Review Article| Volume 39, ISSUE 2, P197-213, June 2019

Decision Support Tools within the Electronic Health Record

Published:March 28, 2019DOI:


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        • Baron J.M.
        • Dighe A.S.
        Computerized provider order entry in the clinical laboratory.
        J Pathol Inform. 2011; 2: 35
        • Georgiou A.
        • Lang S.
        • Rosenfeld D.
        • et al.
        The use of computerized provider order entry to improve the effectiveness and efficiency of coagulation testing.
        Arch Pathol Lab Med. 2011; 135: 495-498
        • Westbrook J.I.
        • Georgiou A.
        • Lam M.
        Does computerised provider order entry reduce test turnaround times? A before-and-after study at four hospitals.
        Stud Health Technol Inform. 2009; 150: 527-531
        • Schreiber R.
        • Shaha S.H.
        Computerised provider order entry adoption rates favourably impact length of stay.
        J Innov Health Inform. 2016; 23: 166
        • Schreiber R.
        • Peters K.
        • Shaha S.H.
        Computerized provider order entry reduces length of stay in a community hospital.
        Appl Clin Inform. 2014; 5: 685-698
        • Prgomet M.
        • Li L.
        • Niazkhani Z.
        • et al.
        Impact of commercial computerized provider order entry (CPOE) and clinical decision support systems (CDSSs) on medication errors, length of stay, and mortality in intensive care units: a systematic review and meta-analysis.
        J Am Med Inform Assoc. 2017; 24: 413-422
        • Rubinstein M.
        • Hirsch R.
        • Bandyopadhyay K.
        • et al.
        Effectiveness of practices to support appropriate laboratory test utilization: a laboratory medicine best practices systematic review and meta-analysis.
        Am J Clin Pathol. 2018; 149: 197-221
        • Bindraban R.S.
        • Ten Berg M.J.
        • Naaktgeboren C.A.
        • et al.
        Reducing test utilization in hospital settings: a narrative review.
        Ann Lab Med. 2018; 38: 402-412
        • Zhang Y.
        • Padman R.
        • Levin J.E.
        Reducing provider cognitive workload in CPOE use: optimizing order sets.
        Stud Health Technol Inform. 2013; 192: 734-738
        • Wolf M.
        • Miller S.
        • DeJong D.
        • et al.
        The process of development of a prioritization tool for a clinical decision support build within a computerized provider order entry system: experiences from St Luke's Health System.
        Health Informatics J. 2016; 22: 579-593
        • Fear F.
        Governance first, technology second to effective CPOE deployment: rapid development of order sets provides the foundation for CPOE, but healthcare organizations first need an effective governance plan built around clinician workflow.
        Health Manag Technol. 2011; 32: 6-7
        • Kim J.Y.
        • Dzik W.H.
        • Dighe A.S.
        • et al.
        Utilization management in a large urban academic medical center: a 10-year experience.
        Am J Clin Pathol. 2011; 135: 108-118
        • Chan A.J.
        • Chan J.
        • Cafazzo J.A.
        • et al.
        Order sets in health care: a systematic review of their effects.
        Int J Technol Assess Health Care. 2012; 28: 235-240
        • Avansino J.
        • Leu M.G.
        Effects of CPOE on provider cognitive workload: a randomized crossover trial.
        Pediatrics. 2012; 130: e547-e552
        • Zhang Y.
        • Levin J.E.
        • Padman R.
        Data-driven order set generation and evaluation in the pediatric environment.
        AMIA Annu Symp Proc. 2012; 2012: 1469-1478
        • Choi J.
        • Atlin C.R.
        Path of least resistance: how computerised provider order entry can lead to (and reduce) wasteful practices.
        BMJ Open Qual. 2018; 7: e000345
        • Martins C.M.
        • da Costa Teixeira A.S.
        • de Azevedo L.F.
        • et al.
        The effect of a test ordering software intervention on the prescription of unnecessary laboratory tests - a randomized controlled trial.
        BMC Med Inform Decis Mak. 2017; 17: 20
        • Seppanen K.
        • Kauppila T.
        • Pitkälä K.
        • et al.
        Altering a computerized laboratory test order form rationalizes ordering of laboratory tests in primary care physicians.
        Int J Med Inform. 2016; 86: 49-53
        • Olson J.
        • Hollenbeak C.
        • Donaldson K.
        • et al.
        Default settings of computerized physician order entry system order sets drive ordering habits.
        J Pathol Inform. 2015; 6: 16
        • Iturrate E.
        • Jubelt L.
        • Volpicelli F.
        • et al.
        Optimize your electronic medical record to increase value: reducing laboratory overutilization.
        Am J Med. 2016; 129: 215-220
        • Sadowski B.W.
        • Lane A.B.
        • Wood S.M.
        • et al.
        High-value, cost-conscious care: iterative systems-based interventions to reduce unnecessary laboratory testing.
        Am J Med. 2017; 130: 1112.e1-7
        • Dickerson J.A.
        • Cole B.
        • Conta J.H.
        • et al.
        Improving the value of costly genetic reference laboratory testing with active utilization management.
        Arch Pathol Lab Med. 2014; 138: 110-113
        • Riley J.D.
        • Procop G.W.
        • Kottke-Marchant K.
        • et al.
        Improving molecular genetic test utilization through order restriction, test review, and guidance.
        J Mol Diagn. 2015; 17: 225-229
        • Van Cott E.M.
        Laboratory test interpretations and algorithms in utilization management.
        Clin Chim Acta. 2014; 427: 188-192
        • Grisson R.
        • Kim J.Y.
        • Brodsky V.
        • et al.
        A novel class of laboratory middleware. Promoting information flow and improving computerized provider order entry.
        Am J Clin Pathol. 2010; 133: 860-869
        • Passiment E.
        • Meisel J.L.
        • Fontanesi J.
        • et al.
        Decoding laboratory test names: a major challenge to appropriate patient care.
        J Gen Intern Med. 2013; 28: 453-458
        • Petrides A.K.
        • Tanasijevic M.J.
        • Goonan E.M.
        • et al.
        Top ten challenges when interfacing a laboratory information system to an electronic health record: experience at a large academic medical center.
        Int J Med Inform. 2017; 106: 9-16
        • Eaton K.P.
        • Chida N.
        • Apfel A.
        • et al.
        Impact of nonintrusive clinical decision support systems on laboratory test utilization in a large academic centre.
        J Eval Clin Pract. 2018; 24: 474-479
        • Fang D.Z.
        • Sran G.
        • Gessner D.
        • et al.
        Cost and turn-around time display decreases inpatient ordering of reference laboratory tests: a time series.
        BMJ Qual Saf. 2014; 23: 994-1000
        • Procop G.W.
        • Yerian L.M.
        • Wyllie R.
        • et al.
        Duplicate laboratory test reduction using a clinical decision support tool.
        Am J Clin Pathol. 2014; 141: 718-723
        • Blechner M.
        • Kish J.
        • Chadaga V.
        • et al.
        Analysis of search in an online clinical laboratory manual.
        Am J Clin Pathol. 2006; 126: 208-214
        • Schmidt R.L.
        • Colbert-Getz J.M.
        • Milne C.K.
        • et al.
        Impact of laboratory charge display within the electronic health record across an entire academic medical center: results of a randomized controlled trial.
        Am J Clin Pathol. 2017; 148: 513-522
        • Sedrak M.S.
        • Myers J.S.
        • Small D.S.
        • et al.
        Effect of a price transparency intervention in the electronic health record on clinician ordering of inpatient laboratory tests: the PRICE randomized clinical trial.
        JAMA Intern Med. 2017; 177: 939-945
        • Silvestri M.T.
        • Xu X.
        • Long T.
        • et al.
        Impact of cost display on ordering patterns for hospital laboratory and imaging services.
        J Gen Intern Med. 2018; 33: 1268-1275
        • Ekblom K.
        • Petersson A.
        Introduction of cost display reduces laboratory test utilization.
        Am J Manag Care. 2018; 24: e164-e169
        • Goetz C.
        • Rotman S.R.
        • Hartoularos G.
        • et al.
        The effect of charge display on cost of care and physician practice behaviors: a systematic review.
        J Gen Intern Med. 2015; 30: 835-842
        • Feldman L.S.
        • Shihab H.M.
        • Thiemann D.
        • et al.
        Impact of providing fee data on laboratory test ordering: a controlled clinical trial.
        JAMA Intern Med. 2013; 173: 903-908
        • Rudolf J.W.
        • Dighe A.S.
        • Coley C.M.
        • et al.
        Analysis of daily laboratory orders at a large urban academic center: a multifaceted approach to changing test ordering patterns.
        Am J Clin Pathol. 2017; 148: 128-135
        • Jackups Jr., R.
        • Szymanski J.J.
        • Persaud S.P.
        Clinical decision support for hematology laboratory test utilization.
        Int J Lab Hematol. 2017; 39: 128-135
        • Ducatman A.M.
        • Tacker D.H.
        • Ducatman B.S.
        • et al.
        Quality improvement intervention for reduction of redundant testing.
        Acad Pathol. 2017; 4 (2374289517707506)
        • Chadwick D.R.
        • Hall C.
        • Rae C.
        • et al.
        A feasibility study for a clinical decision support system prompting HIV testing.
        HIV Med. 2017; 18: 435-439
        • Moyer A.M.
        • Saenger A.K.
        • Willrich M.
        • et al.
        Implementation of clinical decision support rules to reduce repeat measurement of serum ionized calcium, serum magnesium, and N-Terminal Pro-B-type natriuretic peptide in intensive care unit inpatients.
        Clin Chem. 2016; 62: 824-830
        • Gottheil S.
        • Khemani E.
        • Copley K.
        • et al.
        Reducing inappropriate ESR testing with computerized clinical decision support.
        BMJ Qual Improv Rep. 2016; 5
        • Love S.A.
        • McKinney Z.J.
        • Sandoval Y.
        • et al.
        Electronic medical record-based performance improvement project to document and reduce excessive cardiac troponin testing.
        Clin Chem. 2015; 61: 498-504
        • Samuelson B.T.
        • Glynn E.
        • Holmes M.
        • et al.
        Use of a computer-based provider order entry (CPOE) intervention to optimize laboratory testing in patients with suspected heparin-induced thrombocytopenia.
        Thromb Res. 2015; 136: 928-931
        • McWilliams B.
        • Triulzi D.J.
        • Waters J.H.
        • et al.
        Trends in RBC ordering and use after implementing adaptive alerts in the electronic computerized physician order entry system.
        Am J Clin Pathol. 2014; 141: 534-541
        • Howell L.P.
        • MacDonald S.
        • Jones J.
        • et al.
        Can automated alerts within computerized physician order entry improve compliance with laboratory practice guidelines for ordering Pap tests?.
        J Pathol Inform. 2014; 5: 37
        • Collins R.A.
        • Triulzi D.J.
        • Waters J.H.
        • et al.
        Evaluation of real-time clinical decision support systems for platelet and cryoprecipitate orders.
        Am J Clin Pathol. 2014; 141: 78-84
        • Levick D.L.
        • Stern G.
        • Meyerhoefer C.D.
        • et al.
        Reducing unnecessary testing in a CPOE system through implementation of a targeted CDS intervention.
        BMC Med Inform Decis Mak. 2013; 13: 43
        • Baron J.M.
        • Lewandrowski K.B.
        • Kamis I.K.
        • et al.
        A novel strategy for evaluating the effects of an electronic test ordering alert message: optimizing cardiac marker use.
        J Pathol Inform. 2012; 3: 3
        • Procop G.W.
        • Keating C.
        • Stagno P.
        • et al.
        Reducing duplicate testing: a comparison of two clinical decision support tools.
        Am J Clin Pathol. 2015; 143: 623-626
        • Dunbar N.M.
        • Szczepiorkowski Z.M.
        Hardwiring patient blood management: harnessing information technology to optimize transfusion practice.
        Curr Opin Hematol. 2014; 21: 515-520
        • Overhage J.M.
        • Tierney W.M.
        • Zhou X.H.
        • et al.
        A randomized trial of “corollary orders” to prevent errors of omission.
        J Am Med Inform Assoc. 1997; 4: 364-375
        • Riley J.D.
        • Stanley G.
        • Wyllie R.
        • et al.
        The impact of an electronic expensive test notification.
        Am J Clin Pathol. 2018; 149: 530-535
        • Dalal S.
        • Bhesania S.
        • Silber S.
        • et al.
        Use of electronic clinical decision support and hard stops to decrease unnecessary thyroid function testing.
        BMJ Qual Improv Rep. 2017; 6 ([pii:u223041.w8346])
        • Algaze C.A.
        • Wood M.
        • Pageler N.M.
        • et al.
        Use of a checklist and clinical decision support tool reduces laboratory use and improves cost.
        Pediatrics. 2016; 137
        • Nikolic D.
        • Richter S.S.
        • Asamoto K.
        • et al.
        Implementation of a clinical decision support tool for stool cultures and parasitological studies in hospitalized patients.
        J Clin Microbiol. 2017; 55: 3350-3354
        • Ancker J.S.
        • Edwards A.
        • Nosal S.
        • et al.
        Effects of workload, work complexity, and repeated alerts on alert fatigue in a clinical decision support system.
        BMC Med Inform Decis Mak. 2017; 17: 36
        • Baysari M.T.
        • Tariq A.
        • Day R.O.
        • et al.
        Alert override as a habitual behavior - a new perspective on a persistent problem.
        J Am Med Inform Assoc. 2017; 24: 409-412
        • Lam J.H.
        • Ng O.
        Monitoring clinical decision support in the electronic health record.
        Am J Health Syst Pharm. 2017; 74: 1130-1133
        • Carli D.
        • Fahrni G.
        • Bonnabry P.
        • et al.
        Quality of decision support in computerized provider order entry: systematic literature review.
        JMIR Med Inform. 2018; 6: e3
        • Garner A.E.
        • Lewington A.J.
        • Barth J.H.
        Detection of patients with acute kidney injury by the clinical laboratory using rises in serum creatinine: comparison of proposed definitions and a laboratory delta check.
        Ann Clin Biochem. 2012; 49: 59-62
        • Baron J.M.
        • Cheng X.S.
        • Bazari H.
        • et al.
        Enhanced creatinine and estimated glomerular filtration rate reporting to facilitate detection of acute kidney injury.
        Am J Clin Pathol. 2015; 143: 42-49
        • Laposata M.E.
        • Laposata M.
        • Van Cott E.M.
        • et al.
        Physician survey of a laboratory medicine interpretive service and evaluation of the influence of interpretations on laboratory test ordering.
        Arch Pathol Lab Med. 2004; 128: 1424-1427
        • Schmidt R.L.
        • Panlener J.J.
        • Carasso S.M.
        • et al.
        Impact of continuous improvement of laboratory test result comments on requests for consultation: a case series.
        Am J Clin Pathol. 2016; 145: 666-670
        • Nichols J.H.
        Quality in point-of-care testing.
        Expert Rev Mol Diagn. 2003; 3: 563-572
        • Poon E.G.
        • Gandhi T.K.
        • Sequist T.D.
        • et al.
        “I wish I had seen this test result earlier!”: dissatisfaction with test result management systems in primary care.
        Arch Intern Med. 2004; 164: 2223-2228
        • Roy C.L.
        • Poon E.G.
        • Karson A.S.
        • et al.
        Patient safety concerns arising from test results that return after hospital discharge.
        Ann Intern Med. 2005; 143: 121-128
        • Roy C.L.
        • Rothschild J.M.
        • Dighe A.S.
        • et al.
        An initiative to improve the management of clinically significant test results in a large health care network.
        Jt Comm J Qual Patient Saf. 2013; 39: 517-527
        • Plebani M.
        Harmonization in laboratory medicine: requests, samples, measurements and reports.
        Crit Rev Clin Lab Sci. 2016; 53: 184-196
        • Plebani M.
        • Panteghini M.
        Promoting clinical and laboratory interaction by harmonization.
        Clin Chim Acta. 2014; 432: 15-21
        • Miller W.G.
        • Tate J.R.
        • Barth J.H.
        • et al.
        Harmonization: the sample, the measurement, and the report.
        Ann Lab Med. 2014; 34: 187-197
        • Kurant D.E.
        • Baron J.M.
        • Strazimiri G.
        • et al.
        Creation and use of an electronic health record reporting database to improve a laboratory test utilization program.
        Appl Clin Inform. 2018; 9: 519-527
        • Wright A.
        • Feblowitz J.C.
        • Pang J.E.
        • et al.
        Use of order sets in inpatient computerized provider order entry systems: a comparative analysis of usage patterns at seven sites.
        Int J Med Inform. 2012; 81: 733-745
        • Wright A.
        • Sittig D.F.
        • Carpenter J.D.
        • et al.
        Order sets in computerized physician order entry systems: an analysis of seven sites.
        AMIA Annu Symp Proc. 2010; 2010: 892-896
        • Schreiber R.
        • Sittig D.F.
        • Ash J.
        • et al.
        Orders on file but no labs drawn: investigation of machine and human errors caused by an interface idiosyncrasy.
        J Am Med Inform Assoc. 2017; 24: 958-963
        • Sittig D.F.
        • Campbell E.
        • Guappone K.
        • et al.
        Recommendations for monitoring and evaluation of in-patient Computer-based Provider Order Entry Systems: results of a Delphi survey.
        AMIA Annu Symp Proc. 2007; 2007: 671-675
        • Wright A.
        • Ai A.
        • Ash J.
        • et al.
        Clinical decision support alert malfunctions: analysis and empirically derived taxonomy.
        J Am Med Inform Assoc. 2018; 25: 496-506
        • Yoshida E.
        • Fei S.
        • Bavuso K.
        • et al.
        The value of monitoring clinical decision support interventions.
        Appl Clin Inform. 2018; 9: 163-173
        • McDaniel R.B.
        • Burlison J.D.
        • Baker D.K.
        • et al.
        Alert dwell time: introduction of a measure to evaluate interruptive clinical decision support alerts.
        J Am Med Inform Assoc. 2016; 23: e138-e141