An Assessment of Why Physicians' Electronically Ordered Add-on Laboratory Tests Are Not Performed in a Large, University Hospital Laboratory

With the universal adoption of the electronic medical records systems in hospitals, physicians often tend to abuse the features that allow for unrestricted electronic laboratory tests orders for so-called “add-on” testing. An add-on test is a physician order for a test to be performed on a specimen that has already been collected for other testing purposes. We have observed that having physicians electronically do add-on laboratory orders does not work well since there are many issues involved that may make the add-on ordered test impossible for the laboratory to perform. This leaves the laboratory staff having to contact the physician by telephone to let them know there is a problem. To address this issue, we monitored add-on test orders for a seven day period and observed the following: 1) a total of 1,062 add-on tests were electronically ordered, 2) 883 (83%) of add-on tests were performed and 3) 179 (17%) of add-on tests were not performed. We investigated the major reasons why these add-on tests could not be performed and summarized our findings into 10 major categories which can be broken down into 21 subcategories. As shown in the figure, 34 % (60/179) of add-on tests not performed were specimens collected in the wrong tube/container, 29% (52/179) of tests not performed were duplicate orders, while for 14% (25/179) of add-on tests not performed, no specimen was available in the laboratory. We conclude physician add-on orders require either 1) a sophisticated rules-based assisted expert physician order entry system to alert the physician when an add-on test is possible or 2) a more collaborative approach with the laboratory....such as physicians calling the laboratory and placing the order verbally. Unfortunately, many hospitals including ours do not have the level of IT technology required to do expert system assisted physician add-on order management.