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Can Tech Change Physician Behavior?

9:39 PM Posted by David Do, MD No comments
Providers in the hospital order many more lab studies on patients than medically necessary. A common practice during a patient's admission is to order a set of labs and, with one click, copy ahead to an entire week. It has become a part of the culture--ordering labs a week ahead of time--and contributes heavily to unnecessary costs. Many have proposed to remove this copy feature. I think that is unwise--it fails to address the fundamental problem, and in fact it creates news problems. Here's why:

1. Copying is necessary
In a survey of residents in the hospital, people reported that the intervention would make it harder to care for critically-ill patients, including trending hemoglobin in a bleeding patient, sodium in a hyponatremic patient, or DIC labs in a cancer patient. It takes at least five clicks and several key presses to order a single lab in our inpatient EMR. Providers already spend a substantial part of their days working in the EMR, and to order these labs for a census of eight patients could take up to ten extra minutes daily. I have heard, however, that not all institutions have a copy feature, so we should be able to live without it. EMRs vary in usability, and most (like our outpatient EMR) require fewer clicks than the inpatient EMR we currently use.

2. Efficiency matters
Disabling the copy feature may very well decrease the total number of labs ordered--but so would an intervention that requires house staff to draw all their patient's labs. Efficiency is critical. The average intern work day is a nonstop stream of orders, documentation, and telephone calls. An efficient EMR means that they spend more time talking to and examining patients and thinking about the big picture.

I liken this problem to one in the outpatient EMR. EPIC progress note templates encourage cookie-cutter exams of questionable reliability. The destruction of templates would probably lead to more accurate notes but at the expense of time. The fundamental problem here is a lack of time, and documentation is poor not because of templates but because providers rush through documentation to keep pace with their clinic day. 

3. Its a barrier 
Great technological solutions should make it easier to do the right thing rather than raise barriers. The true problem with lab overuse is a lack of thought. The solution, therefore, would be to prompt people to think about it. Some teams, for example, have pioneered the use of a rounding checklist. One question on this checklist is, "does the patient need lab studies tomorrow?". If not built in as a part of rounds, perhaps we could send an electronic notification that tells the provider exactly which labs are ordered for their patients. This prompts the user to think briefly about each item. 

Instead of asking our technology to make it harder to order labs, we should ask our technology to make it easier for the provider to order the labs he/she wants.  

Residents want to reduce the number of lab draws. They want to save their patients from the discomfort, and they want to avoid incidental findings. When I have the luxury of extra time, I think about which labs i need and cancel unnecessary ones. Work load often prevents them from being thoughtful about the labs they order. We can provide them the tools to be better doctors, rather than adding an obstacle to ordering labs.  


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