April 24, 2019
2 min read

EHR alert significantly reduces inappropriate gastrointestinal testing

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Jasmine Marcelin, MD
Jasmine R. Marcelin

Researchers from the University of Nebraska Medical Center and Nebraska Medicine found that incorporating a “hard stop” command into the electronic health record led to a significant reduction in inappropriate gastrointestinal testing.

“As this study demonstrates, automated clinical decision support rules that are built into these systems can help facilitate action, leading to appropriate antimicrobial stewardship and use of laboratory tests when used intentionally,” Kristi Kuper, PharmD, BCPS, senior clinical manager for infectious diseases in the Center for Pharmacy Practice Excellence at Vizient, said in a news release.

Kuper co-authored a white paper published at the same time by The Society for Healthcare Epidemiology of America that reviewed how information technology can improve antimicrobial stewardship programs.

In the white paper, Kuper and colleagues reviewed stewardship-related functionality within IT systems, either EHR-based or add-on clinical decision support systems (CDSSs), and described how the IT platforms could be used to improve antimicrobial use.

Among their suggestions, the authors said documentation should be made easier and more intuitive, so it is less time consuming.

“The technology available today continues to evolve, and additional improvements should be made to expand the functionality of the systems both in the acute-care setting and across nonacute areas of care,” the authors concluded. “The challenge is to determine which EHR, add-on CDSS, or a combination of both will best fulfill the needs of an institution in a cost-and workflow-efficient manner.”

In the study, Jasmine R. Marcelin, MD, assistant professor of infectious diseases and associate medical director of antimicrobial stewardship and infection control at the University of Nebraska Medical Center, and colleagues evaluated gastrointestinal pathogen panel testing (GIPP) before and after they implemented the EHR alert to stop inappropriate GIPP ordering.

They noted that, although GIPP is more rapid and sensitive than traditional stool culture and detects 22 common pathogens, it is expensive to perform and could lead to unnecessary use in inpatient settings, where pathogens other than Clostridioides difficile and norovirus are uncommon.

The study compared GIPP testing in hospitalized patients with diarrhea during two periods, from January 2016 to March 2017 and April 2017 to June 2018. During the second period, a “hard stop” alert was implemented in the EHR that prevented clinicians from ordering GIPP testing more than once in patients hospitalized for more than 72 hours, Marcelin and colleagues explained.

According to the findings, 1,587 GIPP tests were ordered over 212,212 patient-days during the first period, a rate of 7.48 tests per 1,000 patient-days, and 1,165 GIP tests were ordered over 222,343 patient-days during the second period, for a rate of 5.24 per 1,000 patient-days.


Marcelin and colleagues reported a decrease in the rate of inappropriate tests ordered, from 21.5% to 4.9% (P < .001). When only GIPP orders that triggered the hard stop were calculated, total savings were approximately $67,000.

“When including encounters in which the GIPP test order was initiated but not completed (using silent [best practice advisory] data), GIPP testing was reduced by 46%, for a potential savings of $168,000. These savings also accounted for the cost of alternative testing,” they wrote.

They said the $168,000 figure “could potentially cover a large majority of a stewardship full-time equivalent.”

“We can improve the care we deliver by hardwiring criteria for appropriate test ordering and diagnostic stewardship into the electronic health record,” Marcelin said in the release. “We found that when it comes to diarrheal illnesses in the hospital, asking physicians to reconsider if the testing is appropriate through hardwired alerts saves money without compromising quality of care.” – by Bruce Thiel


Kuper KM, et al. Infect Control Hosp Epidemiol. 2019;doi:10.107/ice.2019.51.

Marcelin JR, et al. Infect Control Hosp Epidemiol. 2019;doi:10.1107/ice.2019.78.

Disclosure: The authors report no relevant financial disclosures.