Lean Lab Thinking: Make Rules Work for You as You Transition to Evidence-based Practices

Transcription

1 Lean Lab Thinking: Make Rules Work for You as You Transition to Evidence-based Practices Nancy Stoker Orchard Software Corporation June 22-23, 2016

2 Learning Objectives Recognize how rules help manage laboratory processes Design rules in Harvest LIS Identify best practices testing cascades Distinguish what s new with rules in Harvest LIS

3 Introduction to Rules Importance of Rules Rules & Laboratory Workflow in Harvest LIS

4 What do rules do for us? We are continually asked to do more with less. Harvest LIS and Copia have tools that automate/enhance many processes. Process automation handled by the LIS supports greater efficiency.

5 THIS is what rules do for us Advanced, configurable rules reduce errors by offering decision support through all phases of testing. Analytical Preanalytical Postanalytical

6 Rules & Laboratory Workflow in Harvest LIS

7 Pre-analytical Rule Types in Harvest LIS Patient Match Select specific demographic criteria required to match incoming records to existing patient files Order Entry* Used to automatically correct, or to alert user to get the order right Examples: remove duplicate tests, route lab orders, assign proper billing codes

8 Pre-analytical Rule Types in Harvest LIS Split Order Split an order into two or more orders Based on: sample type, storage temperature, testing location, tube type, order location, etc. Label Printing Print labels to a specified printer under certain conditions

9 Analytical Rule Types in Harvest LIS QC Rules Allow approval of associated patient order choices based on the QC file s approval status Or, automatically order QC based on associated patient order choices Result Evaluation Rules Apply decision support to facilitate auto-approval, trigger additional testing, reruns, comments, etc.

10 Analytical Rule Types in Harvest LIS Micro Threshold Set criteria (drug, bug, and occasionally source) for automatic interpretation of manual sensitivities/mic Assign deduced drug interpretations Result Approval Set criteria to prevent manual approval of results based on specific text, severity, users, etc. Prevent AP report creation or issue

11 Post-analytical Rule Types in Harvest LIS Result Delivery Use to select printer/fax destination to which a report is sent Send to Host Override the release preferences for billing and result records

12 Post-Analytical Rule Types in Harvest LIS CPT* Replace an order choice s CPT/billing codes with one or more new codes Or, append codes/modifiers to existing codes

13 Harvest LIS Rules Order Entry Result Evaluation CPT Codes

14 Using Order Entry Rules Success does not consist in never making mistakes but in never making the same one a second time. George Bernard Shaw

15 When do order entry rules fire? Whenever an order is created or modified Order entry rules look at the entire order Each rule can be configured to fire only for particular type(s) of orders Override ability in the Order Patient Samples (OPS) window OE Rules will NOT fire when ordering directly from Release Stored Orders (RSO) Auto-accession function in Preferences

16 Order Entry Rule Configuration Options

17 Override an Order Entry Rule

18 Order Entry Rules Enhance Quality Conditions Actions

19 Eliminate Waste: Don t Lose $$$ Due to Habit Calculate your cost/test annually and accurately Negotiate reference lab pricing aggressively Route tests to reference lab based on patient insurance company reimbursement If reimbursement is less than your cost/test, and TAT is acceptable, why do the test in-house?

20 Example 1: Refer PSA to Reference Lab if Current order choice is PSA Patient primary insurance company is X Diagnosis (ICD-9) = V76.44 (Screening PSA)

21 Condition 1: Current Order Choice is PSA

22 Condition 2: Primary Insurance Company is X

23 Condition 3: Diagnoses Code = V76.44

24 Action: Route Testing to Reference Lab X

25 Let s Talk About Conditions AND AND with exceptions Condition 1 AND Everything in Condition 2 EXCEPT Browsers use AND/OR Formulas can also use Boolean AND/OR/NOT Truth values

26 Eliminate Non-value-added Testing Focus on test utilization: Develop sequential protocols for test orders. Eliminate obsolete tests. Reduce unnecessary testing combinations. Physician education KEY!

27 Ex 2: Thyroid Cascade Testing Remove FT4 Work with your lab Medical Director to educate physicians re: cascade testing Create order choice: Thyroid Cascade Remove FT4 if ordered in conjunction with Thyroid Cascade

28 Condition 1: Current Order Choice Contains FT4

29 Cond. 2: Other Order Choice Contains Thyroid Cascade

30 Action: Remove Order Choices

31 Result Evaluation Rules Don t be afraid to give up the good to go for the great. John D. Rockefeller

32 Result Evaluation Rules fire when Manually approve from Review Results, Work In Progress, AP and Micro worksheets Unlike order entry, result evaluation rules fire one order choice at a time Result evaluation rules do NOT fire when creating provisional reports Result evaluation rules do NOT fire if auto-approval rules are in place

33 Decision Support to Improve Efficiency Develop reflex algorithms or sequential protocols for test orders Helps reduce non-value added testing Auto-approval

34 Testing Algorithms Provider orders the cascade rather than each test Based on initial results, auto-reflexes to the next logical test Develop in tandem with ordering providers

35 Example 1: Thyroid Testing Cascade

36 Create a New TSH Order Choice TSH - Thyroid Cascade Order choice will trigger algorithm for Thyroid Cascade Allows you to keep TSH with no Thyroid Cascade as an order choice option *(more on this, later)

37 TSH Thyroid Cascade Low Thyroid Cascade - TSH (3rd Generation) is low Reflex FT4 TSH (3rd Generation) is low AND FT4 is low or normal Reflex FT3

38 Condition: TSH < 0.3

39 Actions: Hold TSH & Reflex FT4

40 Associated Order Choice: TSH Thyroid Cascade

41 Condition: TSH <0.3 AND FT4 <0.5

42 Actions: Hold TSH, FT4 & Reflex FT3

43 Associated Order Choice: FT4 AND Evaluate All Tests in Current Order

44 Powerful New Feature for Rules Evaluation Cross-panel Rules Available since the June 2014 release of v9.0 Evaluates results for multiple tests across the entire order All test conditions are applied to the entire order Supports complex algorithms valuable tool to support test utilization efforts Assist ordering physicians and eliminate waste

45 TSH Cascade: High TSH (3rd Generation) is high Reflex FT4 FT4 is normal Reflex Anti-TPO

46 Condition: TSH > 6.0

47 Action: Hold TSH & Reflex FT4

48 Associated Order Choice: TSH Thyroid Cascade

49 Condition: TSH > 6.0 AND FT4 is Normal

50 Action: Reflex Anti-TPO

51 Associated Order Choice: FT4 AND Evaluate All Tests in Current Order

52 Let s Talk $$$ Algorithms are great for efficiency BUT you need to get paid (in the current regulatory environment) Understand how your billing is set up Is billing handled by Harvest LIS or your EHR? How does your EHR process billing for reflex testing? In the new healthcare model, this may be irrelevant

53 Summary for Thyroid Testing Algorithm Cross-panel rules allow rule conditions to include results from multiple tests within an order, panel or sample ID Supports low and high testing cascades Lab tests are associated with order choice: TSH Thyroid Cascade Understand how reflex testing is billed at your facility

54 Ex 2: Auto-approval Improves Productivity Depending on your lab menu and patient population, 40% 80% of results could qualify Medical Directors are getting more comfortable with auto-approval. Is your staff? Reduce costs by simplifying processes Free up valuable tech time to concentrate on other intensive job duties Configure and validate in test system

55 Test system, you say? What is a test environment? A copy of your database set up on a separate workstation You provide the workstation Included with your Service & Support Agreement Tech Support can help you set this up Valuable tool to test all rules! Algorithms and auto-approval

56 Auto-verification in Three Easy Steps 1. Lab Tests Table: Set approval low and high for quantitative results 2. Result Evaluation Rules Table: Set conditions to hold lab test results that don t meet auto-approval criteria 3. Order Choices Table: Enable rules-based autoapproval

57 Start with Single Order Choices High volume order choice with clear-cut rule conditions is a good place to start TSH Hemoglobin A1C As your comfort level increases, write rules for chemistry tests in a BMP Auto-approve as many (or as few) as you wish

58 TSH: Two Rules & Great Time Savings TSH is less than Approve Low TSH is greater than Approve High Make sure your approve result doesn t auto-approve results that trigger Thyroid Cascade All normal TSH will auto-approve

59 Set Approval Low at Lab Test Level

60 Result Evaluation Rule Condition: TSH < Approve Low

61 Actions: Hold TSH

62 Associated Order Choices: TSH & TSH Thyroid Cascade

63 Write Your Rule for TSH > Approve High Highlight your rule for TSH < Approve Low Select Copy button (Copy button is your friend) Change condition and description to > Approve High Actions and associated order choices are the same

64 Order Choices Table: Enable Rules-based Auto-approval

65 Let s Talk About the Slightly Scary Pop-up

66 Select Enable rules-based auto-approval You will get the opportunity to accept responsibility or leave auto-approval off, for now Simply a warning that your rules must be written to hold ANY/ALL results that you don t want autoapproved

67 Other Rule Conditions: Lots of Options

68 Test Your Rules Put your test system to good use Validate your rules Once validation is complete, move to your production system

69 CPT Code Rules If you don t have time to do it right, when will you have time to do it over? John Wooden

70 When do CPT rules fire? Creating an order Printing requisition or invoice from RSO Printing Billing Summary Report clinical only AP/Micro CPT rules fire via Edit Billing window AP unique Specimen-level CPT rules AND source-level CPT rules Specimen rules fire first, then source (when using parts)

71 CPT Rules with Split Orders CPT rules evaluate split orders as Other Order Choices Looks at all other order choices in the order, whether they are in RSO or not

72 Most Testing Still Reimbursed by CPT Code Design CPT code rules to automatically consolidate or change billing codes when testing conditions require Add mandatory billing modifiers to change CPT code from screening to diagnostic, based on ICD-9/ICD-10 and insurance carrier

73 Ex 1: UA Macroscopic Reflex UA Microscopic Dip UA (CPT 81003) results trigger result evaluation rule: Reflex order choice: Urine Microscopic Configure rule to change CPT code to Complete Urinalysis (CPT 81001) if macroscopic and microscopic order choices are present

74 Condition: Order Choice in Order: Udip, UMic

75 Actions: Replace CPT with 81001

76 Example 2: Screening PSA with Medicare If insurance is Medicare AND ICD-9 is V76.44 Change PSA CPT code from to G0103

77 Set Three Conditions: OC, Insurance, Dx

78 Action: Replace CPT Code with G0103

79 CPT Code Changes to G0103 if Dx is V76.44

80 Use Harvest LIS tools to assist! Use Harvest LIS to: Streamline/automate processes Help physicians order tests in result-based cascades Bill properly (correct CPT codes and/or modifiers) and capture charges for your work

81 Doing More with Less Use Harvest LIS rules engine to do more with less People Time Valuable resources

82 Learning Objectives Review Recognized how rules help manage laboratory processes Designed rules in Harvest LIS Identified best practices testing cascades Distinguished what s new with rules in Harvest LIS

83 Questions?

84 2016 Upcoming Training Courses Orchard Harvest LIS System Administrator July August 9-11 September October November December Orchard Harvest LIS Advanced User July August October 4-6 Nov./Dec Orchard Pathology Administrator June August October December 6-8 Orchard Harvest LIS Microbiology Module June August October December 6-8 To schedule, contact your Account Manager or call Orchard Copia Administrator & Integration Training Courses June August September October October December 6-8

85 Orchard Resources White papers: orchardsoft.com/whitepapers collaboration blog: blog.orchardsoft.com Newsletter online: orchardsoft.com/newsletters enewsletter sign up: orchardsoft.com/newsletters Orchard Resource Center (ORC): orc.orchardsoft.com Questions user forum: orc.orchardsoft.com/questions

86 P.A.C.E. Credit & Feedback Visit the P.A.C.E. table to complete the sign in form, once per day, to receive full credit Be sure to enter your address; a P.A.C.E. certificate will be ed to each user after the symposium Complete the feedback form for the event and for P.A.C.E. feedback

87 Day 2 P.A.C.E. Program Information P.A.C.E. Provider Number: 526 Program Number: Program Title: Day 2 Orchard Symposium 2016 Speakers: Jon Payne, Sheri Boes, Clair Smith, Yuri Dozier, Jacob Eickhoff, David Bracewell, Shaun Mohle, Natalie Dorsch, Greg Lyons, Nancy Stoker, Gwenn Brode, Wendy Forgey, Nathan Sweany, Brad Brimhall, MD, MPH; Thomas Novicki, PhD, DABMM; Matt Pollock, Derick Wilson, Debbie Schilling, John Kramer, Steve Brady, Chris Lamb, Beth Eder, John Miller, Seth Bosworth, Leigh Boje Contact Hours: 5

88 Thank you!