Laboratory Stewardship

The current healthcare climate creates a great 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 helping to decrease unnecessary laboratory testing and phlebotomy. Such initiatives result in increased patient and provider satisfaction and reduced healthcare costs.

Our success has been made possible through an open and transparent process, the support of our health system’s leadership, multidisciplinary participation of individuals throughout our organization, and our committee’s willingness to learn and change.

These are successful strategies we have developed and/or implemented to promote appropriate laboratory testing.

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Laboratory Stewardship Best Practices

Since 2011, several ongoing interventions have been integrated into Cleveland Clinic, including:

  • Hard Stop Alerts
  • Restricted Use
  • Regional Smart Alerts
  • Laboratory Genetic Counseling
  • Expensive Test Notifications

These along with several other test utilization strategies have ultimately prevented 203,343 unnecessary tests, resulting in cost savings of nearly $7 million.

Avoided Tests

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 2019, the alert fired 3,683 times.

As a result, 3,543 unnecessary duplicate tests were prevented for a total savings of $49,510 and a success rate of 96%.

Prevented Tests

Overridden Stops

  • Prevented
  • Overridden

Since 2011, Hard Stop Alerts have prevented 41,717 unnecessary tests for a total savings of $628,255.

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.

Many resources are required for genetic testing: it is typically expensive, complicated to perform and interpret, and has variable insurance coverage, often including prior authorization requirements.

This CDST 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 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 2019, 46 unnecessary molecular genetic tests were prevented for a total savings of $44,430.

Prevented Tests

Since late 2011, the Restricted Use initiative has prevented 647 unnecessary molecular tests for a total savings of $1,184,648.

03. Laboratory Genetic Counselors

Utilizing genetic counselors within the laboratory is a proven laboratory stewardship strategy.

These highly knowledgeable individuals provide pre-analytic value through test selection guidance and triage of incoming orders. Laboratory genetic counselors contribute to post-analytic settings by providing input regarding genetic counseling and follow-up testing.

At Cleveland Clinic, laboratory genetic counselors review genetic test orders, including clinical indications, before testing is performed. Working with the ordering providers, genetic counselors ensure that the ordered test is the most appropriate option for the patient and will suggest alternative approaches for the provider to consider, if necessary.

In 2019, 541 genetic tests were changed or canceled for a total savings of $278,713.

*Over the past year, cost-savings per intervention have gone down slightly, as interventions are occurring on less expensive tests.

Prevented Tests

Since 2011, Laboratory Genetic Counselors have prevented 2,147 unnecessary tests for a total savings of $2,263,795.

04. Regional Smart Alerts

Smart 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 Smart Alert soft stop 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 Smart Alert from their workstation without assistance.

The development of Smart Alerts expands the best practices and cost-savings initiatives achieved through Hard Stop Alerts implemented on Main Campus to regional locations.

In 2019, 9,596 unnecessary duplicate tests were prevented for a total savings of $67,287.04.

Prevented Tests

Since 2013, Regional Smart Alerts have prevented 46,017 unnecessary duplicate tests for a total savings of $355,186.

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 are occasionally unaware of 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 2019, 460 expensive tests were averted for a total savings of $365,585.

Prevented Tests

Since late 2013, 1,581 expensive tests have been avoided and saved $1,692,910.

Totals Per Intervention: 2011 – 2019

Unnecessary Tests Avoided

Cost Savings

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.

This 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 the use of such tests is supported; however, the team recognizes there is substantial waste in the system and believes 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 has always been avenues provided for the ordering provider to override the intervention if they believed it was necessary.

The Right Test for the Right Patient at the Right Time.

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