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Path of least resistance: how computerised provider order entry can lead to (and reduce) wasteful practices
  1. Joseph Choi1,2,
  2. Cori Rebecca Atlin1
    1. 1 Division of Emergency Medicine, Department of Medicine, University of Toronto, Toronto, Ontario, Canada
    2. 2 Department of Emergency Medicine, University Health Network, Toronto, Ontario, Canada
    1. Correspondence to Dr Joseph Choi; joseph.choi{at}


    Background Computerised provider order entry (CPOE) is rapidly becoming the mainstay in clinical care and has the potential to improve provider efficiency and accuracy. However, this hinges on careful planning and implementation. Poorly planned CPOE order sets can lead to undetected errors and waste. In our emergency department (ED), lactate dehydrogenase (LDH) was bundled into various blood work panels but had little clinical value.

    Objectives This quality improvement initiative aimed to reduce unnecessary LDH testing in the ED.

    Methods A group of ED physicians reviewed CPOE blood work panels and uncoupled LDH in conditions where it was deemed not to provide any clinically useful information. We measured the daily number of LDH tests performed before and after its removal. We tracked the frequency of other serum tests as controls. We also analysed the number of add-on LDH (ie, to add LDH to samples already sent to the lab) as a balancing measure, since this can disrupt work flow and delay care.

    Results Through this intervention, we reduced the number of LDH tests performed by 69%, from an average of 75.1 tests per day to 23.2 (P<0.0005). The baseline controls did not differ after the intervention (eg, a complete blood count was performed 197.7 and 196.1 times per day preintervention and postintervention, respectively (P=0.7663)). There was less than one add-on LDH per day on average.

    Conclusions CPOE care templates can be powerful in shaping behaviours and reducing variability. However, close oversight of these panels is necessary to prevent errors and waste.

    • decision support, computerised
    • emergency department
    • information technology
    • quality improvement
    • decision making

    This is an Open Access article distributed in accordance with the Creative Commons Attribution Non Commercial (CC BY-NC 4.0) license, which permits others to distribute, remix, adapt, build upon this work non-commercially, and license their derivative works on different terms, provided the original work is properly cited and the use is non-commercial. See:

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    • Contributors JC conceived and planned the project, conducted the physician group survey, implemented the interventions, collected the data, analysed the data, drafted and edited the report and submitted the report. CRA conceived and planned the project and helped draft and edit the report.

    • Funding The authors have not declared a specific grant for this research from any funding agency in the public, commercial or not-for-profit sectors.

    • Competing interests None declared.

    • Patient consent Not required.

    • Provenance and peer review Not commissioned; externally peer reviewed.

    • Collaborators Paul M Yip.

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