Modifying Provider Ordering Behaviors Helps Address Lab Overutilization and Low-Value Testing


Discover how one health system used point-of-order clinical decision support to correct undesirable ordering behaviors without disrupting providers’ workflow. 


Carle Health
Urbana, Ill.


Improving lab utilization despite increasing test loads and changing regulations; providing rapid access to real-time data on testing activities


CareSelect® Lab


  • Implemented a lab stewardship program based on clinical decision support (CDS) to address lab overutilization and low-value testing
  • Realized 39% decrease in inappropriate 1,25 dihydroxyvitamin D tests within 30 days
  • Reduced inappropriate High-Sensitivity CRP tests by 77% within 30 days
  • Decreased inappropriate ESRs by 30% across the board, and by 70% in some departments
“Lab stewardship isn’t just a cost issue for the lab, hospital, or integrated system. I believe it is important to focus on the effect that unnecessary care has on patients, both economically and clinically.”

R. Bruce Wellman

M.D., pathologist and medical director for Transfusion, Coagulation and Apheresis Services, Carle Health

The Customer:

Carle Health is a vertically integrated health system based in Urbana, Illinois, that includes a large multi-specialty physician group, three hospitals with more than 450 beds, and a health plan that spans six states. Carle Health’s lab supports both inpatient and outpatient practices.

The Challenge: Accessing Real-Time Testing Data to Build a Lab Stewardship Program

Like most hospital labs today, Carle Health’s lab struggles with increasing test loads, shifting reimbursement models, and changing regulations. Carle Health’s journey to improving lab utilization started in 2014, when its lab team began to gather and share data on blood utilization and best practices. The health system then adjusted its electronic health records (EHR) to implement those practices across the organization.

Within three years, Carle Health had built out transfusion best practices and reduced overall blood use by 35% to 40% per 100 patient bed days. In 2017, the health system began to address overutilization of inpatient C-difficile PCR testing using the EHR, achieving a 50% reduction in testing.

“It was a good start,” said R. Bruce Wellman, M.D., pathologist and medical director for Transfusion, Coagulation and Apheresis Services at Carle Health. “But we needed more. We understood that data—joined to vetted, evidence-based guidelines—would be key to building a successful lab stewardship program.”

“To change provider behavior effectively, you have to understand what is actually taking place at your institution. You also have to identify which best practices you want to promote,” said Dr. Wellman.

While Carle had already rolled out a few utilization guidelines in the EHR, it lacked the available databases to provide rapid access to real-time data on testing activities, which was vital to planning and implementing a broad stewardship program.

The Solution: Aggregated Ordering Data Provides Transparency into Utilization Patterns

In the fall of 2018, Carle Health began working with Change Healthcare to focus on low-value testing. The health system implemented CareSelect® Lab, a decision support tool that integrates with leading EHRs to provide point-of-order guidance on the appropriateness of every unique lab, pathology, and genetic test order in real time. Its underlying clinical guidance includes more than 1,800 best practice rules and guidelines that are authored, curated, and maintained by Mayo Clinic physicians and scientists.

CareSelect Lab gave Carle Health access to not only evidence-based guidelines, but also to an aggregated view of its data that helped the health system decide which undesirable ordering behaviors to target—and where and how to target them.

“Being able to compare use and misuse by specialty and individual practices, and to see the variation of ordering practices within specialties, lets us target messaging to the areas where interventions can have the greatest impact,” said Dr. Wellman.

After turning on CareSelect Lab in surveillance mode, Carle Health evaluated its data. Two items emerged, both concerning C-reactive protein (CRP) orders. First, the team saw a high failure rate against the “commonly confused” guideline for CRP vs. high-sensitivity CRP (HS-CRP). There were also frequent orders for erythrocyte sedimentation rate (ESR) in scenarios in which CRP was a more appropriate test, according to the Mayo guidelines used by CareSelect Lab.

Carle decided to act on the CRP issues and to address another commonly confused test: 1,25 dihydroxyvitamin D. Since it seemed likely that providers were simply picking the wrong name from a list of search results based on the test’s name, Carle made changes to the orderable test names in its EHR search. This made it easier for providers to find the test they needed—and made it harder to confuse tests with similar names.

Carle addressed the ESR vs. CRP issue with an email memo that showed the guideline against which Carle’s current ordering practices had been evaluated. The memo also provided insight about each test’s cost versus actual clinical value, including details on how much Carle billed insurance for each test—costs which in some cases could be denied by the insurer and get passed on to the patient.

CareSelect® Lab

Decision Support to Help Reduce Unnecessary Laboratory Testing and Wasteful Spending

CareSelect Lab is a decision support tool that integrates with leading EHR solutions and aggregates clinical knowledge around a select menu of routine conditions. It then translates that knowledge into maintained medical policies and best-practice recommendations.

This cloud-based CDS tool includes more than 1,800 best practice rules authored, curated, and maintained by Mayo Clinic physicians and scientists. The guidelines are grounded in evidence-based research, industry best practices, and vetted Mayo Clinic policies and procedures. Collectively, they constitute one of the most comprehensive and detailed set of evidence-based tools for clinical laboratory testing available today.

Results: Evidence-Based Guidelines and Provider Communication Significantly Reduces Inappropriate Ordering

Within one week of implementing the changes, Carle Health saw results on all its targeted testing, and ordering dropped dramatically for two of the three tests. In the first 30 days after rolling out a noninterruptive intervention, Carle Health saw significant reductions in targeted orders.

Inappropriately ordered 1,25 dihydroxyvitamin D tests dropped by 39%, while HS-CRP orders fell by 77%. The health system also realized an overall drop of inappropriate ESR orders across the board, with orders in some specialties falling by as much as 70%.

“That Carle achieved these results with no interruption to their providers’ ordering workflows is a prime example of how a tool like CareSelect Lab promotes good stewardship,” said Greg Mogel, M.D., CMO of CareSelect at Change Healthcare. “Evidence-based guidelines let you show providers the best test to order, while data analytics let you show them what they are currently ordering. Providers want to do the best thing for their patients. This data from Carle shows that if you give providers the right information, in the right way, they will respond favorably, and you will get good results.”

“Continually improving the value of care for patients is vital,” said Dr. Wellman. “Lab stewardship isn’t just a cost issue for the lab, hospital, or integrated system, I believe it is important to focus on the effect that unnecessary care has on patients, both economically and clinically.”

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