Smartalert — Implementing Machine Learning–Driven Clinical Decision Support for Inpatient Laboratory Utilization Reduction

Repetitive laboratory testing that is unlikely to yield clinically useful information is a common practice that burdens patients and increases health care costs. Education and feedback interventions have limited success, while general test ordering restrictions and electronic alerts impede appropriate clinical care. We introduce and evaluate SmartAlert, a machine learning–driven clinical decision support (CDS) system integrated into the electronic health record that predicts stable laboratory results to reduce unnecessary repeat testing. This Case Study describes the implementation process, challenges, and lessons learned from deploying SmartAlert targeting complete blood count (CBC) utilization in a randomized controlled pilot across 9270 admissions in eight acute care units across two hospitals between August 15, 2024, and March 15, 2025. The results show a significant decrease in the number of CBC results within fifty-two hours of SmartAlert display (1.54 vs. 1.82; P< 0.01) without adverse effect on secondary safety outcomes, representing a 15% relative reduction in repetitive testing. Implementation lessons learned include interpretation of probabilistic model predictions in clinical contexts, stakeholder engagement to define acceptable model behavior, governance processes for deploying a complex model in a clinical environment, user interface design considerations, alignment with clinical operational priorities, and the value of qualitative feedback from end users. In conclusion, a machine learning–driven CDS system backed by a deliberate implementation and governance process can provide precision guidance on inpatient laboratory testing to safely reduce unnecessary repetitive testing. (Funded by the Agency for Science, Technology, and Research and others.)