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A New Look at Results Management

While in active clinical practice, a typical day of seeing patients ended with completing dictations and reviewing test results. Result reports piled up quickly, and the first problem I had in dealing with them was coming up with a way to prioritize them for action. Eventually, I settled on using a spreadsheet to keep track of things. This addressed the tracking issues, but I still had to put in just as much time considering what to do about abnormal results.

Abnormal results often sparked a literature search or a textbook perusal. Impromptu calls to colleagues for a little advice were not out of the question. Consider the steps required to address an abnormal finding:

  1. Review chart
  2. If the result is as expected, stop
  3. If unexpected, decide on a course of action:
    1. Additional tests
    2. Another visit
    3. Referral
    4. Change of diagnosis
    5. Change in management
  4. Proceed with plan of action

Typically, these steps occur outside of an actual patient visit, are essential for quality care, and require no less intellectual input than a visit.

The presence of an EHR does not automatically eliminate tracking issues or follow-up failures, nor does it reduce the number of clinician hours required to manage abnormal results (1, 2, 3). Even when EHRs do help with tracking headaches, the time and actions required to determine a course of action largely remain the same. Clinicians must still add on hours at the end of each day in order to manage results. The sticky notes and pile of charts waiting for review may be gone, but little else has changed. However, as the saying goes, “problems are just opportunities in disguise.”

It seems that results management brings together a few issues, which, if resolved, could provide a range of benefits to all involved. First, busy clinicians need help in creating processes for managing test results. Clearly, results management is an important clinical activity that requires a structured approach in order to be effective. Considering the importance of results management to the quality of care, why not make it a reimbursable activity? Doing so would acknowledge the value of results management as a key part of clinical work.

Secondly, results management is in accord with the precepts of Meaningful Use. Incorporation of clinical lab results into the EHR as structured data is an ongoing MU objective. This offers a good starting point for promoting results management features in EHRs. EHRs with bi-directional laboratory interfaces are becoming more prevalent, and this is an essential feature for managing the tracking aspects of results management. The next step is adding features that allow clinicians to document actions taken when managing test results, thereby providing a mechanism for justifying reimbursement. Since a chart review is frequently required (and possibly the first step) in managing abnormal results, one possibility would be to create a results management visit type that could be used as a basis for reimbursement.

Should the ONC take such an approach, it potentially creates a situation in which the interests of the ONC/CMS, vendors, and clinicians are aligned (something that is not always evident). For example, by making results management a part of MU and reimbursable, ONC/CMS would provide a positive incentive for having an EHR, thus further driving adoption. (Get an EHR or suffer penalties is not a positive incentive; get an EHR and receive pay for previously unreimbursed and unacknowledged work is.) Since Medicare patients, on average, have more tests than younger patients do, the impact of improved results management might well have an immediate effect on their care quality.

Vendors might benefit from results management reimbursement because documenting results management activities would be difficult without an EHR. Thus, adopting an EHR would offer a clear, calculable economic advantage to clinicians who are sitting on the fence, especially while EHR incentives are available. Finally, the R&D efforts that go into creating results management capabilities could spur innovation while improving patient safety, aiding in product differentiation, and increasing sales.

Results management happens in every practice every day, albeit with varying results. Why not elevate it to a cause célèbre and create a policy from which vendors, clinicians, ONC/CMS, and — most of all — patients can mutually benefit? Indeed, for everyone trying to bolster primary care, promote MU, increase EHR adoption, and improve the quality of care, reimbursing results management activities is a great place to start.

Sources:

  1. Yackel TR, Embi PJ. Unintended errors with EHR-based result management: a case series. J Am Med Inform Assoc. 2010 Jan-Feb;17(1):104–7.
  2. Hysong SJ, Sawhney MK, Wilson L, Sittig DF, Esquivel A, Singh S, Singh H. Understanding the management of electronic test result notifications in the outpatient setting. BMC Med Inform Decis Mak. 2011 Apr 12;11:22
  3. Elder NC, McEwen TR, Flach J, Gallimore J, Pallerla H. The management of test results in primary care: does an electronic medical record make a difference? Fam Med. 2010 May;42(5):327–33.

Comments:

6 responses to "A New Look at Results Management"
  • July 20, 2012
    Bruce Slater
    said:

    Great idea, Jerome. The problem is making it budget neutral. My sense is the Feds are not in a generous mood, given the 27% fee cut coming in 2013.
    Bruce

  • July 26, 2012
    Sarah Corley
    said:

    I think many vendors do already have templates for handling results management, I know that we do. I agree that it is critically important and labor intensive to diligently manage abnormal results if you have a typical patient mix that we as Internists see. I doubt that you will see a separate reimbursement for this activity but rather would predict that this would be part of the work expected of a PCMH and that would help justify a higher global level of reimbursement for practices which make sure they are carefully considering how to manage abnormal results.

  • July 26, 2012
    Jerome Carter
    said:

    Bruce and Sarah,
    the idea is not so much that I expect an actual change in reimbursement, it is more that this activity should be recognized as a key care delivery activity that impacts care quality and work hours. The references cited speak to the fact that the simple presence of an EHR does not necessarily improve results management. The question of why this is so requires further exploration.

    As the EHR incentive programs move forward, a greater focus on EHR features/functions that are specifically targeted at improving clinicians’ productivity would be a winning proposition for all. Results management is an excellent place to start. Actually being reimbursed for this critical activity would be a lagniappe!

  • August 11, 2012
    Michael H. Zaroukian
    said:

    Hi Jerome,

    Thanks for your post highlighting the importance of this set of activities which adds roughly 1-2 hours per week (25%-50%)for each half-day clinic I conduct each week. When I have raised the issue of this as unreimbursed care, the answer I’ve been given (and cited in CMS literature) is that this activity is factored in as part of the payment formula already. Notwithstanding my skepticism in this regard, it is clear that putting our patient’s needs first means applying our best thinking and professional diligence to results ordering, tracking, resulting and follow-up, all of which could benefit from continued enhancements in bidirectional interfaces between EHRs and lab/rad service providers or HIE intermediaries, result-specific data presentation to make interpretation and next steps easier without adding to the “navigation burden” of the system, and applying patient-specific clinical decision support tools to make it easy to take the next step based on the patient context, such as “This patient has an elevated potassium level and is on an ACE inhibitor and oral potassium supplements. The serum creatinine has also increased 20% since the previous assessment 92 days earlier, with an increase in BUN:creatinine ratio from 12 to 31, suggesting the possibility of prerenal azotemia. One or more of the following orders/actions may be appropriate in this patient:
    o Discontinue potassium supplement
    o Modify or discontinue ACE inhibitor
    o Encourage fluid intake and repeat renal panel
    o Instruct patient to avoid salt substitutes and potassium-rich foods
    o Obtain nephrology consultation
    o Etc.

    While incremental payment for this activity per se is unlikely, the trend toward paying more for high value underscores the importance and business case for doing this well, and the demand for EHR/HIT systems that help us do this better.

  • September 20, 2012
    Joe Bormel
    said:

    Hi Jerome,
    Great post and comment stream.

    “Results Management” overlaps with “Provider Inbox Management”. As mandated EHR use becomes the norm, we’re all seeing scalability issues. I just posted on this topic, here: http://www.healthcare-informatics.com/blogs/joe-bormel/want-fail-approach-stage-2-stage-1-part-1 . As Sarah referenced, we (vendors) have a variety of ways to expedite, contextually-aware clinical decision supported options (including of the excellent examples elaborated by Michael Zaroukian.)

    I agree with your and your comment threads conclusion that there are real and new costs, especially professional time that are involved. I think we all implicitly hoped that EHR adoption would be relatively inexpensive!

  • September 21, 2012
    Jerome Carter, MD
    said:

    Joe, thanks for your comments. This post really raises two issues: reimbursement for results management and how EHR technology supports results management. The scalability issues that you raise must be added to this discussion. We are a long way from realizing the full potential of EHRs as patient care tools and improving them requires a willingness to assess their performance on common clinical tasks. Overall, I think the questions asked and problems identified will lead to better software.

    Jerome Carter, MD
    EHR Science blog — http://www.EHRScience.com
    “Explorations in the Design and Implementation of Clinical Systems”

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