By Gary Palgon, VP Healthcare Solutions, Liaison Healthcare Informatics
Major shifts within the U.S. healthcare system present new challenges and opportunities for clinical labs and other diagnostic service providers. Changes to healthcare ground rules mandated by payers and the federal government are driving a shift towards value-based care, resulting in changes to the business models under which clinical labs and other diagnostic service providers operate.
In order to negotiate favorable contracts and participate successfully in value-based healthcare organizations, labs must demonstrate their ability to contribute to the business objectives of those organizations.
The data on orders and results collected by diagnostic labs represents a tremendous source of potential value to help value-based healthcare organizations meet their goals of delivering quality care while controlling costs. However, the ability to realize this potential depends on the type, quality and timing of information provided by the IT systems used for electronic lab ordering and results by lab vendors and their clinician customers.
This discussion outlines key capabilities of EHRs (electronic health records system) and lab outreach systems needed for labs to participate successfully in the shift towards value-based healthcare systems.
Understanding the Business Context
Most labs find themselves engaged in multiple contract arrangements with provider organizations and payers. Each of these arrangements requires somewhat different information strategies to assure success.
- Lab Services for ACOs: Whether a lab competes to provide services to an ACO or other value-based organization or the ACO has been formed by a lab’s parent organization, the lab must demonstrate its value in meeting the ACO’s economic and care quality objectives. This goes beyond traditional assessment of testing costs by requiring that the lab contribute to the care program for each patient.
- Narrow Care Networks: Payers will continue to drive toward limiting choice in selection of labs for members within their plans, and labs must compete aggressively to be selected as a preferred lab by these payers. Payers require price concessions and increasingly demand that labs assist providers in measuring and controlling test utilization.
- Traditional Fee-For-Service: Despite the move to value-based models, most labs will continue to provide some fee-for-service lab testing, though the mix of tests is likely to change over time. Low-cost standardized tests will increasingly be provided by non-traditional test facilities such as physician office labs and retail drugstores, while specialty labs will continue to focus on high-end testing.
Winning Information Strategies for Labs
Provide Electronic Orders with Decision Support
Even with the massive shift to EHRs in ambulatory practices, most lab tests are still ordered on paper. Providers often overlook the value of a complete and consistent electronic lab order and thus have not demanded this capability from their EHR vendors. Interoperability challenges with different EHRs have kept interface costs high, especially for bidirectional interfaces that can transmit electronic orders to the lab.
Efficient and easy-to-use lab ordering applications are rare, and those provided by LIS vendors have seen limited adoption in unaffiliated ambulatory practices. Physician adoption represents a major challenge for electronic ordering applications. Smooth integration of electronic ordering into existing EHR workflows provides a significant point of leverage in increasing the value of electronic ordering solutions.
Labs that are leading the way in implementing electronic lab orders with a variety of EHR systems often partner with outreach vendors such as Liaison Healthcare, whose ordering applications can operate as standalone orders/results portals or integrate smoothly with EHRs using a variety of approaches: HL7 messages, demographics-only integration or web service integration.
To meet ACO care quality objectives, electronic ordering applications must help ensure that unnecessary tests are avoided, evidence-based testing protocols are followed, and important routine tests for chronic conditions are not missed. To be effective, these decision-support capabilities must be provided at the point of order.
Additional order management functions such as the following provide significant benefits to labs and providers as well:
- Support for standing and future orders, with the ability to automatically release orders to the lab at the appropriate time
- Improved patient matching of results with the EHR, greatly reducing lab result interface errors
- Medical necessity checking and conformance with other payer-specific rules to assure reimbursement
- Support for both provider-collected specimen workflows and patient service center workflows
- Order management reports, such as open orders and ordering patterns by test and by provider
- Specimen management reports for phlebotomists and couriers
Provide Flexible and Timely Access to Lab Results
The highest priority for the lab’s provider customers is to automate delivery of lab results into the practice EHR, taking into account the great variation among EHRs in their support for HL7 formats, patient and order matching requirements, and handling of discrete data.
Outreach solutions that focus only on HL7 delivery to the EHR are generally limited in their ability to support the flexible access providers need for viewing and sharing lab reports. With the increase in team-based care of ACO and PCMH models, more flexible lab result access is required. Beyond delivery of results to the EHR, labs need to support remote provider access and information sharing with other providers and the patient.
Web access to lab reports is an important first step for providers on rounds, in multiple locations or after hours. Providers increasingly use mobile devices such as smartphones to receive alerts when lab reports return so they can follow up quickly with their staff or the patient. Providers also need to be able to share lab reports with other members of the care team and provide simple, visual lab reports for the patient.
Retain Patient Health Context when Ordering
A key advantage of orders placed from the practice EHR is that patient health context is available to the ordering provider at the point of order. However, with the increase in team-based care as well as the involvement of specialists in treating chronic conditions, information within any single EHR is likely to be incomplete. For example, tests ordered by other providers or medications not in the ordering provider’s medication list can affect the ability to choose the right set of tests.
To provide a more complete test history, some labs aggregate test information across multiple practices for use by the ordering provider, but this still leaves gaps where tests may have been ordered from other labs. Payers generally have a more complete lab test history, but this information is not generally available to the ordering provider, and test results are typically not available from the payer.
If the providers in the patient’s care team are in an affiliated organization such as an ACO or CIN (Clinically Integrated Network), information can be shared among practices and presented to the ordering provider at the time of order, if the lab ordering application has the appropriate interfaces. Some ordering applications can use an HIE or other healthcare data repository to fill in the information gaps about the patient’s condition. To provide this capability, labs should select ordering applications that can provide a rich patient context at the point of order.
Engage the Patient
Changes to CLIA and HIPAA guidelines in 2014 now require that labs provide patients with their lab reports on request. However, labs are not required to interpret this information in the context of the patient’s condition and treatment. Lab reports contain mandated testing information and describe results in terms meaningful to providers, but patients often find these reports confusing or misleading.
A lab that helps engage the patients in their care is more valuable to an ACO. An informed patient is more likely to conform to their treatment plan and stay healthy, limiting their costs to the healthcare organization.
A better approach is for labs to select provider outreach applications that include patient-friendly lab reports, which present important information in terms that patients can understand and act upon. These applications, such as EMR-Link from Liaison Healthcare, can deliver the lab report on paper, through a variety of patient portals and PHRs, and via mobile devices.
Improve Ordering Patterns
The set of available diagnostic tests and guidelines around the best tests for a given condition is continually changing. Value-based care and good medical practice require that tests be chosen for diagnostic effectiveness as well as cost.
Labs can provide important information to providers and other organizations on how tests are being utilized and how ordering patterns can be improved. Practices and ACOs can also put themselves in a stronger position in negotiating payer agreements by showing that they are proactive in helping to control testing costs.
Labs can assist ACOs and practices with reports that show tests ordered by provider and by patient condition, and by providing timely information about new and obsolete tests and changes to testing recommendations. This information should be available online and in real time to the provider organization so that it can be used effectively in decision-making.
Information Technology Requirements
Addressing the variety of requirements across the various business contexts in which the lab participates is difficult for traditional lab outreach vendors, who typically focus on order entry applications and HL7 lab results delivery. Emerging lab network providers that can address this range of requirements typically deploy cloud-based solutions to meet the changing connectivity and application access needs of labs. This approach also greatly simplifies the connectivity management and infrastructure requirements for the lab, allowing them to focus on their core business requirements.
For success in today’s healthcare business climate, labs should evaluate their customer outreach solutions against requirements such as these:
- The lab ordering application’s ability to fit easily into a variety of practice systems and workflows, including EHRs with differing capabilities, different locations of specimen collection and evolving payer requirements for test justification, order splitting, and billing
- The ability to manage and share lab results data by presenting reports in different formats (including patient-oriented formats), patient test history and delivery to mobile devices as well as to the practice EHR
- The ability to connect to patient data repositories such as HIEs, ACO management systems and clinical data repositories to present a broader picture of patient health at the point of order
- The ability to conform to evolving payer requirements such as Medicare and non-Medicare medical necessity checking, as well as complex clinical appropriateness checking now being pilot tested by lab benefit systems (LBS)
- The ability to report on practice ordering patterns, not just at the level of utilization of different tests, but also for patients with specific conditions, ordering patterns of different providers and the ability to meet ACO value-based care goals
- The ability to provide guidance in selecting tests, including the most up-to-date evidence-based guidelines for a variety of chronic conditions
By carefully considering the requirements of the information technology systems used to handle lab ordering and results data, labs can enhance the value they offer to healthcare organizations by giving those organizations the data they need to meet cost and quality objectives. The ability to add value in these ways offers a clear differentiator that helps labs survive and thrive under a market-wide shift towards value-based care.