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

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.