There is important and timely work being done by many clinical laboratories in the area of test utilization management (ie, laboratory stewardship) focusing primarily on the critical role of data collection and analysis in the selection of appropriate interventions and improvement projects. Utilizing software tools designed to provide near real-time data in a flexible and powerful format can guide laboratory directors toward utilization management improvement opportunities for tests and ordering providers.
Whether we continue with the Affordable Care Act (ACA) as it currently exists or with some alternative legislation, there will be continued and increasing pressure placed upon all health care providers to deliver the highest quality patient care with demonstrably excellent outcomes and satisfaction levels, all at the lowest possible cost. This is the essence of the Institute of Healthcare Improvement’s Triple Aim.1 The historical trend of health care costs increasing far faster than the rate of inflation as they continue to consume an ever-increasing portion of American’s disposable incomes will come to an end, as the current situation is not sustainable. Whether that resolution comes through a chaotic and desperate disruption in the marketplace or through a more measured process depends largely upon the timely efforts and commitment of everyone in our industry. Without question, given the ubiquitous influence of laboratory test results upon the initiation, maintenance, and monitoring of patient care in virtually all settings, the clinical laboratory will play a key role in the success or failure of those efforts.
Impact of Test Utilization Management
Of all the options available to laboratorians to affect positive change, test utilization management (UM) is among the most effective and universally achievable. Historically, clinical laboratories thrived on the basic premise of delivering, in a timely manner, whatever tests a care provider chose to order, regardless of the time, cost, or other resources involved. The following is a traditional refrain: It is not the lab’s job to tell the ordering provider what to order. However, health care has evolved to a point where thousands of lab tests are now available and, as might be expected, many providers are not sufficiently educated in their proper utilization. Today’s hospital environment demands shorter inpatient lengths of stay and is experiencing testing personnel shortages and dwindling reimbursements, all while health delivery processes are gaining in complexity and a steep rise in overall health care costs continues (especially for patient out-of-pocket costs). Studies have shown that approximately 20% of ordered tests are unnecessary, while roughly 45% of the time, tests that would have provided more optimal patient care were not ordered.2 These factors suggest the laboratory does have a responsibility to help guide the provider in ordering the right tests at the right time and in the right sequence.
Defining the Term
The term utilization management speaks to three different aspects of test utilization: overutilization, underutilization, and mis-utilization. Overutilization—when tests are ordered without consideration of the clinical indication—may include abuse of standing orders and order sets, multiple providers ordering the same test simultaneously, or simply ordering tests that are not medically necessary. Mis-utilization includes ordering an outdated test, ordering a test out of sequence, or ordering the wrong test (eg, look-alike names in test catalog). In view of the above statistics, a laboratory that performs 1.5 million billable procedures annually at an average direct cost of $5-10 per test may have the potential to save $1.1 to $3.7 million per year by eliminating over- and mis-utilized tests. Cost avoidance notwithstanding, this represents an enormous opportunity to improve patient care and reduce waste. Adding complexity to the problem is test underutilization—tests that could have added clinical value through more expeditious diagnosis and intervention or more effective monitoring of a disease or other medical condition. Lab stewardship and UM programs should not ignore underutilization as an equally important opportunity to improve patient care.
The Value of Data
Despite overwhelming factors in favor of engaging in UM, success is not guaranteed. There are arguably three key elements necessary for a successful UM program: Data, people, and interventions. The lack of adequate resources in any of these areas will almost certainly result in a middling UM effort, even if an abundance of the other two elements exists. Herein, we examine the critical requirements for the extraction and objective interpretation of relevant data as a prerequisite for UM success.
Acting without good data and the inferences that follow is akin to trying to hit one of several targets while blindfolded. The problem is not simply missing the intended target, but the potential damage and waste of resources that result from hitting the wrong target. One such resource at risk is the good will of the physician providers who rely heavily upon the services of clinical laboratories. Another such resource is time; arguably the most valuable resource of all. Yet another problem is the real cost of trying to fix something that is not broken, or seeking to improve something of lesser importance while a higher priority problem remains unaddressed (ie, opportunity cost). The gravest risk is that the patient receives suboptimal and perhaps dangerous care.
Fortunately, most clinical laboratories, hospitals, and health systems have the necessary resources within their information systems and the technical expertise to accomplish an effective data extraction and analysis for UM purposes. Unfortunately, there is typically fierce competition for these resources and technical support, which may create unwanted delays in the initiation or sustaining of UM efforts. The capacity to collect timely and meaningful data may be widely variable, depending upon the specific EHR in use, the skill and experience of those who administer it, and the ability of lab stakeholders to effectively express their data requirements to those who analyze the data and create the reports.
While it may be tempting to forge ahead before having reliable and timely supporting data, starting off in the wrong direction is worse than waiting for reliable guiding data, as you may do serious damage to your credibility with stakeholders, especially physicians. Thus, when considering what data to collect and how to collect it, the following questions may be of value:
- Who are your intended audiences and stakeholders?
- What do they value?
- What forces and pressures are they dealing with?
- How can your data help them and you to solve high priority problems? (In other words, what is in it for them, and what is in it for you?)
Once these questions have been addressed, it becomes a matter of enlisting computer application specialists and engaging in a dialog to help convey your needs. Data analysis often is complicated, so do not expect IT report writers to automatically optimize this process. The laboratory director should know best the questions that need to be asked and answered by the data. Start with top tests or test groups by volume and/or cost (follow the 80/20 rule). Look for quick wins to help justify the use of current and future resources. In so doing, the following will help to create a successful data extraction and analysis process:
- What computer applications contain the needed data?
- Where do the applications reside, and who controls and oversees them?
- What resources are necessary to access them?
- How will the lab director and other users guide the process to ensure the collected data is meaningful and effective?
Establish Data Parameters
In gathering data, it is usually best to be general and inclusive. Specific focusing and targeting can ensure by applying filters to the data that will highlight improvement opportunities. Such filters should ideally include test volume, test cost, test category (eg, routine, esoteric, referred, commonly mis-ordered), user-defined flexible time periods, ordering provider name, CPT codes, ICD-10 codes, etc. These types of objective data provide the directional basis for UM interventions, will help ensure those interventions are supported by your stakeholders, and will yield significant patient care and cost avoidance benefits (see TABLE 1).
Generating timely data in a form that can be easily analyzed is the Holy Grail of data analysis and laboratory stewardship. Recognizing this, several vendors have developed applications that reside within or on top of LIS or EHR applications, and provide user-friendly and timely filters to analyze key metrics as they are produced. While this can be elegant and simple, it may require an investment in the form of initial licensing and ongoing maintenance fees.
Alternatively, some laboratories have developed applications that provide actionable test utilization data at little or no cost. One option is a tool developed using a commercially available application such as Tableau Software. This allows for the creation of a custom dashboard that provides real-time access to user-friendly data analysis of the tests. Data can be quickly filtered by test cost, test volume, time period (updated through the end of the month prior to the current month), test category, ordering provider name, and more (see TABLE 2).
However you opt to extract and analyze your data, it is critically important to involve the right stakeholders as you move forward in your laboratory stewardship efforts. With everyone on board and with data analysis in hand, you can let the information guide you to select the interventions that will address your highest priority stewardship improvement opportunities. Key metrics should be measured initially and then re-measured and reported regularly so test utilization improvements can be accurately quantified and shared with organization leaders. This is important to justify the expenditures of time and money on stewardship efforts. If your experience is similar to most organizations with mature laboratory stewardship programs, documented resource savings will be significant and impressive. Most important, your patients will receive the excellent care they deserve and for which you strive.
1. Berwick DM, Nolan TW, Whittington J. The Triple Aim: Care, Health, and Cost. Health Affairs. 2008;27(3):759-69.
2. Zhi M, Ding EL, Theisen-Toupal J, Whelan J, Arnaout R. The Landscape of Inappropriate Laboratory Testing: A 15-Year Meta-Analysis. PLOS ONE. 2013;8(11):e78962. https://doi.org/10.1371/journal.pone.0078962
Robert B. Carpenter, MS, MT(ASCP), is a senior health care consultant at ARUP and a former administrative laboratory director whose expertise and consultative interests include test utilization management, outreach operations, technical assessment, strategic business planning, and lab networking.
Joseph R. Miles, MT(ASCP), MHS, is a senior health care consultant and former administrative laboratory director.