Use of Electronic Clinical Decision Support and Hard Stops to Decrease Unnecessary Thyroid Function Testing.

Area of Science:

• Clinical Chemistry and Laboratory Medicine
• Health Services Research
• Medical Informatics

Background:

• Thyroid function tests (TFTs) are frequently over-ordered in inpatient settings, leading to unnecessary healthcare costs and resource utilization.
• Free T3 (fT3) and Free T4 (fT4) testing are typically indicated only when Thyroid Stimulating Hormone (TSH) levels are abnormal, barring specific clinical exceptions.

Purpose of the Study:

• To implement and evaluate a Clinical Decision Support (CDS) and Hard Stop (HS) system within the Electronic Medical Record (EMR) to reduce unnecessary TFT orders.
• To optimize the ordering of fT3 and fT4 tests based on TSH results, thereby minimizing waste in laboratory testing.

Main Methods:

• Developed and integrated a clinical algorithm into the EMR to enforce ordering guidelines for fT3 and fT4 based on TSH levels.
• Incorporated a reflex rule to automatically order fT3 and fT4 when TSH results are abnormal, ensuring appropriate testing.
• Analyzed pre- and post-intervention ordering data, comparing the ratios of fT3 and fT4 orders to total TSH orders.

Main Results:

• The ratio of fT4 orders to TSH orders decreased by 35.2% (from 44.6% to 28.9%) post-intervention.
• The proportion of fT4 tests ordered due to an abnormal TSH increased significantly by 126.1% (from 36.8% to 83.2%).
• The ratio of fT3 orders to TSH orders decreased by 55.2% (from 6.2% to 2.9%), with both reductions being statistically significant.

Conclusions:

• The implemented CDS and HS system effectively reduced unnecessary thyroid function test orders, demonstrating the potential for significant cost savings.
• This initiative highlights the success of technological integration in EMR systems for optimizing clinical laboratory test utilization.
• Reducing unnecessary laboratory testing allows for better allocation of healthcare resources towards direct patient treatment and care.