Novel Best Practice Advisories to Reduce Unnecessary Testing: A High Value Intervention

From the 2022 HVPA National Conference

Stephan Castellanos MD, MBA (Johns Hopkins Hospital), Jessica Lin MD, MBA, Amit Pahwa MD, Katie Anicich MBA, Pamela Johnson MD, Lenny Feldman MD


Over-testing leads to inflated direct and indirect costs of care. Re-ordering tests prior to a given recommended interval, whether secondary to a lack of awareness of information in the patient’s chart or a lack of knowledge of the given recommended interval, most often increases costs without benefiting patients. Best Practice Advisory (BPA) pop-ups and alarms can potentially be used to curb over-testing, but also can burden providers in a healthcare system. With physician burnout reaching unprecedented levels, healthcare needs to account for the effects value-based interventions like BPAs have on both workflow and wellness.


We created and deployed BPA pop-ups in our EMR to reduce the ordering of unnecessary tests. We are assessing the efficacy of the pop-ups including the impact/acceptance of those pop-ups on and by providers.


Three labs were included in this pilot project: Thyroid Stimulating Hormone (TSH), Erythrocyte Sedimentation Rate (ESR), and Hemoglobin A1c (HbA1c). The BPA fired if the provider ordered a repeat lab prior to the end of the recommended time frame (e.g., TSH- 6 weeks, ESR- 1 week, HbA1c- 90 days), and informed the provider of the recommended time frame for reordering the lab and the most recent lab result including the date of that result. The BPA would fire regardless of whether the most recent result came from an inpatient or outpatient encounter. Each BPA was a soft stop—if the provider decided to proceed with the order, they had to provide a reason. We analyzed ordering practices for each lab in the 12 months leading up to the introduction of each BPA pop-up. We analyzed the number of times each BPA fired and whether the provider followed the recommendation of the BPA. We then conducted a survey of providers at our home institution and affiliated hospitals to assess their impression of the pop-ups.


Cost savings were calculated based on current CMS billing practices. The TSH BPA fired 2,435 times from 11/3/21-3/31/22, and providers canceled their TSH order 58.69% of the times the BPA fired. This percent reduction represents $42,870 in savings to the patient. The ESR BPA fired 2,424 times from 7/13/21-3/31/22, and providers canceled their ESR order 43.69% of the times the BPA fired. This percent reduction represents $10,590 in savings to the patient. The HbA1c BPA fired 2,590 times from 7/13/21-3/31/22, and providers canceled their order of HbA1c 76.56% of the times the BPA fired. This percent reduction represents $79,320 in savings to the patient. Our provider survey is currently being collected.


The implementation of these three BPAs has impacted provider ordering practices and generated potential cost-savings for patients via reduced testing.

Clinical Implications

Novel BPAs for labs commonly repeated too early reduce reordering and potentially reduce bills to patients and insurers. Our survey results will help answer the question as to whether the additional burden placed on providers by having to click through the BPAs outweighs potential benefit to patients and insurers.

What are academic medical centers across the country doing to improve healthcare value?

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Review article detailing 25 labs to refine for high value quality improvement | July 2020

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