The Patient Protection and Affordable Care Act (PPACA) represents the greatest change to our healthcare system since the introduction of Medicare in 1965. The PPACA significantly restructures how healthcare is delivered and how providers are compensated.
The shift from volume and profitability of services (fee for service) to patient outcomes (value-based models) has had implications for all aspects of healthcare delivery, including the clinical laboratory, and certainly including the physician office lab (POL). Each stage of the testing process must be evaluated to ensure that maximum efficiencies and improved patient care are being realized. For the POL, it has made an effective laboratory information system (LIS) more important than ever. An LIS that is well-suited to the lab’s needs can no longer be seen as a luxury—if it ever really could—but now must be seen as a virtual necessity. The value of the right LIS can be seen in the pre-analytic, the analytic, and the post-analytic phases of testing.
The pre-analytic phase
With an efficient LIS, many of the pre-analytic steps are automated, which results in fewer errors. The advantages can be seen in terms of specific benefits.
Positive patient identification and accurate patient demographics: It is not uncommon for a lab order to be generated in the Electronic Medical Records (EMR). When the order is received in the LIS, a label is printed that includes at least two forms of patient ID. Patient demographic information is updated in the order messages are received from the EMR, ensuring accuracy. The ability to use a barcode printed label for samples confirms complete, accurate labeling, accurate programming on the instrument, and positive identification throughout all phases of testing. Hand-written names that are incomplete or illegible are eliminated, resulting in accurate identification. Most laboratory errors are pre-analytic labeling or collection errors. Using barcode labels will help reduce them.
Specimen requirements: The LIS allows POLs to see current procedure terminology (CPT) codes, cost, collection container, patient preparation, specimen storage, and stability with one mouse click. This saves time for phlebotomists, as they do not have to go to other sources for information.
Test utilization: Most important, the lab should assist its providers in determining which tests should be ordered in certain situations. Frequently used tests can be created in the LIS, which improves test utilization and minimizes waste. Creating “super groups” in the EMR and LIS allows each provider to order custom groups of tests, making the ordering process quicker for the provider and the phlebotomist creating the requisitions.
The analytic phase
During the analytic phase, a robust LIS assists the POL facility in providing the best patient outcomes:
Monitoring result discrepancies: The LIS includes delta checking, allowing laboratorians to alert a provider to changes in a patient’s condition.
Documenting all corrective action: The LIS documents quality control failures and corrected reports so the documentation is readily available for inspections.
Management review: The LIS can store proof of review by the managerial staff for the analytical review of the test systems for defined tests or selected personnel. In larger POLs, management review is useful when training new staff, as the new employee can complete the review but the supervisor is allowed to review what the employee did, and evaluate where the new employee might need additional training.
Quality control: The LIS assists with ensuring the QC is acceptable and can disable release of results if certain criteria are not met. The clinic where one of the present authors works no longer prints QC, as the LIS stores values, graphs, corrective action, and proof of review. Prior to the LIS implementation, staff wrote the corrective action on the printed reports, which was sometimes illegible or incomplete. Since implementation, rules have prompted the laboratorian to enter a corrective action note in the LIS, dramatically improving documentation and allowing QC to go paperless. The LIS Scheduler creates paperless schedules for the staff on external QC, maintenance, assignments, QA, and tracking. In the morning, the Task Scheduler orders AM controls with three keystrokes; printing all QC labels and ensuringeverything is up and running.
Automated test reflex or testing cascade: The LIS will drive the best test utilization in this area. In the physician office setting, lab staff must work closely with providers to develop the testing rules and sequence of testing, enabling providers to order a test while the rules will automatically order the appropriate tests based on the initial results. Auto-Verification Rules allow rapid flow of results (within the pre-defined ranges) into the patient chart, eliminating the need for interface review of test results within defined ranges. They also allow users to set up ordering rules and automatic reflex testing rules based on results, eliminating the risk of forgetting to do a reflex test and generating the electronic billing change. Standing Order and Call Documentation features are also used in the LIS to keep track of orders and document attempts and outcomes of contact with a patient, enabling better patient outcomes.
The post-analytic phase
A potent LIS will also have a large impact on the lab as data access and analytics will be required as healthcare shifts to a value-based system.
Result dissemination: Labs must ensure that results are reliably sent from the point of data entry to final report destination in a timely manner. Electronic bidirectional interfaces with Electronic Health Records, Practice Management Systems, and Reference Lab systems enable accurate, up-to-date information in the LIS and all systems.
Analytics: Data management can be used to improve efficiency. Data can be analyzed to determine turnaround times, specimen rejections (QNS, hemolysis, incorrect tube, etc.), provider test utilization, and workload to ensure appropriate staffing.
The LIS is more critical than ever in the physician office lab setting. Labs will need a strong LIS partner that is able to adapt as testing menus and workflows shift. The LIS must continually advance to meet the molecular testing requirements and assist the lab in delivering the data required to ensure maximum efficiency and the best possible patient care.
