“Routine” daily inpatient labs are ineffective at improving patient outcomes and are associated with antibiotic overuse and delayed hospital discharge. Despite recommendations from the ABIM in the “Choosing Wisely” program, limited progress has been made in curbing inappropriate testing. In particular, admonitions from ID consultants that daily measurement of inflammatory markers is unneeded have gone largely unheeded. Since online messaging tools are helpful in areas such as medication compliance, it was hypothesized that EMR-based “click-able” hyperlinks to “Choosing Wisely” recommendations within the ID consultant daily progress note might provide a psychologically stronger “nudge” toward appropriate use.
In a community teaching hospital, from 1 September 2017 through 31 March 2018, 38 stable patients with requested ID consultation and 3 or more sequential daily measurements of CBC and/or CRP were sequentially assigned to receive either standard ID advice including that daily testing was unneeded, or additionally a hyperlink to the URL for the Choosing Wisely recommendation. At 48 hours, patient data was analyzed for whether daily labs continued or stopped. Significance was assessed with 2x2 contingency testing. In addition, relevant provider comments in the daily progress notes were assessed.
Of 19 consultations with hyperlinked recommendations, 10 showed cessation of daily CBC/CRP testing. Of 19 without the hyperlink, only 4 showed discontinuation by 48 hours (p=.04 Fisher Exact). Comments ranged from appreciative to defensive, with the former more common from House Officers compared with Attending physicians.
Inclusion of a clickable hyperlink in the EMR progress note from an ID consultant may provide a more effective psychological nudge away from inappropriate testing compared to text advice alone. Physicians in training may be more receptive to this messaging.
R. Colgrove, None