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Impact of an Electronic Expensive Test Alert

Cleveland Clinic, under the leadership of Gary Procop, has been a leader in demonstrating the value of clinical decision support tools (CDST) in reducing unnecessary laboratory test orders. Recently, they published their 3-year experience with an Expensive Test Notification CDST. The CDST alerted providers that the test being ordered cost at least $1,000. The alert also warned providers that charges for testing may be substantially greater than costs and that patients may be responsible for charges not covered by insurance.

Cleveland Clinic targeted 36 tests in 2014, 43 tests in 2015 and 67 tests in 2016. The alert displayed test cost in thousand dollar increments, ranging from $1000 to $9999. Costs for tests performed in house were defined as the cost of materials and labor. The cost for send out tests was the price paid by Cleveland Clinic for each test. The CDST required some customization of the basic functionality of their EPIC system. The provider was required to respond in order to proceed with the order. The CDST was passive, meaning that the alert was a soft stop that could be overridden by the provider at the point of order entry.

The investigators monitored the type of test ordered, the identity of the provider and whether or not the provider proceeded or abandoned the order. The latter parameter was termed the abandonment rate. During the 3-year study period, the Expensive Test Notification CDST was activated 3,448 times. Orders for hematology-oncology gene tests, hereditary pancreatitis gene panels, paraneoplastic antibody panels, and universal microbial identification triggered the most alerts.

The Cleveland Clinic employs 3,400 physicians and 1900 residents. During the 3-year period, 545 unique ordering providers ordered expensive tests. During each year, 91% of these 545 providers placed orders for less than 10 expensive tests and abandoned 26% of their orders. Nine percent of providers entered orders for more than 10 expensive tests each year and accounted for 59.8% of all orders entered. This group abandoned only 5.0% of their orders following activation of the Expensive Test Notification CDST.

Even though the overall abandonment rate during the 3-year study was only13.2%, the cost savings of $696,007 was substantial. The observation that more frequent users of expensive tests were less likely to abandon their order when confronted by the cost, suggests that these providers might be more knowledgeable about the clinical usefulness of the test.

Following the lead of the Cleveland Clinic, my institution has implemented an Expensive Test Notification CDST for tests that cost more than $500 and $1000. During the first year, we have observed a 20% abandonment rate, resulting in approximately $800,000 in projected cost savings. Notification of providers that they are placing an order for an expensive test can result in substantial cost savings.


Riley JD, et al. The impact of an electronic expensive test notification. Am J Clin Pathol 2018;149:530-535.

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