Computerized Physician Order Entry (CPOE) and embedded Clinical Decision Support (CDS) have been shown to improve quality of care and reduce medical errors [1–3]. CPOE and CDS can also improve resource utilization through more appropriate use of laboratory tests and diagnostic studies. While a few Random-Controlled Trials (RCTs) have addressed CDS and CPOE efficacy [2, 4, 5], there are inherent limitations on the external validity of such studies. As a result, observational studies are also necessary in order to understand how these technologies can be successfully employed by healthcare providers. However, documentation of provider-initiated interventions is often limited, and as a result, more studies of implementation at the point of care are needed to understand and measure CDS and CPOE effectiveness [6, 7].
We describe the development and use of a CDS intervention in a CPOE system; an alert, in response to an administratively identified medical error of overuse of a diagnostic laboratory test. We discuss the complexity of effective CPOE implementation and demonstrate the benefits achieved by this quality improvement initiative through a reduction in inappropriate testing and lower medical care costs [2, 7].
The medical error motivating this intervention was identified by the Test Utilization Committee (TUC) at the Lehigh Valley Health Network (LVHN), in Allentown, PA on September, 2008. The TUC noticed critical care patients were being tested daily, and sometimes twice daily, for B-Type Natriuretic Peptide (BNP). BNP is secreted by the heart in response to changes in pressure that occur in patients with congestive heart failure (CHF). It is used as a marker to gauge the change in severity of CHF over time. Repeat and/or serial BNP testing is inappropriate for guiding the management of heart failure and may in fact be clinically misleading . Given that additional BNP tests during an acute exacerbation of CHF provide no relevant clinical information, it was initially unclear why so many tests were being ordered. This overuse did not likely result in adverse clinical events , but it did significantly increase treatment costs.
All CDS interventions in response to identified errors involve critical success factors such as a culture of acceptance of both technology and embedded ‘cognitive forcing strategies” (rules and alerts, standardized order sets, etc.) . This report describes how one healthcare system designed a targeted CDS intervention to reduce unnecessary testing (and associated costs) in a CPOE system, and evaluates its effectiveness. This intervention was part of a larger initiative to create an “advanced”  CDS environment capacity at LVHN. Advanced CDS development moves beyond basic CPOE functions to respond to identified medical errors, evidence-based information changes, potential unintended consequences and continuous quality improvement (CQI) over time, benefiting from a supportive socio-technical infrastructure .
This study emerges from a growing body of literature that seeks to rigorously evaluate applications of Health IT in daily practice. A range of studies have focused on a sociotechnical approach in order to evaluate the multiple factors that contribute to effectiveness of these new tools [12–14]. Factors that have contributed the use and ability to evaluate decision support technologies include greater emphasis by providers on knowledge-management, and an increasing quantity of patient-specific data from genetic testing and electronic health records . The enhanced ability of providers to analyze clinical practice patterns has also contributed to studies seeking to define what constitutes “appropriate testing” .
Among decision support tools, alerts and rules have received a great deal of attention in the literature due to the significant potential to improve care. CPOE systems have been shown to reduce medical errors and overall medical costs [1–3, 17]. Several other studies and recent review articles [2, 3] generally support the potential of CPOE and CDS to improve care, but note that most of the evidence related to effectiveness of these tools is from academic hospitals rather than community hospitals and or primary care facilities. Alerts and rules have also received a great deal of attention in the literature due to identified barriers to their acceptance and implementation [14, 18–21], and unintended consequences [14, 22–25]. For example, this CDS intervention, and the development of the CPOE system in general, was designed to minimize “alert fatigue” that may occur when clinicians are overwhelmed by the number of alerts .
CPOE development and implementation
Lehigh Valley Health Network (LVHN) is the largest health care provider in the Lehigh Valley region of Pennsylvania with: three not-for-profit hospitals; nine health centers in four counties; primary and specialty care practices throughout the region; pharmacy, imaging and lab services; and preferred provider services. In fiscal year 2012, LVHN had over 54,000 acute admissions and 173,000 emergency department visits. The primary service area of Lehigh, Northampton and Carbon counties has a combined population of more than 800,000, making it Pennsylvania’s third most populated region. Minorities comprise more than 54% of all Allentown residents (the region’s largest city), almost 43% of whom are Hispanic or Latino.
LVHN’s Information Technology (IT) Department was an early adopter of CPOE and CDS. The network has been named one of the 100 Most Wired and 25 Most Wireless hospitals by Hospitals and Health Networks magazine. IT applications at LVHN are implemented through a socio-technical infrastructure that facilitates input from providers and includes an evaluative component pre and post implementation. Examples of this infrastructure include the Test Utilization Council (TUC) that identified over-testing for BNP, and enterprise wide Clinical Decision Support Committee, safety committees, and technology assessment groups. These groups and committees maintain an ongoing sensitivity to work flow issues in the implementation of CDS, including just-in-time evidence-based decision support (clinical knowledge) . The discussion below demonstrates an adaptation to overcome a socio-technical barrier to effective usage of this technology—intrusion into the physician work flow.
LVHN began implementation of CPOE in 2001; by 2006, all beds were converted and CPOE use was mandatory. Concurrent with the implementation of CPOE was the installation of a closed loop medication administration system including embedded clinical decision support, automated pharmacy robot dispensing, online medication administration documentation and bar code medication administration. At LVHN, the implementation of this closed loop medication administration system is estimated to have reduced potential harmful medication errors by 80%. a
The initial approach to CDS at LVHN was very deliberate. The implementation team was acutely aware of the impact that CPOE and CDS interventions had on physician workflow as well as their potential for generating alert fatigue. Consequently, interventions that would “add clicks” (such as alerts and rules) and standardized order sets were added judiciously during the early stages of the CPOE rollout—the “basic stage” . As the physicians acclimated to the system, they became more receptive to an increasing number of CDS interventions. Moving physicians along this “continuum of intrusion”  was considered an important success factor by all stakeholders for this CDS intervention.
Identification of BNP over-testing as a medical error
In September 2008, the Senior Clinical Pathologist noticed critical care patients were being tested daily, and sometimes twice daily, for B-type natriuretic Peptide (BNP). The issue was brought to the TUC and prioritized as a high volume (and high cost) test requiring further investigation and intervention. Research revealed that repeat BNP testing is usually not indicated during a hospital stay . The TUC recommended modifying LVHN’s existing CPOE system to employ an expert rule to alert the ordering clinician that a BNP had been performed during the current admission and that repeat testing would add no value to the clinical decision making process.