Use of Laboratory Decision System as a Test Utilization Management Tool in Clinical Settings, Current and Future Perspectives

Abstract

Managing laboratory test utilization has been a growing problem for the healthcare industry for a long time. With an ever-increasing number of tests, especially in the area of molecular genetics where per test costs are very high, inappropriate utilization is creating a financial burden on healthcare overall. Several large healthcare institutions have made efforts to solve this problem and have developed their own test utilization management approaches. These include, physician education, providing test pricing information, utilizing reminders in Computerized Provider Order Entry (CPOE) systems and/or setting up committees to authorize the use of expensive or complex tests. While these approaches have achieved some minor success in curbing test overutilization and generating cost savings, a robust automated Clinical Laboratory Decision Support System has still been sorely lacking. We present, here, a newly developed Laboratory Decision System, LDSTM as a potential method to address test utilization management in clinical settings. A study of provider and payer use of LDSTM revealed significant improvements in test ordering and management on both sides: a significant reduction in unnecessary tests from the provider’s side and measurable improvement in medical necessity checks from the payer’s side. methods for reducing wasteful testing. A study published by the American College of Physicians (ACP), in 2012, stemming the Tide of over treatment in U.S. Healthcare, explains “the impact of unnecessary tests on healthcare cost totals up to $250 billion a year” [4]. Timely, relevant and actionable data is needed for doctors to accurately order tests, and for labs and other rendering providers to deliver services efficiently and get paid in a timely manner. Further, the rapid growth in molecular and genetic testing (welcomed new tools for diagnosis and disease management) poses a challenge for both healthcare providers and for commercial payers regarding proper utilization of these specialized tests. Given their relatively high cost, inappropriate use of these tests represents an additional financial burden on an already over-taxed healthcare system [2,4,5]. Since laboratory testing provides 70-85% of the objective data upon which physicians base their diagnoses and treatments, laboratory diagnostics has become the single highest-volume medical activity in the U.S., with an estimated 4-5 billion tests performed annually [5]. Inappropriate testing consists of both overand underutilization, which together can dramatically increase healthcare costs. Overutilization refers to tests that are ordered when not clinically indicated, while underutilization refers to tests that are clinically indicated but not ordered. A Harvard Medical School 15Introduction Currently, physicians are challenged by a lack of access to centralized information regarding thousands of available clinical laboratory tests [1]. A study conducted by the Common wealth Fund Survey of Public Views of the U.S. Health Care System showed that over 23% of tests ordered by physicians had previously been performed. Such duplication increases the cost of care while further delaying or confusing the patient’s diagnosis and care [1,2]. Physician uncertainty related to appropriate laboratory utilization was studied by the Center for Disease Control (CDC) in 2011. The study surveyed 1,768 primary care physicians in the U.S and demonstrated that 14.7% had uncertainty in selecting and ordering the correct test and 8.3% had difficulty interpreting tests [3]. When these statistics are applied to over 300 million patient laboratory visits a year in the U.S, inappropriate test ordering and interpretation potentially impacts 23 million patients annually [3]. Such inappropriate test utilization has further downstream clinical and cost impact on our overall healthcare system. The survey also indicated that more than three-quarters of physician respondents indicated that consulting an expert, checking e-references or specialist referrals was helpful in reducing uncertainty in ordering and interpreting lab tests [3]. For these and other compelling reasons, payers, particularly Medicare, are beginning to require standardization of practices and Sci Forschen O p e n H U B f o r S c i e n t i f i c R e s e a r c h Citation: Leblow L, Hamill T, Beqaj SH (2019) Use of Laboratory Decision System as a Test Utilization Management Tool in Clinical Settings, Current and Future Perspectives. J Clin Lab Med 4(1): dx.doi.org/10.16966/2572-9578.128 2 Journal of Clinical and Laboratory Medicine Open Access Journal year meta-analysis indicated that overutilization and underutilization of laboratory tests occurs 20.6% and 44.8% of the time respectively [6]. Inappropriate testing may lead to incorrect or delayed diagnoses and treatments, which negatively impact patient recovery time and associated costs. Test overutilization often increases the likelihood of false-positive results which can result in incorrect diagnoses, additional inappropriate testing, increased costs, and adverse outcomes due to unwarranted intervention [6,7]. Additionally, a consequence of ordering tests which are not indicated often can be the failure to order tests which are clinically ‘indicated’, further compounding the problem. Test underutilization can contribute to an increase in morbidity due to delayed or missed diagnoses and, paradoxically, can lead to downstream overutilization, again resulting in higher costs and poorer patient care [2,7]. With industry and governmental shifts from traditional fee-forservice to value-based care, over/underutilization is a critical issue that affects the bottom line with respect to increased costs and poor clinical outcomes. In order to meet the goals of modern healthcare, medical providers and insurance payers are searching for solutions that will help in making optimal decisions in the selection of diagnostic tests and ensuring the appropriate utilization of laboratory resources. Current Approach to Test Utilization Problem There have been several efforts by large healthcare institutions to counter test utilization problems. However, it is worth listing the main factors influencing ordering behavior: ease of ordering in CPOE, ignorance of test characteristics, peer or supervisor pressure to be extremely thorough, fear of litigation, impatience, desire for certainty of diagnosis, financial incentives, and patient demand [2,5,8,9]. In general, the overall management of these factors requires new tools, education, changes in habits and reward feedback loops [8,10-12]. Two important studies that have attempted to analyze and solve the problem of test utilization are the Veterans Affairs Hospital study [13] and the Massachusetts General Hospital (MGH) study [8,14]. The Veterans Affairs Hospital study managed test utilization by implementing a modified and improved laboratory information system that allowed them to setup special rules, restrictions, reminders and notifications, which lead to reduction in unnecessary tests and decreased cost [13]. The MGH study developed a laboratory utilization management program that required committee review and approval for test orders and acted as a ‘governor’ against practitioners ordering ‘inappropriate’ tests. This method is predictably costly as it necessitates the ‘handson’ participation of expensive experts including pathologists and genetic counselors in decision making and does not result in timely responses [2,5,8,14]. Over burdened clinicians cannot afford to spend large amounts of time tracking down a pathologist for an answer that they often require immediately. Several other studies have used similar strategies to reduce unnecessary test ordering and cost reduction, especially with respect to sending out tests which are often poorly reimbursed, and, therefore, create financial burdens for many small and large hospitals [8,15,16]. Future Approach to Test Utilization Problem Clinical decision support system Selecting appropriate medical tests is an ongoing and growing problem in many specialties including radiology, cardiology, Pulmonology and pharmacology. Since radiology diagnostic imaging is more costly than laboratory testing, the U.S. government has approved a reimbursement reward system for insurance providers that utilize a Clinical Decision Support System (CDSS) to improve imaging utilization and, thereby, decrease unnecessary orders and cost [15]. For example, there is a 2015 “Advanced Imaging Bill” which mandates that government-approved imaging services will only be reimbursed if the insurance claim confirms that appropriate-use criteria was consulted or a CDSS was used [17,18]. The Bill also recommends use of CDSS for other diagnostic test ordering, if available. Accordingly, CDSS’s are currently available for cardiology, medication management, oncology and urology. These developments strongly indicate that there also is a substantial need for a laboratory CDSS to aid healthcare providers in selecting and ordering laboratory tests and reducing inappropriate testing [11,12]. Currently, there are some partially developed and semi-manual lab CDSS’s that help physicians order laboratory tests; however, these modules are provider-driven and require inconvenient interactive user questions to access the information needed [911,19,20]. In addition, these systems do not provide any scoring system for tests based on medical evidence, clinical relevancy and medical necessity as used by radiology CDSS’s. Laboratory decision support system To address these challenges, Medical Database, Inc (MDB) has developed a laboratory decision support platform that includes an easy-to-use test ordering and utilization management application, also known as the Laboratory Decision System or LDSTM. This platform gives healthcare providers access to a systematic and in-depth resource to assist in selecting and ordering the most appropriate laboratory te