August 2021 – Clinical Informatics

The correct answer is: Implement a Clinical Decision Support tool for vitamin D testing within the electronic health record as part of a Quality Improvement initiative.

Utilization of 25-OH vitamin D testing as part of screening for Vitamin D deficiency in patients has rapidly increased in clinical practice, despite not much evidence demonstrating any associated benefits with measurement and supplementation. In 2014, $323 million was spent on Vitamin D level testing in Medicare patients alone. In 2013, as part of the ABIM Choosing Wisely campaign, the American Society for Clinical Pathology recommended against performing population-based screening for Vitamin D deficiency. As more health care organizations shift towards quality-based care, increasing emphasis is being placed on limiting unnecessary spending and resource utilization that do not lead to better patient outcomes.

Clinical Decision Support (CDS) tools, typically integrated within the electronic health record, have been demonstrated to reduce rates of unnecessary orders and procedures and subsequently improve quality of clinical care. Types of CDS include pop-up alerts, order sets, infobuttons, documentation templates, and other clinical workflow tools. Additional advantages of CDS tools are that they can deliver actionable insights and expedite incorporation of new knowledge at the point of care. Potential pitfalls for CDS tools that are not properly implemented include provider alert fatigue and significant disruption to clinician workflows.

The third answer choice above is incorrect, as there are indications for Vitamin D testing that can, and should, be initiated in settings outside of the Endocrine subspecialty (i.e., workup for individuals with abnormal blood calcium levels, malabsorption syndromes, and chronic kidney disease, to name a few). The first and fourth answer choices are incorrect, as there have been multiple clinical trials that have not shown benefit of population-wide screening of Vitamin D and subsequent supplementation (e.g. cancer, Type 2 diabetes, depression, osteoarthritis, etc.).

References

1. Choosing Wisely. American Society for Clinical Pathology. February 21, 2013. http://www.choosingwisely.org/clinician-lists/american-society-clinical-pathology-population-based-screening-for-vitamin-d-deficiency/. Accessed June 15, 2021.
2. Felcher AH, Gold R, Mosen DM, Stoneburner AB. Decrease in unnecessary vitamin D testing using clinical decision support tools: making it harder to do the wrong thing. J Am Med Inform Assoc. 2017;24(4):776-780. doi:10.1093/jamia/ocw182
3. LeFevre ML, LeFevre NM. Vitamin D Screening and Supplementation in Community-Dwelling Adults: Common Questions and Answers. Am Fam Physician. 2018 Feb 15;97(4):254-260. PMID: 29671532.
4. Sattar N, Welsh P, Panarelli M, Forouhi NG. Increasing requests for vitamin D measurement: costly, confusing, and without credibility. Lancet. 2012;379(9811):95-96. doi:10.1016/S0140-6736(11)61816-3
5. Tcheng, J. E., S. Bakken, D. W. Bates, H. Bonner III, T. K. Gandhi, M. Josephs, K. Kawamoto, E. A. Lomotan, E. Mackay, B. Middleton, J. M. Teich, S. Weingarten, and M. Hamilton Lopez, editors. 2017. Optimizing Strategies for Clinical Decision Support: Summary of a Meeting Series. Washington, DC: National Academy of Medicine