Fixing folate testing for high-value care

Adding a message to the physician order entry system led to a decrease of 80% in tests ordered.

Where: Johns Hopkins Hospital in Baltimore.

The issue: Reducing low-value testing and interventions.


John Hopkins is famous for many things, including high-quality clinical care, but providing cost-effective, high-value care has not historically been one of them, according to hospitalist leaders there. “In general, for a long time, Hopkins internal medicine has not been synonymous with high-value care,” said Lenny Feldman, MD, FACP, associate professor of internal medicine and pediatrics. “We've been teaching our medical students and residents about high-value care for a couple years now....We decided that if we were really going to teach about these issues locally and nationally, we actually needed to work on projects here at Hopkins in our department of medicine.”

How it works

The department formed a high-value care committee to take charge of the effort, but to ensure engagement in the effort, the leaders let the hospital's clinicians choose the focus. “We threw out a wide net of things that we thought were low-value care practices and also asked for other input,” said Amit Pahwa, MD, assistant professor of medicine and pediatrics. They held a large meeting with all the stakeholders they could find—including nurses, information technologists, pharmacists, administrators, pathologists, and radiologists—to select the initial projects. “Through a vote of the department, we came up with our top 4 projects, and then we had champions for each project present to our [committee] why their project should be taken on. In this way, we picked our first 2 projects. Each one of those champions eventually became a project leader,” said Dr. Pahwa.

The first project the committee targeted was unnecessary folate testing, and the intervention was very simple. “We ended up just putting this message in the [physician order entry system] that essentially said, ‘Our committee recommends against routine testing for folate,’” said Dr. Pahwa. “It wasn't an annoying pop-up that everyone has to click on to acknowledge it; it was just a tweet-length message that was easily visible when someone orders a lab.”


The little message had a big effect. Before implementation, an average of 122 serum folates and 103 red blood cell folates were ordered on inpatients every month. After implementation, there were only 36 and 17 orders per month, respectively. “It went down 80%, and sustained that, which was great,” said Dr. Pahwa.

Based on that success, the department has moved on to target other examples of overuse, including repeated blood typing and screening; Hepatitis C viral load and genotype testing; inappropriate use of telemetry; treatment of asymptomatic bacteriuria; and ordering of a chest X-ray, electrocardiogram, and urinalysis for all admissions.


Some of these projects have been less smooth sailing than the folate intervention. For example, the attempt to reduce unnecessary telemetry started with a small change in physician order entry system. “We tried to do something simple by just asking residents to put in, ‘What's the diagnosis you're using it for?’ to make them try to justify the reason they're ordering it. And that didn't help at all,” said Dr. Pahwa.

Another challenge is foreseeing the consequences of reducing unnecessary care. For example, Dr. Feldman previously worked on reducing creatine kinase-MB (CK-MB) measurement. “If you do that, and you don't talk with the lab, who have all of the reagents for the CK-MB, and you've been ordering thousands of them and you abruptly go to none, that creates problems,” said Dr. Feldman.

Likewise, reducing routine orders for a chest X-ray, electrocardiogram, and urinalysis on admission requires collaboration with the emergency department. “They're actually the ones ordering that test. They are used to knowing that they need all 3 of those tests completed before medicine will admit a patient, which is not necessary from a medical standpoint, but it's been a kind of ingrained thing,” said Dr. Pahwa.

Lessons learned

On the positive side, clinicians, especially new ones, appear increasingly interested in collaborating on such projects, according to Dr. Pahwa. “When I first started here, if I told the residents not to order labs on someone, they would almost chuckle and look at me weird, but now we have started to create a high-value culture,” he said. “They're really interested in figuring out how to best use the health care resources we have.”

Next steps

Although the Johns Hopkins program has tackled a number of projects, these are still the low-hanging fruit of high-value care, according to Dr. Feldman. “We haven't tackled the issue of what to do when there are 2 effective treatments or diagnostics. One costs more than the other and may be slightly more effective. How do we decide which to use?”

He encourages other hospitals and hospitalists to think about such questions. “It really needs to be re-examined on every level—why we do the things that we do, and to figure out which of the things that we do actually are helping people,” Dr. Feldman concluded.