Cost reminders via CPOE lead to fewer test orders

Displaying the cost of a test via computerized provider order entry systems prompted a 9 percent reduction in the number of tests ordered, according to a study published in JAMA Internal Medicine.

The study compared the number of tests ordered over six months when the CPOE system at Johns Hopkins Hospital displayed the cost of 61 tests to a six-month baseline when costs were not presented. Meanwhile, 6 percent more tests were ordered when cost information was not presented, according to a MedPage Today article.

"Displaying the Medicare allowable fees of diagnostic tests at the time of ordering can modestly affect provider ordering behavior," the study's authors wrote. "Whether broadening this intervention and coupling it with educational interventions related to cost consciousness and stewardship of resources will increase its effect on clinical practice deserves further study, provided that providers are not inappropriately incentivized to limit needed care."

In an accompanying commentary also published in JAMA Internal Medicine, William Tierney, M.D., of Indiana University in Indianapolis, said the cost information might have prompted physicians to stop and weigh the benefits and cost. He also posed the possibility that some necessary tests were skipped in the name of economy.

"My question is whether [electronic health records] and [clinical decision support] will be an ax that indiscriminately reduces testing and treatment, regardless of its appropriateness, or a scalpel carefully carving off unnecessary or even hurtful interventions while sparing necessary interventions," Tierney said. "Clearly, more evidence is needed on whether and how EHRs might lower costs while maintaining or even improving quality."

The Lehigh Valley Health Network in Pennsylvania recently reported that CDS alerts against repeat tests for B-Type Natriuretic Peptide (BNP) in heart failure patients reduced unnecessary testing by 21 percent and saved approximately $92,000 a year. Those alerts were considered a "soft stop" for physicians, who could order the tests anyway if they chose.

A study in Archives of Internal Medicine, however, found that tests on Medicare patients often spawn more tests, a practice that goes unchecked in a fee-for-service world.

At FierceHealthFinance, editor Ron Shinkman advocates for a financial means test. Speaking to hospitals earlier this month, he wrote:

"Testing is a source of reliable revenue, and it still seems like a good business proposition to overutilize a $25 test rather than spend $25,000 to defend a questionable patient lawsuit. But given the number of patients with large deductibles and out-of-pocket costs, it is no longer fair to them to perform tests without an actual purpose behind them."

To learn more:
- find the research
- check out the commentary
- here's the MedPage Today article

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