Reducing Unnecessary Phlebotomy Testing Using a Clinical Decision Support System

From the 2019 HVPAA National Conference

Ms. Valerie Strockbine (The George Washington University), Dr. Cathie Guzzetta (The George Washington University), Dr. Eric Gehrie (Johns Hopkins Medicine), Dr. Qiuping (Pearl) Zhou (The George Washington University)


Overuse of phlebotomy testing offers little to improve patient outcomes but may subject patients to additional morbidity. Type and screen tests are active for three days from the date the specimen is collected, yet our blood bank laboratory observed type and screen tests were often unnecessarily ordered in our organization. Low-cost, high-frequency tests are ordered recurrently, unnecessarily, and contribute to the high cost of health care. Reducing unnecessary phlebotomy tests can cut costs without compromising quality.


To determine the effectiveness of a clinical decision support system (CDSS) on reducing unnecessary type and screen tests, estimate the cost saved by the CDSS implementation, and describe the unnecessary ordering practices by provider type.


Our value improvement initiative was a separate-sample pretest posttest design at a mid-Atlantic academic hospital to examine the number of appropriate versus unnecessary type and screen tests ordered three months before and three months after implementation of a CDSS. A CDSS was embedded in our computerized order entry (COPE) system to promote appropriate test ordering. The CDSS appears when a type and screen is ordered informing the provider of the date and time the current test expires. Cost savings was estimated using time-driven activity-based costing. Pre-intervention (801 tests) and post-intervention (801 tests) periods were used to describe ordering practices by provider type.


There were a total of 26,206 pre- and 25,053 post-intervention specimens. Significantly fewer unnecessary type and screen tests were ordered after the intervention (12.3%, n=3,073) than before (14.1%, n=3,691; p<0.001) representing a 16.7% reduction. The results demonstrated an estimated yearly savings of $142,612 after CDSS implementation. The majority of the tests were ordered by physicians (85.3% before and 83.1% after the intervention) compared to advanced practice nurses and physician assistants.


Unnecessary testing continues in health care and contributes to excessive health spending without adding value. Phlebotomy testing is one example of how providers can reduce waste and control healthcare costs for low-cost, high-frequency tests. Our study demonstrated that CDSSs impacted a variety of provider types, reduced unnecessary phlebotomy tests, and achieved yearly cost savings. To further improve test ordering practices of all provider types, we recommend additional interventions such as organizational support, education, audits, and feedback.

Clinical Implications

The harms of inappropriate ordering have only been partly examined. In this era of precision medicine, ordering the right test, at the right time, for the right reason can reduce cost, reduce waste, and improve quality, outcomes, and satisfaction for patients. By preventing over-ordering of phlebotomy tests patient discomfort, iatrogenic anemia and subsequent treatment, and health care spending can all be reduced. Until the establishment of national quality measures aimed to control the number of low-cost, high-frequency tests, health systems must find a way to reduce unnecessary health services. CPOE is widely used in a variety of health care settings and can incorporate CDSS to guide all provider types to make judicious decisions at the time of care.

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