Taking aim at overuse: daily labs, high-cost send-outs

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William Check, PhD

April 2014—As reimbursement models change, achieving better test utilizationWilliam Check, PhD April 2014—As reimbursement models change, achieving better test utilization will become a survival strategy. And in the hard work to imp will become a survival strategy. And in the hard work to improve test use, the computerized physician order-entry system appears to be the work tool with the winning record.

Inpatient laboratory tests at Massachusetts General Hospital fell by 21 percent between 2002 and 2007, despite a seven percent increase in the number of discharges. Per discharge, inpatient tests dropped by 26 percent (Kim JY, et al. Am J Clin Pathol. 2011;135:108–118). Kent B. Lewandrowski, MD, associate chief of pathology and director of laboratory and molecular medicine at MGH and professor of pathology at Harvard Medical School, calls the number of inpatient tests per discharge “a global benchmark,” saying, “It rolls up all of our individual utilization initiatives.”

‘”Variability in a process is almost always a sign of waste,” says Anand Dighe, MD, PhD

Financial incentives in health care in the U.S. have tended to be poorly aligned with quality outcomes and, for outpatient testing in particular, encourage overuse, says Anand Dighe, MD, PhD, associate pathologist and director of the core laboratory at MGH and associate professor of pathology, Harvard Medical School. “In the pure outpatient fee-for-service environment we’ve been operating in for the last couple of decades, we got paid well for outpatient laboratory tests. We’ve encountered few [payer] rejections and not had to confront bundled payment until recently. Now,” he says, “more contracts are paying for the total cost of patient care over a year or more and bundling all aspects of inpatient and outpatient care.” No longer will the hospital be paid $50 for a comprehensive metabolic panel, for example. “That expense will come from the overall patient bill.” Further, payers are increasingly scrutinizing payments for molecular testing such that “now, especially when done in a reference lab, molecular testing really hits the bottom line.”

In anticipation of reimbursement changes, Drs. Dighe and Lewandrowski and their colleagues have been working to optimize test ordering. In one project to curb test ordering in the surgical intensive care unit, they used several interventions. One was lectures to SICU personnel on the recommended use of tests, which Dr. Lewandrowski calls a weak intervention. Stronger interventions were creating guidelines for lab test ordering, auditing providers and giving feedback to the SICU director, requiring physician orders for all tests and holding nurses responsible, and banning daily recurring (QD) orders for most tests.

The laboratory has seen a sustained 30 percent reduction in the volume of test orders from the SICU, starting in the first month in which the project was implemented, Dr. Lewandrowski says, emphasizing that it was a team effort. Several of the steps depended on the hospital’s computerized provider order-entry system, or CPOE.

Use of the CPOE catalyzed another utilization program, the Bigelow Rational Lab Test Ordering Project, begun in May 2008 and designed to reduce ordering of QD laboratory tests. Physicians were in the habit of putting in QD “until discontinued” orders for complete blood count, electrolytes, glucose, calcium, and other analytes. In addition to being wasteful, daily labs are thought to be a major contributor to hospital-acquired anemia.

“Bigelow is a classic teaching service and largely run by residents,” Dr. Dighe explains. Three teams on Bigelow, known as the intervention group, were not allowed to order recurring labs. They were told to anticipate tomorrow’s labs in each day’s progress note. Control teams followed usual ordering procedures. Using the prior October to April as a comparison period, ordering of QD CBCs by the intervention group in May was only about five percent of the baseline level, compared with 50 percent in the control group. QD electrolytes also dropped substantially.

Physicians actually favored the more stringent ordering system: 85 percent said the intervention improved or had a neutral effect on care, and 64 percent said the intervention should be instituted as standard protocol. Nurses, too, were in favor. One commented, “So many patients actually got to sleep for more than two hours at a time.”

“Think outside the lab: Consider other utilization impacted by laboratory testing,” says Kent Lewandrowski, MD.

In November 2012, Dr. Dighe and his colleagues went one step further. They created a functional specification for the CPOE that would restrict QD ordering and got approval from the physician order entry committee. In February of last year they met with internists and hospitalists, and in April they went live. Now all daily lab orders require a reason and are monitored. Inputting a QD order triggers a pop-up. One message: “Daily labs are not indicated in most cases…. All daily labs will be monitored.”

The result: a sharp drop in non-template daily orders. Moreover, thanks to this single intervention, the overall volume of testing has declined by about five percent. “We have seen a sustained reduction that has not gone back up,” Dr. Dighe says.
They have since added another intervention: e-mails to those using what appear to be inappropriate orders. Rules behind the scene trigger the message, which begins: “You are receiving this e-mail because during the past week you placed four or more orders for recurrent daily labs without an apparent approved indication.” Messages are sent weekly to frequent offenders. Dr. Dighe describes this intervention as “relatively mild,” but says, “It does seem to work.”

“In this situation we made it inconvenient to order daily labs,” he says. “We can make it impossible. In the new provider order-entry system we can eliminate that choice. We’ll probably do a target intervention in July with the new residents. That will ratchet up the pressure quite a bit.” Is it easier to make changes with residents than with others? “Just the opposite,” Dr. Dighe says. “Residents are incredibly busy. By ordering lab tests daily times four or five they shortcut the system. When we deal with the professional staff or hospitalists, they rarely put in anything but orders for the next day.”

The CPOE is central to all of these activities. It’s a “key leverage point to improve ordering practices, prevent ordering errors, and avoid preanalytic error,” Dr. Dighe says. Not long ago it was estimated that only 12 percent of U.S. hospitals used CPOE. “It has since increased,” he notes, adding that he’s seen it quoted as high as 70 percent. “For the EMR, we may now be at 50 percent,” he says, due to the incentive of stage two meaningful use dollars.

“Pathology should have control over the content of all laboratory order-entry modules,” Dr. Dighe insists, and such control begins whenever a new system is implemented. Partners Healthcare, of which MGH is a member, is currently implementing a new $1 billion EMR system, and initially there was no pathology representation on several key EMR committees. “We thought that this was a gross oversight,” Dr. Dighe says. “So many decisions are based on lab tests. We argued that pathology needs to be at the table.”

For pathology to make its case, he says, “you have to talk with one voice.” In a large system such as the one in which MGH operates, which consists of six main and other hospitals, speaking with one voice can be difficult. “We came together very early,” Dr. Dighe says. “The two pathology chairs at Brigham and Women’s and MGH argued to the EMR executive committee that they needed to add pathologists to the various teams.” Pathology’s request was granted in part, he says, because “we had a good track record of contributing to our homegrown order-entry systems.”
Of course, CPOE is only one of the first steps in the laboratory testing process. Ordering, collection, processing/analysis, interpretation, and reporting can all be managed and enhanced through informatics. Dr. Dighe, who has informatics training, and his colleagues built a middleware program for the MGH laboratories that connects the hospital clinical information systems to the LIS and facilitates information flow about testing services (Grisson R, et al. Am J Clin Pathol. 2010;133:260–289).

How many laboratories can afford to have a trained informaticist on staff? Perhaps more than think they can. “I was not hired as an informatics person,” Dr. Dighe says. “I was hired as an assistant chemist. I still do a lot of chemistry and hematology and am director of the core lab. Pathology departments are looking for people who can do both informatics and laboratory medicine. There’s just so much data crunching and so many ways we need to rely on computerizing now.” More than 10 pathology residency programs have established an informatics track in the past decade, according to Dr. Dighe.