Curbside Consult with Dr. Jayne 10/12/15

All’s still relatively quiet on the ICD-10 front, so I’m catching up on other projects that have been pushed to the side during the transition. Most of my clients are seeing some sporadic claims issues, but nothing that is going to cause a major cash flow disruption. As long as practices have processes in place to monitor the revenue cycle and take action as soon as they see patterns forming, they should be fine, although it will take a good month to see how things are really working.

Some practices still haven’t sent a large volume of claims. I continue to be surprised when I see practices that don’t bill every night or don’t have requirements for their providers to complete charts in a timely manner. I don’t have a lot of visibility into how ICD-10 is going on the hospital space, so I look forward to hearing from readers.

I’m working on a lab project for a client. It’s the kind of project I enjoy – extremely detail-oriented, beneficial to end users and patients, but something that practices don’t seem to have time to deal with. Essentially it’s an analysis of their lab ordering patterns with an eye towards redoing their primary ordering screen and some order sets. The practice set up their orders when they went live on EHR in 2010 and haven’t touched it since. A lot has changed in the last five years. They’ve added vendors. Vendors have changed test codes. The community standard of care has changed. Professional organization recommendations have changed.

I’ve pulled all their ordering data and can manipulate it by provider, specialty, location, and time. Right now I’m working on the tedious (yet oddly satisfying) task of updating the vendor order codes to make sure they’re all correct. Luckily they’re using two national reference labs that were happy to provide me digital versions of their orders master. Unluckily, they’re also using a hospital lab where all the knowledgeable lab staff seem to be out of the office on an ongoing basis. They won’t give me their order master (citing “intellectual property”), so I’m at a bit of a disadvantage. I’m not sure how having a copy of the orders master is going to cause them harm since they have an online directory for providers to reference.

Their level of cooperation may also explain why the practice sends such a small portion of its business to the hospital lab. If their day-to-day service is anything like what I’ve experienced, I’d steer clear. One would think it was in their best interest to assist customers in cleaning up their orders, because every time they receive an invalid one, they have to call the office for a clarification. But I guess it’s like everything else with being short staffed. Additionally, I’m sure it didn’t occur to them to plan for the eventuality that if all their customers go to EHR, eventually they’re all going to have to update their orders masters. Interoperability seems like a great idea until you realize you don’t have the resources to support it.

Keeping vendor codes in sync can be a full-time job. Some of the national reference labs change codes as often as weekly. Some are better than others at telling you what codes have been retired or replaced. Others leave you guessing somewhat. I’m seeing some challenges, though, with the various vendors coming up with proprietary tests which can make it hard on the end users. Say a user wants to order a serum porcelain level (a common med school/residency joke). In many cases, the physician doesn’t care whether the test is run via liquid chromatography or liquid chromatography and mass spectrometry – they just want the value. For a large number of tests, the methodology doesn’t make that much of a difference.

Of course there are tests where it makes a tremendous difference and I would expect to see the methodology specified in the name of the test to make it clear. Labs, however, seem to be trademarking various methodologies – perhaps one calls it “PorcelainPure” and the other calls it “TruPorcelain.” It’s impossible for the end user to figure out what they’re ordering without going to websites and comparing. This becomes more of an issue when patients are switching insurance or employers (and therefore lab providers) and end up having serial tests done at different facilities. It’s also a problem when the tests really are equivalent but the labs have trademarked them as a marketing strategy. It’s getting to the point where we almost need generic and branded labs like we have for drugs. I’ve seen it become more complex even over the last two to three years, so I can’t imagine what the next decade will bring.

Once I get all the codes up to speed, I’ll provide them with a program to help keep the codes up to date. Usually I suggest monthly, but a lot of organizations aren’t staffed to keep up with that. They may elect to do it quarterly or twice a year. I stress that it should at least be done every six months or more often if the lab provides clear information on the nature of changes to its orders master. After that, I’ll start reviewing the data based on ordering patterns and we’ll really start doing some clinical transformation.

In midsize practices, it’s interesting to see how different providers order even when they share a specialty. I see a lot of variation in ordering of metabolic test panels. Some habitually order more comprehensive panels whether they’re indicated or not. There is also a lot of variation in cholesterol testing and pap testing. These are conditions where the indications are well identified in national recommendations and guidelines, so you can imagine what it looks like when we analyze ordering on less-common conditions and diagnostic workups.

There can be emotional minefields associated with analyzing ordering patterns. What do you do with your senior partner who is ordering tests based on outdated recommendations? Many groups are unwilling to deal with those kinds of issues head-on, so I end up creating educational programs where everyone in the group gets re-educated as to the current standard of care. Although it’s good to make sure everyone is following guidelines, it’s a tremendous waste of resources when everyone else is already in line and you could just deal with an individual directly.

There are a lot of people out there who never want to ruffle anyone’s feathers, which makes it easy to see why they’re having challenges delivering the kind of care they want to deliver and that patients expect. As the old saying goes, sometimes you have to break some eggs to make an omelet.

Once we analyze the ordering patterns, I’ll make suggestions on updates to the main orders screen and the order sets. We want to get the most commonly ordered tests in prime position for ease and speed of selection. There’s an art to it, though, because if you make too dramatic of changes, it can cause issues with muscle memory and the staff getting back up to speed.

We also have to figure out the timing and how we’ll train users, etc. There’s a lot more to it than just updating templates, and often my role is to help an IT team understand that. We need to give the users time to practice so they’re not hunting around when they’re patient-facing.

I’ll be working on this for a while, so I’m interested to hear how readers approach similar projects. Do you like your eggs over easy or sunny side up? Email me.

Email Dr. Jayne.