Lean Lab Thinking: Make Rules Work for You as You Transition to Evidence-based Practices Nancy Stoker Orchard Software Corporation June 22-23, 2016
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
Introduction to Rules Importance of Rules Rules & Laboratory Workflow in Harvest LIS
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.
THIS is what rules do for us Advanced, configurable rules reduce errors by offering decision support through all phases of testing. Analytical Preanalytical Postanalytical
Rules & Laboratory Workflow in Harvest LIS
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
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
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.
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
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
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
Harvest LIS Rules Order Entry Result Evaluation CPT Codes
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
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
Order Entry Rule Configuration Options
Override an Order Entry Rule
Order Entry Rules Enhance Quality Conditions Actions
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?
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)
Condition 1: Current Order Choice is PSA
Condition 2: Primary Insurance Company is X
Condition 3: Diagnoses Code = V76.44
Action: Route Testing to Reference Lab X
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
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!
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
Condition 1: Current Order Choice Contains FT4
Cond. 2: Other Order Choice Contains Thyroid Cascade
Action: Remove Order Choices
Result Evaluation Rules Don t be afraid to give up the good to go for the great. John D. Rockefeller
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
Decision Support to Improve Efficiency Develop reflex algorithms or sequential protocols for test orders Helps reduce non-value added testing Auto-approval
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
Example 1: Thyroid Testing Cascade
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)
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
Condition: TSH < 0.3
Actions: Hold TSH & Reflex FT4
Associated Order Choice: TSH Thyroid Cascade
Condition: TSH <0.3 AND FT4 <0.5
Actions: Hold TSH, FT4 & Reflex FT3
Associated Order Choice: FT4 AND Evaluate All Tests in Current Order
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
TSH Cascade: High TSH (3rd Generation) is high Reflex FT4 FT4 is normal Reflex Anti-TPO
Condition: TSH > 6.0
Action: Hold TSH & Reflex FT4
Associated Order Choice: TSH Thyroid Cascade
Condition: TSH > 6.0 AND FT4 is Normal
Action: Reflex Anti-TPO
Associated Order Choice: FT4 AND Evaluate All Tests in Current Order
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
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
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
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
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
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
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
Set Approval Low at Lab Test Level
Result Evaluation Rule Condition: TSH < Approve Low
Actions: Hold TSH
Associated Order Choices: TSH & TSH Thyroid Cascade
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
Order Choices Table: Enable Rules-based Auto-approval
Let s Talk About the Slightly Scary Pop-up
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
Other Rule Conditions: Lots of Options
Test Your Rules Put your test system to good use Validate your rules Once validation is complete, move to your production system
CPT Code Rules If you don t have time to do it right, when will you have time to do it over? John Wooden
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)
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
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
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
Condition: Order Choice in Order: Udip, UMic
Actions: Replace CPT with 81001
Example 2: Screening PSA with Medicare If insurance is Medicare AND ICD-9 is V76.44 Change PSA CPT code from 84153 to G0103
Set Three Conditions: OC, Insurance, Dx
Action: Replace CPT Code with G0103
CPT Code Changes to G0103 if Dx is V76.44
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
Doing More with Less Use Harvest LIS rules engine to do more with less People Time Valuable resources
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
Questions?
2016 Upcoming Training Courses Orchard Harvest LIS System Administrator July 12-14 August 9-11 September 13-15 October 11-13 November 15-17 December 13-15 Orchard Harvest LIS Advanced User July 26-28 August 16-18 October 4-6 Nov./Dec. 29-1 Orchard Pathology Administrator June 28-30 August 23-25 October 25-27 December 6-8 Orchard Harvest LIS Microbiology Module June 28-30 August 23-25 October 25-27 December 6-8 To schedule, contact your Account Manager or call 800-856-1948. Orchard Copia Administrator & Integration Training Courses June 28-30 August 23-25 September 13-15 October 11-13 October 25-27 December 6-8
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Day 2 P.A.C.E. Program Information P.A.C.E. Provider Number: 526 Program Number: 526-902-16 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
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