The ABIM Foundation’s Choosing Wisely campaign – under which more than 50 specialty societies have each identified five common practices that are often unnecessary – has received a significant amount of national attention. One of the Choosing Wisely recommendations by the Society of Hospital Medicine is to avoid "repetitive CBC and chemistry testing in the face of clinical and lab stability," which may be particularly relevant for patients hospitalized at UCSF. Frequent laboratory testing contributes to hospital acquired anemia, patient discomfort, spurious results that can prompt unnecessary testing, and healthcare expense.  Providers at UCSF obtain two or more hemoglobin results on more than 10% of hospital-days, most of which are not significantly different than the first, and rampant use of complete blood counts with differentials had prompted projects in the past which did produce sustained reductions in ordering practices.  

However, as a quaternary referral center, clinicians at UCSF care for patients with complex disease processes who may benefit more frequent laboratory testing, so a push to reduce lab testing across-the-board may not be fully patient-centered.  UCSF therefore has a unique need to strike a balance between the value of reassuring laboratory monitoring and unnecessary testing.

We propose a CHV project to improve patient care and reduce healthcare costs by eliminating unnecessary inpatient laboratory orders at UCSF for tests that have low value - tests that provide minimal clinical benefit given their expense.  One potential solution would be the creation of a targeted, real-time feedback system generated through automated Clarity queries and analysis which would be innovative, sustainable, and extensible.  We believe that in addition to the direct benefits, this will create a more high-value based culture at UCSF and create spillover reductions in other unnecessary ordering practices.