Risk Factor Controls When Ordering Patient Cardiac Testing
February 23, 2022
By Dr. Abraham Morse and Kristen Lewis
Instituting key controls in hospital processes provides for better outcomes and increased patient safety. Across departments, these controls can help provide a significant reduction in indemnity losses, a reduction in claims management costs, improved value-based reimbursement performance, and optimized reserve capital allocation. In this blog series, we will look at some sample risk scenarios and how controls play a role in outcomes. To visit EisnerAmper’s Controls Library, click here.
We have all seen medical shows where someone is brought into the ER, and doctors start calling out rapid orders for a variety of tests to begin ruling things out. Real life is more complex, and hospitals have brought in decision support tools to enable the professionals to quickly and efficiently order the correct tests.
Let’s take the case of a patient who comes to the ER with chest pain. The EKG looks normal, but it is not diagnostic for myocardial infarction. The patient is going to need an additional workup before a decision is made about potentially admitting to the ICU or discharging them altogether. An echocardiogram seems to make the most sense, but which one should be ordered?
There is a higher risk of problems popping up with the order when a non-cardiologist is ordering cardiac tests. In some hospitals, the emergency department (“ED”) doctor is charged with doing an echocardiogram order, but there are many different kinds of echocardiograms. The correct test is determined by factors such as patient condition, age, and chest or esophageal instrumentation; there are also ones ordered where drugs need to be administered to stimulate the heart in specific ways. The ED doctor can certainly order one if they think a patient needs it, but if a specialty echocardiogram is needed, it’s always best to bring in a specialist.
Hospitals can build a check into their electronic health records system by restricting the kinds of echocardiograms that can be ordered by certain staff. In so doing, the hospital can ensure that a consult by a specialist must happen before the order goes through. By editing the providers’ “preference” list, it will only contain procedures they are authorized to order. Performable tests also shouldn’t be ordered separately. By setting up fewer orders and more effectively curating permissions, guardrails make sure the right orders are sent to the right labs.
One risk that has a big impact on the ordering of tests is the lack of standardized names for the tests, so it can be easy to order the wrong test or send it to the wrong lab. In addition, protocols may vary by location for certain tests. Doctors who practice between various hospitals may have even more difficulty because the labs have different capabilities and order alignment.
The solution to the risks with ordering cardiac tests is standardizing protocols as well as the tests doctors may order by role. A great deal of attention also should be paid to the cultural process: training and accountability for protocols as well as increased communication about how the standards work in action.
Our ED doctor wanted to order a specialty echocardiogram, but with the system and culture of accountability in place at the hospital, she brought in a specialist to consult on the situation. The advanced test was not necessary, and a different one was instead performed. The patient received the better care option, was tested in the right way, received their diagnosis more rapidly, and the hospital saved the time and cost of an unnecessary test.
Click here to learn more about how controls can impact patient safety across different departments.