Simplifying molecular testing through electronic order entry

Abstract

Abstract Our solid-tumor molecular laboratory receives more than 3,000 orders each year, with about two-thirds coming from internal providers. Before this project, molecular tests were ordered using one of two different paper forms, which the care team then faxed or e-mailed to the Genetics Preanalytical Service (GPS). These requests led to frequent modifications and cancellations due to the complexity of molecular testing. A small fraction of requisitions were lost due to transmission errors. We undertook a project to design, develop, and implement computerized physician order entry (CPOE) in Epic (Epic Systems Corp., Verona, WI) and Sunquest (Clinisys, Tucson, AZ). We conducted extensive interviews with the directors of the molecular lab, laboratory medicine IT, GPS, anatomic pathology staff, laboratory scientists, laboratory genetic counselors, oncologists, clinicians, and nurse coordinators. The order itself and other technical changes underwent iterative review and testing by a subset of interviewees. Five oncologists participated in formal beta-testing. The user interviews allowed us to produce a detailed process diagram that drew attention to specific areas of repetition or risk. We proposed a new workflow that would eliminate repetition, provide redundant order-tracking, and automate some lab processes. Once approved, we built the electronic order in Epic and modified existing laboratory programs and interfaces as needed. The process of placing an order, which previously typically involved both nurses and doctors over several calendar days, was now being completed in fewer than 5 minutes by a single practitioner. Requisition status events were no longer created manually in Sunquest by GPS. Certain data-entry tasks were eliminated through the incorporation of label printers. Within one month of launch, more than 50% of somatic molecular orders arrived via CPOE, increasing to 90% within six months. At a rate of 125 CPOE orders per month, time savings range from 20 hours per month for GPS staff, 50 hours per month for nursing, and 20 hours per month for physicians. The success of this project demonstrates the feasibility of replacing a paper-based process for a complex test menu with CPOE. Due to the intricacies of molecular testing, such a change will undoubtedly involve multiple divisions. We attribute the success of this project to early involvement by key stakeholder groups, including developers; an extended testing phase to ensure reliability at roll-out; creation of straightforward reference documents; and rapid response to user questions, especially during the first weeks post-launch.