Quality Systems Management
In the past, when the clinical diagnostic world was less complicated than today, primary care physicians could easily keep up with the handful of key lab tests needed to diagnose most conditions they would run across in everyday patient care. Today, there are literally thousands of laboratory tests that clinicians might request as they evaluate a particular patient, and because of the number and complexity of these tests, physicians are realizing they have gaps in their knowledge and understanding of these assays. Increasingly, for physicians to be familiar with the ordering, interpreting and timing of both old and new tests, it is a daunting task.
However, laboratory professionals do know these tests and can play an active role in helping the patient get the right diagnosis at the right time by improving the understanding and utilization of lab tests by the ordering physicians.1 Such test utilization management can be a strategy for encouraging the use of appropriate laboratory and pathology testing with the goal of providing high-quality, cost-effective patient care.2
The Clinical Laboratory’s Role
Laboratory professionals need to be fully engaged with the clinical practice in any test utilization process and able to question clinicians’ test requests, suggest appropriate tests to answer the clinical question being asked and cancel test orders when they are inappropriate for the question at hand. It is the laboratory’s responsibility to identify utilization issues, implement a program that will achieve more effective laboratory testing and establish processes from the beginning to the end of the testing cycle that can lead to a successful laboratory test utilization program.3
The Test Utilization Management Process
A successful solution requires a multi-pronged approach that must involve the clinician, laboratory and clinically engaged pathologists and laboratory directors.
A utilization management process actually starts when the clinician begins to consider what tests are needed to evaluate his or her patient – whether for diagnosis, follow-up, therapeutics or exclusion of disease. Appropriate ordering depends on the clinician having the correct core knowledge to make that decision. The laboratory enters the process early on, as it provides that clinician with the tools to order the correct test.
After the test order or specimen is received in the laboratory, the laboratory professional can play a more active role in the test decision process. Clinical laboratories are beginning to explore how to use algorithms, test guidelines and test formularies to put appropriate medical and utilization reviews in place.4
Suggested Process Steps
- Important test information (clinical indications, overall value of that test, test indications, etc.) is readily available for the ordering clinician to access.
- Requisition redesign. The increased use of better designed information systems that provide ordering guidelines and data about previous tests can contribute to the decision-making process.5
- Team-wide contribution and enforcement. Build a team of representatives from nursing, laboratory, physician and information systems supported by the medical and nursing executive committees to create rules governing laboratory test ordering, including algorithms and test-ordering guidelines. These can guide the clinician through a utilization process to enable appropriate test selection. It may be necessary to actively engage clinicians in discussions regarding the use of algorithms using educational tools.6
- Use of test formularies patterned after the pharmaceutical model. The laboratory test formulary is used to limit access to certain tests and often requires authorization from a pathologist, subspecialist or laboratory committee before a particular test can be ordered.
- Reports must be clear and should integrate all the findings associated with an episode of care.
- Auditing results is a critical step in the utilization process. The audit process can identify which guidelines are not working as planned or need modifications or revisions.