Newsbytes

Pulling out all the stops for test-utilization management

January 2020—Pathologist Ron B. Schifman, MD, practices what he preaches and preaches about what others practice relative to implementing such computer-based test-utilization management techniques as soft stops, hard stops, and those that fall in between. In a 2019 American Association of Clinical Chemistry presentation on strategies and tactics for test-utilization management, and in an interview with CAP TODAY, Dr. Schifman offered insights into a variety of information technology-based interventions.

Computer-based test-ordering interventions run the gamut with regard to complexity, commercial availability, and usefulness and can be tailored to the needs and characteristics of an institution, said Dr. Schifman, professor of pathology at the University of Arizona College of Medicine and chief of pathology and laboratory medicine at the Southern Arizona VA Healthcare System, Tucson. The weakest interventions, known as soft stops, alert providers to a possible problem with a test but don’t stop the order. “The nice thing about soft stops is they’re easy to do, can provide useful information, and nearly all laboratory information systems and EMRs have this capability built into them,” said Dr. Schifman. “Ideally, soft stop messages provide relevant information that might affect the decision to order a test.”

The downside to soft stops, he noted, is that they are “speed bumps” that typically don’t have a significant impact on test ordering, likely because providers get inundated with alerts and messages, which they ignore. Yet despite this drawback, soft stops can save time and money in some situations. For example, said Dr. Schifman, citing a study conducted at the Cleveland Clinic (Riley JD, et al. Am J Clin Pathol. 2018;149:530–535), “When expensive tests—more than $1,000—were ordered, the cost was displayed along with a warning that the patient might be responsible for charges not covered by insurance. This intervention reduced orders by 12 to 14 percent.”

A step up from soft stops are interventions that can be developed by configuring test menus within the computerized physician order entry system. Among these is selecting the most appropriate test nomenclature. “For example,” said Dr. Schifman, “vitamin D orders are easily mixed up. Renaming 1,25 dihydroxyvitamin D as calcitriol is a simple way to address this ‘sound-alike’ test problem.” Another nomenclature technique is to create a test menu using the names of various diagnostic conditions, such as pheochromocytoma, myasthenia gravis, carcinoid, Wilson’s disease, and acute intermittent porphyria, he explained. Selecting one of these names would trigger the most relevant tests or testing algorithms for that condition. “This can be especially helpful in guiding the nonspecialist in ordering the optimal tests,” Dr. Schifman said.

A CPOE intervention that has proven particularly effective at the Tucson VA is to remove tests from the menu that are not commonly ordered or that providers are prone to misorder. To obtain these tests, the clinician must place a free text order with a brief justification.

“We get about 20 of these a day,” said Dr. Schifman. “Most of them can be handled pretty quickly using a business process automation application by Bonitasoft that involves review by a resident or pathologist. A few free text orders are typically changed or discontinued each day after contacting the ordering provider for clarification.”

The most powerful intervention, the hard stop, “requires more resources and more IT support,” said Dr. Schifman. “The hard stop means you can’t order the test without special effort.” Hard stops are triggered by decision support rules that typically are created by customized middleware that interacts with the lab information system and the ordering system, he explained. When a provider tries to order a test through the CPOE system, the middleware intercepts it and processes it using utilization rules to determine whether or not the order should be accepted.

The Tucson VA uses homegrown decision support rules that are designed to manage such inappropriate testing as HbA1c tests that are ordered too frequently and genetic tests that should only be ordered once. Other rules address orders that lack value based on prior results from the same test, such as a repeat hepatitis A test after a positive hepatitis A test, or a different test, such as an anti-HCV order for a patient with a prior positive HCV RNA result.

Before using a hard stop rule, Dr. Schifman recommends back-testing it, if possible, to determine if it’s worthwhile, a process he follows at the VA. “Let’s say we wanted to evaluate a rule that said don’t measure hepatitis A if your previous hepatitis A serology was ever positive,” he said. “Then we would go back through our historical data set and find out how many patients met this criterion. We’re not going to spend the resources to create and test this rule if this condition is infrequent but would proceed, and could project its benefit, if it happens frequently.” Another advantage of back testing is that it can help pinpoint such potential system-based test-ordering issues as poor menu design and panel configuration.

Most hard stop functionality is designed to trigger when the order is being placed in the CPOE system, said Dr. Schifman, but the Tucson VA took a different approach to configuring its homegrown middleware for test utilization. The VA laboratory allows orders to go through and collects the specimens necessary to run the tests. However, the middleware rule can intercept and cancel an order at the accession stage. In such instances, it sends a message to the lab information system that the test has been completed, but the test result is reported as not done and the comment section describes the reason for the cancellation.