Inpatient magnesium testing dropped after the go-live date in March by about 18 percent, “which defied my wildest expectations about how this would go. I was shocked at how successful it is,” Dr. Jackups said. As of January 2026, inpatient magnesium testing remains at this lower volume, he tells CAP TODAY.
All other magnesium testing frequencies remained stable, with a slight increase in once orders. “They’ve got a reason to do it, so we are seeing that switching,” he said, which is an indicator of success.
There are opportunities for workarounds, he noted, pointing to a small rise in laboratory-generated orders. He speculates that the providers did not realize they were canceling the magnesium and thus called the lab to request it be added on rather than repeat the process and avoid risking what they assumed might be another alert.
The daily orders for magnesium tests from the bone marrow transplant and oncology floors plummeted over a couple of months, Dr. Jackups said, and they began to put in once orders. When they tired of that (Dr. Jackups admits to speculating on that), they changed their order set to default—instead of daily it was every Monday and Thursday. “We’ll take it. With these efforts, the idea that you can get perfection or what you think is perfection is not realistic. The goal is improvement,” he said, and especially so on BMT floors that are busy and have highly regimented order sets. “There’s a lot of benefit, a lot of potential for dramatic change, in a service like this one with very regimented order sets.”
The next target for Dr. Jackups and colleagues are CBC/differential orders, which with the CBC are No. 1 on the WashU list of high-volume daily laboratory tests.(Magnesium is No. 3.)
Ionized calcium daily orders are much lower volume but of interest, he said. “We’ve been looking into data about why that’s happening, and I think that will be a target. It’s just the opportunity for us to understand what’s going on there and whether it’s appropriate.”
Whatever the target, he urges, talk to your stakeholders, who also have important things to say. “If you leave them out, you will hear no end of it.”
At Washington University, the clinical laboratory steering committee approves the changes in Epic and did so for magnesium. Recently, the WashU leadership started a laboratory utilization steering committee, “and that’s where the magnesium intervention came from,” Dr. Jackups said. “It takes a long time to get people used to that concept to get things started, but once you do, it becomes clear that is the mechanism we are going to use to change behavior. And people start to accept it and understand it.”
One of the first steps the group took on the issue of test frequencies is one they thought would be a quick win, he said, and that was a list of dozens of test orders they knew should never be daily—several molecular tests, for example. “We removed the daily frequency. We warned people, but we didn’t think it would be controversial,” he said. They waited to see what would happen, and they did get a couple of complaints, after which they restored the daily option or added a particular frequency for the provider or providers. One such test was triglyceride related.
“That was a good first step in just getting them to think about it,” Dr. Jackups said.
An attendee in the ADLM session raised an issue related to at least Epic, if not other electronic health records, and that is preference lists, which are built by the system or each individual. On the list are orders placed frequently.
“They can even default frequencies on it and then share it with others,” Dr. Jackups said, adding, “There’s a benefit in that kind of freedom.” The downside, he said: “They could do whatever they want. So we have to be careful and know what’s going on with those preference lists.”
Thus, one of his first steps in targeting a particular test is to look at what preference list those orders are on and how they are in there. Are they all daily? “When you think about the intervention, and this is Epic specific, if you change something in the order, the orders that are already saved in people’s preference lists don’t change.” Nothing will be fixed if the laboratory fails to realize that. In those situations, he said, “sometimes we make a mass change to everyone’s preference lists.”
But if that’s one of Dr. Jackups’ first steps, monitoring the intervention’s impact is one of the last—and never to be overlooked, he said.
“The people who build the alerts have only so much time—their job is to build what you ask and then move on.” It’s up to the laboratory team to monitor the impact because if it’s not done, he said, “you will not be able to prove it’s successful and then go to your hospital leaders and convince them to do more such alerts.”n
Sherrie Rice is editor of CAP TODAY.