We undertook a series of analyses at each of the six hospital sites to compare test volumes. Our findings showed that when comparing the periods before and after the implementation of EMR, the mean number of tests ordered in each test order episode decreased significantly at all hospitals. The overall rate across all hospitals fell from 4.63 in 2008 to 4.36 in 2011 (p<.001). When test numbers were analysed according to the number of tests per patient admission they were found to be higher in 2011 compared to 2008 for some hospitals (e.g., A and E) but lower in other hospitals (e.g., C and D). However, the mean length of stay for admitted patients was consistently shorter in 2011 than 2008.
Our comparison of the number of tests undertaken per admission and grouped into DRG categories provided examples such as A06B (Tracheostomy w/ventilation >95hrs) where the mean number of tests per admission fell from 181.10 in 2008 to 156.77 in 2011, but where the corresponding mean length of stay rose from 646 hours to 696 hours. Alternatively, for E62A (Respiratory infections) the numbers increased from 40.60 to 42.81 for mean number of tests and decreased from 305 to 289 hours for mean length of stay. Our analysis of the test ordering profiles for the DRG of F74Z (Chest pain) at four hospital EDs highlighted some common test ordering patterns (e.g., Troponin, EUC, and Automated Differential tests were consistently the most frequently ordered tests) but also revealed some major differences between hospitals and for the period before and after the introduction of EMR. The mean number of C-Reactive protein tests per ED presentation varied both between hospitals and between years. At three of the EDs the mean number of C-Reactive protein tests per ED presentation was higher in 2011 than in 2008 (Hospital ED “A”: from a mean of 0.02 C-Reactive protein tests per ED presentation, in 2008, to a mean of 0.08 tests per presentation; Hospital ED “D”: from a mean of 0.24 tests to 0.31 tests; and Hospital ED “F”: from a mean of 0.13 tests to 0.21 tests), while the opposite was true for the ED at Hospital ED “E” (from a mean of 0.11 tests to 0.06 tests).
The introduction of EMR across all the hospitals made it possible to compare add-on testing rates both between hospitals and between pathology departments. Our analysis showed that there was variation between hospitals that ranged from 0.61% in Hospital B (specialist hospital) to 2.24% in Hospital F (metropolitan hospital). Clinical chemistry and haematology were the pathology departments that accounted for the highest volume of add-on tests; in those departments, add-on tests accounted for 2.56%, and 0.69%, respectively, of all ordered tests.
Assessing the appropriateness of test ordering is a complex process. The National Coalition of Public Pathology describes appropriateness as a multifaceted concept which requires consideration of a number of factors usually unique to every individual context.38 Generally, test inappropriateness is assumed to be synonymous with “overuse” and occurs when a test has been ordered without a clinical indication or within a time frame which provides no additional information and therefore provides no value in the diagnosis or treatment of the patient.50 51 These situations are determined by expert consensus based on evidence-based guidelines.38 In this project, we compared the rate of paper and EMR-ordered EUC tests which were ordered within 1-hour and 24-hours of the previous EUC test. In 2011, the proportion of repeat EUC testing occurring within one hour of the previous EUC test was significantly greater for tests ordered with the paper system than electronically-ordered tests (0.69% and 0.25%, respectively). Conversely, a significantly smaller proportion of paper-ordered tests was ordered within 24 hours than for electronically-ordered tests (11.68% and 34.04%, respectively).
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