Opportunity

Positive drug screens from patients who are pregnant or have recently given birth can trigger referrals to the Department of Human Services and lead to Child Protective Services investigations, even when the substance – THC, for example – poses minimal risk to the fetus or infant. Patients who fear the legal and social consequences of a drug screen may avoid getting care, which can lead to worse health outcomes. Urine drug screening (UDS) has also perpetuated health inequities among vulnerable patient populations, as UDS orders are disproportionately high for Black patients and patients with Medicaid.

In 2019, Penn Medicine Obstetrics and Gynecology adopted guidelines specifying that clinicians should obtain patient consent and document the indication for drug screening before a UDS order is placed. However, more than half of patient charts still lacked consent documentation after the guidelines were implemented. 

Intervention

In collaboration with a clinical team based in the Department of Obstetrics and Gynecology, we designed an order panel in the electronic health record (EHR) to help clinicians access and follow the UDS guidelines.   

First, we clearly named the order panel to eliminate confusion about which drug screen order to use and to prevent screening for substances deemed unnecessary, like THC. The order panel displays answers from substance use–related screening questions (“5Ps”) and a link to the full guidelines for convenient reference. Clinicians must select which approved indication they are using to justify the order.

Within the order, clinicians must indicate that the patient consented to a urine drug screen or that a patient declined, in which case the drug screen is not ordered. Documentation for the indication and patient consent (or declination to consent) are automatically pulled from the order and inserted into the patient’s record.  

Impact

This intervention is currently being piloted at the Hospital of the University of Pennsylvania. Results will be posted here when they become available. 

Our goal with the order set is to increase compliance with evidence-based guidelines and ensure that UDS is ordered only when clinically appropriate, thereby promoting equitable care. The hard stop confirms and documents patient consent, which is not only best practice but legally required.

We anticipate that automating order documentation will reduce clinician burden, allowing providers to focus on patient care rather than administrative tasks, and standardize documentation on the patient chart. Additionally, centralizing key resources, such as guidelines and 5P screening responses, can help clinicians make informed decisions faster. The intervention also encourages communication with the Division of Neonatology, promoting coordinated care.

By streamlining these processes, the order panel creates a more efficient, patient-centered, scalable approach to UDS in labor and delivery, improving clinician workflow and reducing potential harm and fear for patients.