Rising health care costs in the United States (US) have created a national interest in high‐value care and methods to reduce wasteful practices.1 Finding solutions for improving appropriate utilization of medical resources often focuses on modifying provider behavior.2 With the near‐universal prevalence of electronic health records (EHRs) in this country, the utilization of clinical decision support systems (CDSS), combined with specific clinical guidelines for appropriate laboratory testing,3 can be used as an integral strategy for improving the value of laboratory ordering.4 The CDSS can be considered intrusive or nonintrusive in the context of the EHR platform for provider ordering. Examples of intrusive CDSS include pop‐up windows requiring active acknowledgement of browsing messages and “hard stops” to ordering practices. An example of a nonintrusive CDSS is text information accompanying orders without an active requirement for provider acknowledgement. Intrusive CDSS are more expensive to create and often lead to provider alert fatigue and dissatisfaction.5-8 Provider surveys show that intrusive CDSS are preferred for alerts such as drug interactions while nonintrusive CDSS are preferred for less urgent information.9 Nonintrusive CDSS, therefore, could be a practical method to reduce laboratory utilization. Prior studies have addressed the use of CDSS on laboratory ordering practices in the outpatient setting,10-12 but few have addressed the utility in the inpatient setting with only a recent emphasis on targeting redundant laboratory ordering.13,14 We conducted a prospective pilot study to evaluate the effect of nonintrusive CDSS on the inpatient utilization of serum and red blood cell (RBC) folate levels, hepatitis C virus (HCV) viral loads (VL) and genotypes, and type and screens (T&S) in a large academic centre.

۲ | METHODS

۲٫۱ | Laboratory test selection

We created utilization messages for the following laboratory tests: serum and RBC folate, HCV VL and genotype, and T&S. We chose these tests because we could provide clear appropriate use messaging and we had evidence of overutilization at an institutional level and from the research literature. In 1998, the US government implemented a mandatory fortification of all cereal grains with folic acid. With this intervention, folate deficiency in the US population decreased to less than 1%, making routine folate testing unnecessary.15,16 Additionally, the lack of gold standard for diagnosing folate deficiency makes the sensitivity and specificity of current biological assays unknown.17 Therefore, we recommended against routine testing of serum and RBC folate in our utilization message. Appropriate indications for HCV VL and genotype were determined after consultation with infectious disease experts at our institution as well as a literature review. Testing indications for HCV VL included either suspicion of acute HCV or the need to distinguish between chronic and cleared HCV in patients with positive antibodies but no prior VL.18,19 We advised that HCV genotype be reserved for patients imminently starting HCV therapy to guide the treatment regimen.19 Notably, these appropriate indications are rare in the hospitalized patient.