Department of Medicine 2016 Tech Challenge

New Uses of Information Technology to Advance the Missions of the Department of Medicine

Empowering the EMR to help providers to choose and order tests wisely

Idea Status: 

Aim:

1)      To reduce redundant and unnecessary  specimen collection from patients with a new order entry strategy

Background:

                As a tertiary referral center, we see many patients who require multi-disciplinary care.  A majority of our patients receive care from multiple providers in different specialties, and as a result these patients often have redundant lab tests ordered.  This often results in submission of multiple specimens for overlapping tests in short periods of time.  The ease of ordering tests on our EMR has not improved our ability to streamline lab test ordering and specimen requirements for patients.  We seek to leverage the power of the EMR to improve coordination of care for patients. 

Proposal:

1)      Modify the EMR to have the order entry window appear parallel to a modified Results Display screen

2)      Flag future labs that have been ordered by other providers and allow easy modification for additional tests that can be consolidated

3)      Separate lab order entry panels into acute (1 time or short interval, recurrence) versus chronic (every 1-12 months, recurrence) to assist with the interface at the phlebotomy lab level

4)      Modify chronic order sets to include a range of acceptable time ranges for lab draws to occur (+/- 1 month for example), and allow the phlebotomist to adjust the lab draw dates to minimize blood draws)

Example:

This is the standard results window for a patient who had labs checked on 1/1/2015.

 

1/1/2015

2/1/2015

3/1/2015

4/1/2015

5/1/2015

6/1/2015

7/1/2015

8/1/2015

9/1/2015

10/1/2015

11/1/2015

12/1/2015

CHEM PROFILE

 

 

 

 

 

 

 

 

 

 

 

 

Na

135

 

 

 

 

 

 

 

 

 

 

 

K

4

 

 

 

 

 

 

 

 

 

 

 

Cl

105

 

 

 

 

 

 

 

 

 

 

 

HCO3

24

 

 

 

 

 

 

 

 

 

 

 

BUN

10

 

 

 

 

 

 

 

 

 

 

 

Cr

1

 

 

 

 

 

 

 

 

 

 

 

Gluc

90

 

 

 

 

 

 

 

 

 

 

 

AG

6

 

 

 

 

 

 

 

 

 

 

 

eGFR

> 60

 

 

 

 

 

 

 

 

 

 

 

Ca

9

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

IRON/ANEMIA PROFILE

 

 

 

 

 

 

 

 

 

 

 

 

Ferritin

 

 

 

 

 

 

 

 

 

 

 

 

Iron

 

 

 

 

 

 

 

 

 

 

 

 

Transferrin

 

 

 

 

 

 

 

 

 

 

 

 

% Sat

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

CBC

 

 

 

 

 

 

 

 

 

 

 

 

WBC

 

 

 

 

 

 

 

 

 

 

 

 

RBC

 

 

 

 

 

 

 

 

 

 

 

 

HGB

 

 

 

 

 

 

 

 

 

 

 

 

Hct

 

 

 

 

 

 

 

 

 

 

 

 

Platelet

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

THYROID

 

 

 

 

 

 

 

 

 

 

 

 

Parathormone

 

 

 

 

 

 

 

 

 

 

 

 

TSH

 

 

 

 

 

 

 

 

 

 

 

 

Free T4

 

 

 

 

 

 

 

 

 

 

 

 

Step 1:  Nephrologist sees patient on 01/2015 and wants to check 1) chem-7 every 3 months x 1 year and 2) Parathormone every 6 months x 1 year.  The following screen will display when future providers want to make additional lab order

 

1/1/2015

2/1/2015

3/1/2015

4/1/2015

5/1/2015

6/1/2015

7/1/2015

8/1/2015

9/1/2015

10/1/2015

11/1/2015

12/1/2015

1/1/2016

CHEM PROFILE

 

 

 

 

 

 

 

 

 

 

 

 

 

Na

135

 

 

***

 

 

***

 

 

***

 

 

***

K

4

 

 

***

 

 

***

 

 

***

 

 

***

Cl

105

 

 

***

 

 

***

 

 

***

 

 

***

HCO3

24

 

 

***

 

 

***

 

 

***

 

 

***

BUN

10

 

 

***

 

 

***

 

 

***

 

 

***

Cr

1

 

 

***

 

 

***

 

 

***

 

 

***

Gluc

90

 

 

***

 

 

***

 

 

***

 

 

***

AG

6

 

 

***

 

 

***

 

 

***

 

 

***

eGFR

> 60

 

 

***

 

 

***

 

 

***

 

 

***

Ca

9

 

 

***

 

 

***

 

 

***

 

 

***

 

 

 

 

 

 

 

 

 

 

 

 

 

 

IRON/ANEMIA PROFILE

 

 

 

 

 

 

 

 

 

 

 

 

 

Ferritin

 

 

 

 

 

 

 

 

 

 

 

 

 

Iron

 

 

 

 

 

 

 

 

 

 

 

 

 

Transferrin

 

 

 

 

 

 

 

 

 

 

 

 

 

% Sat

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

CBC

 

 

 

 

 

 

 

 

 

 

 

 

 

WBC

 

 

 

 

 

 

 

 

 

 

 

 

 

RBC

 

 

 

 

 

 

 

 

 

 

 

 

 

HGB

 

 

 

 

 

 

 

 

 

 

 

 

 

Hct

 

 

 

 

 

 

 

 

 

 

 

 

 

Platelet

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

THYROID

 

 

 

 

 

 

 

 

 

 

 

 

 

Parathormone

 

 

 

 

 

 

***

 

 

 

 

 

***

TSH

 

 

 

 

 

 

 

 

 

 

 

 

 

Free T4

 

 

 

 

 

 

 

 

 

 

 

 

 

Step 2: PCP sees patient on 03/01/2015.  He wants to check an acute CBC and thyroid test to work up excessive fatigue.  Since the patient already has a lab draw ordered for April, and the patient appears to be stable enough to have labs drawn in a month, the PCP orders a CBC and TSH/free T4 in April.  PCP also knows that a chemistry panel is already ordered and does not need to put in a duplicate order.  The phlebotomy system should recognize ALL orders placed for the April draw.

 

1/1/2015

2/1/2015

3/1/2015

4/1/2015

5/1/2015

6/1/2015

7/1/2015

8/1/2015

9/1/2015

10/1/2015

11/1/2015

12/1/2015

1/1/2016

CHEM PROFILE

 

 

 

 

 

 

 

 

 

 

 

 

 

Na

135

 

 

***

 

 

***

 

 

***

 

 

***

K

4

 

 

***

 

 

***

 

 

***

 

 

***

Cl

105

 

 

***

 

 

***

 

 

***

 

 

***

HCO3

24

 

 

***

 

 

***

 

 

***

 

 

***

BUN

10

 

 

***

 

 

***

 

 

***

 

 

***

Cr

1

 

 

***

 

 

***

 

 

***

 

 

***

Gluc

90

 

 

***

 

 

***

 

 

***

 

 

***

AG

6

 

 

***

 

 

***

 

 

***

 

 

***

eGFR

> 60

 

 

***

 

 

***

 

 

***

 

 

***

Ca

9

 

 

***

 

 

***

 

 

***

 

 

***

 

 

 

 

 

 

 

 

 

 

 

 

 

 

IRON/ANEMIA PROFILE

 

 

 

 

 

 

 

 

 

 

 

 

 

Ferritin

 

 

 

 

 

 

 

 

 

 

 

 

 

Iron

 

 

 

 

 

 

 

 

 

 

 

 

 

Transferrin

 

 

 

 

 

 

 

 

 

 

 

 

 

% Sat

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

CBC

 

 

 

 

 

 

 

 

 

 

 

 

 

WBC

 

 

 

***

 

 

 

 

 

 

 

 

 

RBC

 

 

 

***

 

 

 

 

 

 

 

 

 

HGB

 

 

 

***

 

 

 

 

 

 

 

 

 

Hct

 

 

 

***

 

 

 

 

 

 

 

 

 

Platelet

 

 

 

***

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

THYROID

 

 

 

 

 

 

 

 

 

 

 

 

 

Parathormone

 

 

 

 

 

 

***

 

 

 

 

 

***

TSH

 

 

 

***

 

 

 

 

 

 

 

 

 

Free T4

 

 

 

***

 

 

 

 

 

 

 

 

 

Step 3: PCP has follow up appointment with the patient to review lab results.  Because the patient has microcytic anemia, PCP ordered chronic Fe study and CBC every 6 months (colonoscopy plus other work up for patient) to see the response of treatment.  PCP also wants to make sure bleeding is not brisk, so ordered an acute CBC in 1 month to ensure h/h stability.  In additional, because of the stability of the patient’s kidney function, PCP messaged Nephrologist via APEX and requested shifting chemistry lab draw. 

 

1/1/2015

2/1/2015

3/1/2015

4/1/2015

5/1/2015

6/1/2015

7/1/2015

8/1/2015

9/1/2015

10/1/2015

11/1/2015

12/1/2015

1/1/2016

CHEM PROFILE

 

 

 

 

 

 

 

 

 

 

 

 

 

Na

135

 

 

135

 

 

***

 

 

***

 

 

***

K

4

 

 

4

 

 

***

 

 

***

 

 

***

Cl

105

 

 

105

 

 

***

 

 

***

 

 

***

HCO3

24

 

 

24

 

 

***

 

 

***

 

 

***

BUN

10

 

 

10

 

 

***

 

 

***

 

 

***

Cr

1

 

 

1

 

 

***

 

 

***

 

 

***

Gluc

90

 

 

90

 

 

***

 

 

***

 

 

***

AG

6

 

 

6

 

 

***

 

 

***

 

 

***

eGFR

> 60

 

 

> 60

 

 

***

 

 

***

 

 

***

Ca

9

 

 

9

 

 

***

 

 

***

 

 

***

 

 

 

 

 

 

 

 

 

 

 

 

 

 

IRON/ANEMIA PROFILE

 

 

 

 

 

 

 

 

 

 

 

 

 

Ferritin

 

 

 

 

***

 

 

 

 

 

***

 

 

Iron

 

 

 

 

***

 

 

 

 

 

***

 

 

Transferrin

 

 

 

 

***

 

 

 

 

 

***

 

 

% Sat

 

 

 

 

***

 

 

 

 

 

***

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

CBC

 

 

 

 

 

 

 

 

 

 

 

 

 

WBC

 

 

 

8

***

 

 

 

 

 

***

 

 

RBC

 

 

 

4.5

***

 

 

 

 

 

***

 

 

HGB

 

 

 

9

***

 

 

 

 

 

***

 

 

Hct

 

 

 

27

***

 

 

 

 

 

***

 

 

Platelet

 

 

 

200

***

 

 

 

 

 

***

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

THYROID

 

 

 

 

 

 

 

 

 

 

 

 

 

Parathormone

 

 

 

 

 

 

***

 

 

 

 

 

***

TSH

 

 

 

2

 

 

 

 

 

 

 

 

 

Free T4

 

 

 

15

 

 

 

 

 

 

 

 

 

Step 4: Nephrologist receives the message from PCP.  Since the nephrologist is going to see the patient in 07/2015, he decided to keep the lab draw ordered for July but shifted future labs to go in line with CBC/Fe study.  In additional, the nephrologist also noticed the stability of the patient’s kidney function.  He decided to change chemistry to q6 months, too.  As a backup mechanism, the patient’s phlebotomist will also have the option to draw the patient’s 10/2015 and 11/2015 lab together.

 

1/1/2015

2/1/2015

3/1/2015

4/1/2015

5/1/2015

6/1/2015

7/1/2015

8/1/2015

9/1/2015

10/1/2015

11/1/2015

12/1/2015

1/1/2016

CHEM PROFILE

 

 

 

 

 

 

 

 

 

 

 

 

 

Na

135

 

 

135

 

 

***

 

 

 

***

 

 

K

4

 

 

4

 

 

***

 

 

 

***

 

 

Cl

105

 

 

105

 

 

***

 

 

 

***

 

 

HCO3

24

 

 

24

 

 

***

 

 

 

***

 

 

BUN

10

 

 

10

 

 

***

 

 

 

***

 

 

Cr

1

 

 

1

 

 

***

 

 

 

***

 

 

Gluc

90

 

 

90

 

 

***

 

 

 

***

 

 

AG

6

 

 

6

 

 

***

 

 

 

***

 

 

eGFR

> 60

 

 

> 60

 

 

***

 

 

 

***

 

 

Ca

9

 

 

9

 

 

***

 

 

 

***

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

IRON/ANEMIA PROFILE

 

 

 

 

 

 

 

 

 

 

 

 

 

Ferritin

 

 

 

 

***

 

 

 

 

 

***

 

 

Iron

 

 

 

 

***

 

 

 

 

 

***

 

 

Transferrin

 

 

 

 

***

 

 

 

 

 

***

 

 

% Sat

 

 

 

 

***

 

 

 

 

 

***

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

CBC

 

 

 

 

 

 

 

 

 

 

 

 

 

WBC

 

 

 

8

***

 

 

 

 

 

***

 

 

RBC

 

 

 

4.5

***

 

 

 

 

 

***

 

 

HGB

 

 

 

9

***

 

 

 

 

 

***

 

 

Hct

 

 

 

27

***

 

 

 

 

 

***

 

 

Platelet

 

 

 

200

***

 

 

 

 

 

***

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

THYROID

 

 

 

 

 

 

 

 

 

 

 

 

 

Parathormone

 

 

 

 

 

 

***

 

 

 

 

 

 

TSH

 

 

 

2

 

 

 

 

 

 

 

 

 

Free T4

 

 

 

15

 

 

 

 

 

 

 

 

 

 

Summary:

With the new ordering system demonstrated in the above case, we will be able to reduce the number of unnecessary and duplicate blood draws.  Providers will also be more able to communicate easily in order to perform tests together and reduce waste.  Lastly, this system will improve patient satisfaction and care by minimizing frustration for patients. 

Comments

This would be immensely helpful.  We know how nontrivial it is for our patients to go to the lab for phletobomy and should do everything we can to try to help them get what they need in an efficient manner.

I think that improving lab ordering would be a great thing.  Right now, I spend a lot of time checking "future labs" ("approximate dates") etc to avoid patient's labs orders being "used up" in advertently.

Commenting is closed.