The current healthcare climate creates an opportunity for clinical leadership, pathologists, and caregivers to take a role in optimizing the value of laboratory testing.
Test utilization management strategies lead to appropriate and timely diagnoses while decreasing unnecessary laboratory testing and phlebotomy. Such initiatives result in increased patient and provider satisfaction and reduced healthcare costs.
Laboratory Stewardship Best Practices
Since 2011, several ongoing interventions have been integrated into Cleveland Clinic, including:
- Hard Stop Alerts
- Restricted Use
- Laboratory Genetic Counseling
- Regional Soft Stop Alerts
- Expensive Test Notifications
These—along with several other test utilization strategies—have ultimately prevented 302,641 unnecessary tests, resulting in cost savings of more than $8.5 million.
Cost Savings (in $)
01. Hard Stop Alerts
Launched in 2011, the Hard Stop Alert is now a part of Cleveland Clinic culture.
This clinical decision support tool (CDST) notifies providers who attempt to order a test on the Hard Stop list. Tests that trigger a Hard Stop Alert include those that should not be repeated within 24 hours and constitutional / germline genetic tests.
If a provider attempts to order a test on the Hard Stop list, an alert will appear to notify the provider. To prevent duplicate testing, the Hard Stop will display previous test results.
A user cannot electronically bypass a Hard Stop; however, if the duplicate test is necessary for patient care, the ordering provider may contact Client Services to receive a code to override the intervention.
In 2021, the alert fired 24,533 times.
As a result:
- 151 (4.3%) override requests resulted in a test performed, demonstrating a 99% alert-success rate.
- 24,345 unnecessary duplicate tests were prevented for a total savings of $98,928.
Since 2011, Hard Stop Alerts have prevented 69,386 unnecessary tests for a total savings of $771,670.
*The increase seen in 2021 was related to the addition of CBC w/diff and C-reactive protein (CRP) to the Hard Stop Alert list.
02. Restricted Use
The Restricted Use initiative limits the ordering of molecular genetic tests to providers for whom these tests are a routine part of their practice.
This Initiative intends to decrease the use of unnecessary molecular genetic testing and to improve the care of patients tested. Therefore, these tests are restricted to “deemed users” (e.g., pediatric neurology).
Inpatient genetic testing is restricted to the Medical Genetics Service. If a provider believes that a Restricted Use molecular genetic test is required for an inpatient, a Medical Genetics consult is required before the test can be ordered.
Although the number of tests prevented is low, the cost per test is high, which has resulted in substantial savings.
In 2021, 41 unnecessary molecular genetic tests were prevented for a total savings of $37,958.
Since late 2011, the Restricted Use initiative has prevented 724 unnecessary molecular tests for a total savings of $1,253,035.
03. Laboratory Genetic Counselors
Utilizing genetic counselors within the laboratory is a proven laboratory stewardship strategy.
Cleveland Clinic’s laboratory genetic counselors review genetic test orders—including clinical indications—before testing occurs. These highly knowledgeable individuals participate in the sign-out of complex genetic test results (e.g., chromosomal microarray analysis and next-generation sequencing) and provide pre-analytic value through test selection guidance and triage.
Working directly with ordering providers, genetic counselors ensure that the provider’s ordered test is the most appropriate option for the patient, and may suggest alternative approaches to consider if necessary.
The laboratory genetic counselors also advise clinicians about the potential patient costs and insurance authorization requirements associated with genetic testing. They were involved in the project that resulted in new order entry programming to alert Revenue Cycle Management to submit insurance preauthorization requests. Although a notable achievement, there is still much work to do in the area of preauthorization.
In 2021, 322 genetic tests were changed or canceled for a total savings of $211,210.
Since 2011, Laboratory Genetic Counselors have prevented 2,802 unnecessary tests for a total savings of $2,652,255.
Changed or Canceled Tests
04. Regional Soft Stop Alerts
Soft Stop Alerts allow for the flexibility necessary in certain practice settings.
Hard Stops are not optimal for Cleveland Clinic’s Regional Hospitals for several reasons, such as provider mix and incomplete provider use of order entry. A thorough investigation determined that a bypassable duplicate order notification is the most effective solution in these settings.
A Soft Stop Alert appears when a provider attempts to order a duplicate test within a specified time frame. Similar to a Hard Stop, this alert displays previous test information if available. However, although they are discouraged from proceeding with a duplicate test, providers can independently override the Soft Stop Alert from their workstations without assistance.
The development of Soft Stop Alerts expands the best practices and cost-savings achieved through Hard Stop Alerts implemented at Main Campus to regional locations.
In 2021, Soft Stop Alerts deterred 16,625 unnecessary duplicate tests, yielding a cost savings of $69,433.
- Because they are bypassable, Soft Stop Alerts were only ~15% effective in stopping duplicate orders.
- There is a trend towards a higher percentage of Soft Stop Alerts being dismissed over time.
- In comparison, Hard Stop Alerts were 99% effective.
Since 2013, Regional Smart Alerts have prevented 75,368 unnecessary duplicate tests for a total savings of $488,259.
05. Expensive Test Notifications
Expensive Test Notifications alert a provider when a test costs $500 or more to perform.
With the ever-growing list of activities involved in patient care, providers may be unaware of the costs associated with the services that they recommend. By informing them of the price at the time of ordering, providers can evaluate other diagnostic approaches and engage the patient in discussions about their options, since insurance may not fully cover these costs.
Following tests that exceed $500, notifications are categorized in $1,000 increments (>$1,000, >$2,000, etc.).
The implementation of this intervention is described in Volume 149, Issue 7 of the American Journal of Clinical Pathology, published in June 2018 (DOI: 10.1093/ajcp/aqy021).
In 2021, 302 expensive tests were averted for a total savings of $232,811.
Since late 2013, 2,191 expensive tests have been avoided and saved $2,165,676.
Accumulated Totals Per Intervention: 2011 – 2021
1. Hard Stop Alerts
- 69,386 prevented tests
- $771,670 savings
2. Restricted Use
- 724 prevented tests
- $1,253,035 savings
3. Laboratory Genetic Counseling
- 2,802 prevented tests
- $2,652,255 savings
4. Regional Soft Stop Alerts
- 75,368 prevented tests
- $488,259 savings
5. Expensive Test Notifications
- 2,191 prevented tests
- $2,165,676 savings
Unnecessary Tests Avoided
About the Laboratory Stewardship Committee
Cleveland Clinic’s Laboratory Stewardship Committee is a multidisciplinary team that consists of clinicians, pathologists, administrators, and caregivers at Cleveland Clinic who are committed to improving test utilization within our health system. Every clinical department from Cleveland Clinic is invited to designate a representative to participate in this committee.
Our team adheres to Cleveland Clinic’s “Patients First” principle: any recommendations are intended to improve patient care without compromising quality for cost savings. If an expensive test is needed to secure a diagnosis or guide therapy, then we support the use of such tests; however, we recognize there is substantial waste in the system, and we believe that it can be improved through better utilization of resources.
Promoting Best Practices with Other Providers
Developing Evidence-Based Guidelines for Optimal Testing
Conscientious Use of Molecular Testing
Decreasing Unnecessary Phlebotomy
Reducing Unnecessary Duplicate Orders
Reducing Cost Through Judicious Use of Resources
Multidisciplinary collaborations, institutional support, efficient project management & reporting, and excellent IT support have led to results that no singular group could have achieved alone.
The Laboratory Stewardship Committee believes that these efforts have improved the patient experience, decreased unnecessary phlebotomy for commonly-used tests, improved the use of molecular genetic testing, and have helped to decrease Cleveland Clinic’s spend on healthcare costs.
Most importantly, these initiatives have never interrupted patient care: while this committee seeks to implement interventions that promote the best patient care possible, there have always been avenues provided for the ordering provider to override the intervention if they believed it was necessary.