AJCP / Original Article
Duplicate Laboratory Test Reduction Using a Clinical
Decision Support Tool
Gary W. Procop, MD,1 Lisa M. Yerian, MD,1,2 Robert Wyllie, MD,2 A. Marc Harrison, MD,3
and Kandice Kottke-Marchant, MD, PhD1
From the 1Robert J. Tomsich Pathology and Laboratory Medicine Institute and 2Medical Operations, Cleveland Clinic, Cleveland, OH, and 3Cleveland
Clinic Abu Dhabi, Abu Dhabi, United Arab Emirates.
Am J Clin Pathol May 2014;141:718-723
DOI: 10.1309/AJCPOWHOIZBZ3FRW
ABSTRACT
Objectives: Duplicate laboratory tests that are unwarranted
increase unnecessary phlebotomy, which contributes to
iatrogenic anemia, decreased patient satisfaction, and
increased health care costs.
Materials and Methods: We employed a clinical decision
support tool (CDST) to block unnecessary duplicate test
orders during the computerized physician order entry
(CPOE) process. We assessed laboratory cost savings after
2 years and searched for untoward patient events associated
with this intervention.
Results: This CDST blocked 11,790 unnecessary duplicate
test orders in these 2 years, which resulted in a cost savings
of $183,586. There were no untoward effects reported
associated with this intervention.
Conclusions: The movement to CPOE affords real-time
interaction between the laboratory and the physician through
CDSTs that signal duplicate orders. These interactions
save health care dollars and should also increase patient
satisfaction and well-being.
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Upon completion of this activity you will be able to:
• outline ways that the use of computerized physician order entry
(CPOE) can afford the opportunity to interact with clinicians at the
time of order entry through clinical decision support tools (CDSTs).
• describe how a CDST, such as the one used in this study, can avert
thousands of unnecessary duplicate tests and save thousands of
dollars without interruption of patient care.
• list the various factors that can make an intervention of CPOE and
CDSTs possible and sustainable.
The ASCP is accredited by the Accreditation Council for Continuing
Medical Education to provide continuing medical education for physicians.
The ASCP designates this journal-based CME activity for a maximum of
1 AMA PRA Category 1 Credit ™ per article. Physicians should claim only
the credit commensurate with the extent of their participation in the activity. This activity qualifies as an American Board of Pathology Maintenance
of Certification Part II Self-Assessment Module.
The authors of this article and the planning committee members and staff
have no relevant financial relationships with commercial interests to disclose.
Questions appear on p 755. Exam is located at www.ascp.org/ajcpcme.
A major initiative of the Obama administration is
the continued deployment of electronic medical records
throughout the health care system of the United States, and
an important component is the demonstration of meaningful
use. The institution of electronic medical records often has the
accompanying benefit of computerized physician order entry
(CPOE). In addition to decreasing transcription error that
may occur when physician orders are translated and entered
by unit clerks or other health care professionals, CPOE, in
conjunction with clinical decision support tools (CDSTs),
offers the opportunity to present real-time information to the
provider that can alter decision making.
It is clear that unnecessary and wasteful practices in
medicine add cost to an already strained health care system.1-3
When a thorough retrospective review is undertaken, many
© American Society for Clinical Pathology
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CME/SAM
Key Words: Test utilization; Clinical decision support; Meaningful use
AJCP / Original Article
Material and Methods
CDST
The Cleveland Clinic uses Epic (Epic, Verona, WI) as the
hospital information system and Sunquest (Sunquest, Tucson,
AZ) as the laboratory information system. The CDST that was
designed consisted of an immediate electronic notification alert
that a same-day duplicate test was being ordered (ie, a pop-up
box) ❚Image 1❚. In addition, the alert was configured to display
the most recent result for the order that was being attempted, if
available. This latter feature has been particularly appreciated
by the users. This CDST had to be evaluated extensively in
the test environment prior to implementation. Challenges
© American Society for Clinical Pathology
❚Image 1❚ The hard stop clinical decision support tool (CDST)
informs the provider that the test being ordered is a duplicate
that is not usually warranted more than once per day. It also
provides the most recent result for this test. A nonelectronic
means to override this test is provided, but it will necessitate
a telephone call to Client Services. Note: This is a mock-up of
the hard stop CDST; the patient and physician information is
construed and does not represent actual individuals.
encountered during testing included dealing with a single
duplicate test when multiple tests were ordered simultaneously
(ie, the duplicate test was within an order set) and standardizing
the use of exclusion codes used by laboratory processing
personnel, so that when duplicate tests were necessary because
of broken tubes or other specimen collection/transport issues,
the CDST tool would not be activated (ie, a duplicate would be
appropriate in those instances).
Notification, Feedback, and Implementation
This study was reviewed by the Cleveland Clinic
Institutional Review Board. The program was introduced to the
medical staff following approval from Medical Operations and
the institutional leadership. It was introduced via a common
home page used by all physicians at our institution. The initial
phase of the rollout consisted of a pilot of 13 tests. Feedback
was sought from the entire medical staff concerning the
project and the tests for which the CDST would be used prior
to initiation. Feedback was used to modify the test list by one
test due to valid practice differences that were not considered
initially. The second phase of implementation consisted of
adding 77 tests to the activation list. The final phase consisted
of implementing the CDST on the remaining tests in the
entire orderable test menu for which it was deemed medically
appropriate. This list was too extensive to vet with the entire
medical staff, so it was reviewed by all physician members
of the Test Utilization Committee and the most conservative
consensus was used. The final hard stop list consisted of 1,259
tests that would not be allowed more than once per day.
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laboratory tests performed during a patient care episode
may be unnecessary. Thereby, the value and associated cost
of the test in the diagnostic or management process may
be determined. Duplicate testing, although valid in some
instances, is often unnecessary. This, in our experience, is
often performed because the second ordering physician is
unaware of the existing order. Duplicate laboratory tests
have several potential untoward affects. These include pain
associated with the additional phlebotomies; the contribution
toward iatrogenic anemia, which in turn affects wound healing
and infection; and increased health care costs accrued through
specimen collection, transport, testing, resulting, and the
clinical response to the result.4,5 Finally, tests with less than
100% specificity all have a false-positive rate. False-positive
test results must be addressed and may lead to unnecessary
additional testing, which have further implications with
respect to patient safety and increased health care costs.
The Cleveland Clinic has fully implemented CPOE.
Therefore, we examined the possibility of using a CDST
to alert the ordering physician of duplicate test orders. The
earliest form of this CDST that we tried allowed the physician
to bypass the alert and continue to place the duplicate order,
if he or she desired (ie, a soft stop). Two pilot projects were
performed that examined this type of CDST intervention (data
not shown). It proved effective in decreasing redundant orders
for expensive molecular diagnostics tests that were ordered
by specialists on select patient populations (eg, quantitative
cytomegalovirus and Epstein-Barr virus polymerase chain
reaction [PCR] in transplant recipients). However, it proved
ineffective for stopping duplicate test orders for routine
assays (eg, Clostridium difficile PCR). The Test Utilization
Committee of the Cleveland Clinic, therefore, proposed to the
medical leadership of the institution to change the CDST so
that unnecessary duplicate test orders would be completely
blocked for select tests (ie, a hard stop). The impact of this
intervention with respect to financial savings was monitored
for 2 years. We also reviewed patient safety records for the
first year following implementation.
Procop et al / Duplicate Laboratory Test Reduction Using CDST
A method was devised to allow for a physician to bypass
the blocked duplicate order and still place the order, if he or
she felt strongly that a duplicate test was necessary. This was
done to ensure that this intervention could in no way interfere
with patient care. The clinicians who wanted to override
the hard stop were required to call our Client Services area
and provide their name, the duplicate order request, and the
reason they needed the duplicate test. These interactions were
recorded and a monthly report was generated.
Results
In total, 11,790 unnecessary duplicate orders were
blocked by the hard stop CDST in 2 years of activity (2011
and 2012). Of the 12,204 times that this CDST alerted,
the clinician called to request that the duplicate test still be
performed only 414 times (3%). A cost avoidance analysis
of the impact of this revealed a savings of $183,586, which
included materials and labor for laboratory personnel ❚Table 1❚,
❚Figure 1❚, and ❚Figure 2❚.
❚Table 1❚
Hard Stop Alert for Laboratory Ordersa
Year/
Month
Initial
Total
AttemptsAttempts
Actual
Mean
to Order to Order Total
Technical Supply Cost
Laboratory Laboratory Reduction Cost per
Monthly AccumuLabora- Labora- Technical Labor
Cost, Savings, Order
Orders
in Cost
Laboratory Cost
lated Cost
tory Test tory Test Time, min Cost, $ $
$
Permitted Prevented Savings, $ Test, $
Savings, $ Savings, $
2011
January
237
416
1,181
567
1,990 2,557 10
227
–108
10.79
2,449
2,449
February
217
401
1,362
654
2,776 3,429 14
203
–221
15.80
3,208
5,657
March
196
307
1,312
630
2,228 2,857 4
192
–58
14.58
2,799
8,456
April
148
243
1,011
485
2,008 2,494 5
143
–84
16.85
2,409
10,865
May
543
1,105
3,301
1,584
6,427 8,012 25
518
–369
14.75
7,643
18,508
June
589
986
3,994
1,917
8,544 10,461 12
577
–213
17.76
10,248
28,757
578
991
4,063
1,950
5,109 7,060 12
566
–147
12.21
6,913
35,670
July
August
659
1,251
5,068
2,433
9,287 11,720 16
643
–285
17.78
11,435
47,105
1,006
3,830
1,838
6,681 8,519 20
552
–298
14.89
8,221
55,326
September 572
October
552
986
4,301
2,064
4,810 6,875 19
533
–237
12.45
6,638
61,964
November 577
973
4,128
1,981
5,926 7,908 16
561
–219
13.70
7,688
69,652
December 642
1,137
4,888
2,346
15,601 17,947 17
625
–475
27.95
17,472
87,124
2012
January
594
1,009
4,162
1,998
5,480 7,517 20
574
–253
12.66
7,264
94,388
February
532
958
3,612
1,734
6,009 7,751 21
511
–306
14.57
7,445
101,834
March
539
992
4,265
2,047
5,981 8,032 20
519
–298
14.90
7,734
109,567
720
938
5,409
2,596
9,114 11,717 18
702
–293
16.27
11,424
120,991
April
May
689
850
5,100
2,448
7,587 10,083 14
675
–205
14.63
9,878
130,870
June
594
1,053
4,274
2,052
6,361 8,429 24
570
–341
14.19
8,088
138,958
545
914
3,391
1,628
6,819 8,621 23
522
–364
15.82
8,257
147,215
July
August
553
952
3,204
1,538
6,636 8,218 23
530
–342
14.86
7,876
155,091
September 458
816
2,896
1,390
4,901 6,360 10
448
–139
13.89
6,221
161,312
October
419
690
2,714
1,303
5,329 6,811 19
400
–309
16.25
6,502
167,814
November 487
924
3,056
1,467
5,880 7,389 21
466
–319
15.17
7,070
174,885
December 564
1,074
3,422
1,643
7,540 9,208 31
533
–506
16.33
8,701
183,586
183,586
Total
12,20420,97283,944 40,293149,025
189,973
414
11,790b
a
The table demonstrates 2 years of data. The number of initial duplicate order attempts per month is listed. In addition, the total number of attempts to order duplicate tests is listed; the
great difference between the total attempts to order duplicate tests and the initial attempt suggests the physician is not reading the alert, which supports the notion of clinical decision
support tool fatigue (ie, pop-up fatigue). The number of duplicate laboratory tests that were permitted is listed, and the difference between this and the initial duplicate order attempts
represents the actual laboratory orders permitted. The mean cost per laboratory test avoided, the monthly cost savings, and the accumulated cost savings are given, as well as the totals.
b Total laboratory orders prevented: 2011, n = 5,340; and 2012, n = 6,450.
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Monitoring
The number of times the hard stop CDST was activated
and the types of tests for which it was activated were recorded
each month. The internal laboratory costing and timing data,
known for each laboratory test, were used to calculate the cost
avoidance to the system for not performing these unnecessary
duplicate orders; this included materials and labor. We did not
capture cost savings associated with decreased phlebotomy or
specimen collection by other health care providers, specimen
transport, specimen accessioning, specimen processing, or
the time needed for the health care provider to review and
possibly act on the test results. Therefore, although we believe
the laboratory cost avoidance data to be accurate, there was
likely a larger cost avoidance to the system that was more
difficult to quantify.
We monitored activity for untoward complications.
One author (G.W.P.) was the contact for any complaints.
In addition, the Cleveland Clinic uses the Safety Event
Reporting System (SERS) to archive and report untoward
events and injuries. We reviewed the SERS database for the
first year following implementation to determine if there were
any untoward events or patient safety concerns associated
with this project.
AJCP / Original Article
There has been support of this initiative from the medical
staff. During the final phase of implementation, there were
only two instances when clinicians reported that they felt
the CDST was inappropriate for a particular test. Those
complaints were deemed valid, and the tests in question were
removed from the hard stop test list.
The retrospective review of the SERS database for
the first year following implementation demonstrated that
there were no untoward events or patient safety concerns
associated with this project.
Discussion
The annual cost of health care in the United States
has consistently exceeded the annual growth of the gross
domestic product since 1965.6 Costs continue to grow at an
Initial attempt to order lab test
Total attempts to order lab test
Lab orders permitted
Actual lab orders prevented
1,400
1,200
1,000
600
400
200
0
Jan Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec Jan Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec
2011
2012
❚Figure 1❚ The total number of times the hard stop alert fired (blue line), the number of times it initially fired (red line), and the
number of override requests made to Client Services (purple line). The number of actual duplicate tests averted (green line)
is the difference between the number of initial alerts (red line) and the override requests (purple line). The great difference
between the initial firing of the alert and the total attempts made for a particular test (blue line) suggests the physician is not
reading the alert, which supports the notion of clinical decision support tool fatigue (ie, pop-up fatigue).
$250,000
Accumulated cost savings
Monthly cost savings
$200,000
$150,000
$100,000
$50,000
$0
1
2
3
4
5
6
7
8
9
10 11 12 13 14 15 16 17 18 19 20 21 22 23 24
❚Figure 2❚ Monthly and cumulative cost savings achieved using this automated clinical decision support tool.
© American Society for Clinical Pathology
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since intervention in the laboratory would not help avert
unnecessary phlebotomy and its sequelae or save on specimen
collection/transport costs.
We first studied the effects of an electronic notification
of the presence of a duplicate test order as a means to reduce
unnecessary testing. These pilot projects demonstrated that
if the provider were given the option of continuing with
an inappropriate duplicate order, this would occur often,
particularly for a routine test. In addition, a detailed analysis
of order entry patterns during the implementation of the hard
stop CDST showed that in many instances, providers would
try multiple times to place the same duplicate order without
calling Client Services, which suggested that they were not
reading the alert.
Electronic order entry and the electronic medical record
represent significant advances in medical care. However,
systems that do not clearly show pending orders may be
associated with ordering patterns that are excessive and costly.
Electronic notification of duplicate orders through a CDST, as
we have described, is possible in some of these systems. Our
findings suggest that a substantial number of unnecessary,
redundant orders may be blocked with such a CDST and that
significant health care costs may be saved with no untoward
effects on patient care. This project resulted in the avoidance
of 11,790 unnecessary same-day duplicate orders within 2
years, which resulted in a cost avoidance of $183,586. There
were no SERS events or significant complaints associated
with this project.
We believe this initiative was successful for several
reasons. Foremost, the Test Utilization Committee has broad
representation from multiple disciplines. All members are
focused on best practice and optimal test algorithms for
patient care and not on cost reduction. The recommendations
from this group were thereafter discussed with senior medical
leadership, so as to pilot a systemwide change. Support of
medical leadership was essential, as was found by Kim et
al.1 The partnership with leaders and technical experts in
informatics to design, test, and implement the suggested
interventions was the next most important step. The thorough
assessment of the CDST in the test environment was critical
to discover anomalies prior to a true rollout, since these
anomalies, when present in the clinical environment, frustrate
users and diminish support for the project. These assessments
also uncovered inefficiencies in the clinical laboratory that
required attention prior to implementation. The solicitation
of feedback from the medical staff, as well as the ability
to remove tests from the hard stop list in a prompt manner,
was also useful for initial and continued support for this
project. The collegial and nonconfrontational interactions
when requests were made to remove a test from the hard
stop list maintained good working relationships between this
team and the medical staff. The cost savings associated with
© American Society for Clinical Pathology
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alarming rate, with the implementation of new and expensive
diagnostics and interventions. Although many of these tests
and procedures are lifesaving, it has been estimated that more
than $6 billion of the annual expenses for medical care in the
United States are spent on tests and/or procedures that are
unnecessary.7 Many studies have demonstrated great variation
of the use of laboratory testing between different health care
providers for similar diseases, which suggests there is waste in
the system.8-12 More important than the impact of unnecessary
tests and procedures on financial considerations, in some
instances, these may result in patient harm.7 A review of this
literature demonstrates not only the serious need to control
unnecessary testing but also the need for evidence-based best
practices for the appropriate use of these diagnostic tools.
The Test Utilization Committee at the Cleveland Clinic is
a multidisciplinary task force that reports to and is supported by
institutional leadership. This structure affords the opportunity
for participation from all interested staff members from all
departments, which ensures the engagement of participants.
The activities of the committee are approved by institutional
leadership, and the results of interventions are monitored and
reports are provided, which is similar to other models that
have been demonstrably effective.1,13 Kim et al1 provide an
excellent review of their 10-year test utilization experience in
a major urban academic medical center, wherein similar and
other tools were employed. Through these active interventions
and support from institutional leadership, their group was able
to save millions of dollars in blood components and reduce
the amount of inpatient testing by 26%. Their approach and
ours provide opportunities for input and communication from
end users, as well as obtaining support and guidance from
institutional leadership.
An evaluation of the causes of unnecessary, same-day
duplicate orders by our Test Utilization Committee disclosed
that duplications occur for a variety of reasons. One important
reason was that some caregivers considered themselves
too busy to review the pending order list for each patient.
Admittedly, navigation from the routinely used ordering
screen to check for pending orders does take additional steps.
These providers also informed us that they were more likely to
simply place the orders they needed, with the supposition that
the laboratory would find and ameliorate duplicate requests.
Although laboratory technologists may occasionally intercept
duplicate test orders, using them to detect and eliminate
redundant tests would be a gross misappropriation of these
valuable human resources.
Therefore, given this understanding, and knowing that it
has been estimated that physicians control as much as 80% of
the cost in the health care system, we decided to use a CDST
in conjunction with CPOE to intervene directly with the
physician in a reasonable way to control cost.14 In addition,
we wanted to intervene before the specimen was collected,
AJCP / Original Article
Address reprint requests to Dr Procop: Dept of Molecular
Pathology, 9500 Euclid Ave, LL2-2, Cleveland, OH 44195;
procopg@ccf.org.
This publication was supported through a cooperative
agreement with the Cleveland Clinic with funds provided in
part by federal funds from the Centers for Disease Control and
Prevention; Office of Surveillance, Epidemiology, and Laboratory
Services; and Division of Laboratory Science and Standards under
cooperative agreement U47CI000831. The findings in this report
are those of the authors and do not necessarily represent the
official views of the Centers for Disease Control and Prevention.
We thank the members of the Test Utilization and Medical
Operations Committees for their support and ever-innovative
ideas and the members of the Clinical Systems office team for
operationalizing these ideas. Special thanks to Shirley Stahl and
Donna Adams for programming and informatics efforts and to
Rob Tuttle for the financial analyses.
© American Society for Clinical Pathology
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this project is the most easily measured metric, in contrast
to anemia and patient satisfaction, which are determined
by many factors. Although it is more difficult to quantify
the amount of blood not drawn and the patient satisfaction
associated with fewer phlebotomies, we believe these are
important benefits of this initiative. Finally, the indirect
measures of safety, as evidenced by a lack of complaints
concerning these interventions and the review of SERS
events that showed no events related to this intervention,
support that this intervention was safe as well as effective.
The appropriate use of clinical laboratory tests remains
the concern of all health care providers. The resources spent on
unnecessary testing could be better used throughout the system,
such as for better care of patients with chronic diseases. The
initiative described represents a consensus-based approach to
the limitation of unnecessary, same-day duplicate test orders
that may be employed elsewhere, particularly in hospitals
using the same information system. The automated nature
of the system requires minimal maintenance and provides
automated and consistent interventions. We encourage the
formation of multidisciplinary test utilization committees in
hospitals and health care systems where they do not exist.