Hitting a Nerve

Unintended consequences in the drive to simplify computerized test ordering


“X marks the spot!”

It’s one of the classic pirate tropes, bringing to mind images of Long John Silver, buried treasure, and a secret map with an “X” to show the hidden gold.

Doctor using computer Brian Jackson/iStockphoto

Today that “X” (or, in some cases, a check mark or radio button) seems to be indicating where the money is to be lost, rather than found.

Hospital computer systems are increasingly reliant on preprogrammed order lists that you check off rather than the actual test itself. We’ve gone from having to write out the tests we want, to typing them into a box, to checking them off with a mouse.

I’ve seen systems where you’re offered a menu such as:

A. Brain MRI (noncontrast)

B. Brain MRI (w/wo contrast)

C. Head MRA (noncontrast)

D. Head MRA (with contrast)

E. Neck MRA (noncontrast)

F. Neck MRA (with contrast)

G. Brain MRI and head/neck MRA (noncontrast)

H. Brain MRI and head/neck MRA (w/wo contrast)

And that’s just for the brain and its vascular supply. Expand that to the rest of the nervous system, then to the whole body, then to other tests (labs) ... and you get the idea.

I suppose the driving force here is to make the system easier to use. Doctors are busy. It saves time just have to check a box if you want three tests, rather than note all of them individually.

But it’s really not that hard to check off three. Probably less than 5 seconds (as of my last time on call). And this is where, to me, X marks the spot where the money isn’t.

Humans, like most animals, are pretty good at defaulting to a low-energy setting. So if you only have to check off one box instead of three, or five, or whatever, why bother?

If the patient is being admitted for a stroke/TIA, then it makes sense to do the brain MRI and head/neck MRA. But what if it’s just headaches, or a new seizure, or a concussion? I see plenty of times when more tests are done than necessary, simply because the ordering physician either didn’t know what was really needed or because it was easier to just check the box.

This is not, in my experience, rare. I’d say anywhere from one-third to half of patients I’ve consulted on had an overkill neurological work-up, in which tests with no medical indications had been ordered. They’ve generally already been put in the system, or even done, before I get to the bedside.

Dr. Allan M. Block, a neurologist is Scottsdale, Ariz.

Dr. Allan M. Block

I suppose one could say they should wait for the specialist to get there before any of the costly tests are ordered, but that opens up another can of worms. What if a critical finding that needed to be acted upon isn’t found in time because of such a rule? Not only that, but waiting for me to show up and order tests means it will take longer to get them done, adding onto the hospital stay, and (again) running up costs.

So that’s not an answer, either. There really isn’t one, unfortunately.

But, in our haste to make things easier, or faster, or even just flashier, the trend seems to be at the cost of doing things reasonably. At the same time that we’re trying to save money, the single “X” may be marking the spot where we’re actually throwing it away.

Dr. Block has a solo neurology practice in Scottsdale, Ariz.

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