

In the next blog specific examples of administrative interventions will be discussed.