In most medical practices, patients are sent to the lab at the end of their visits for tests the physician ordered. The next day, when the laboratory test results are received, the care team must contact the patient, discuss the results, potentially order additional testing, change medications and make referrals to other providers. This process can overload physicians and staff while also causing important information to be overlooked.
In an episode of the “AMA Moving Medicine” podcast, AMA Chief Experience Officer Todd Unger is joined by Christine Sinsky, MD, to discuss how to get the most out of previsit laboratory testing.
Unger: How would you define previsit lab testing, and why do you think it's so important to implement?
Dr. Sinsky: Previsit lab testing, or as some organizations call it, pre-labbing, is a process where you anticipate ahead of the appointment what a patient's laboratory requirements are, and you arrange for the patient to have that lab a few days before their appointment. The goal is that you have the patient's results with you at the time of the visit.
Now, this works especially well for preventive care and for chronic illness care, where you can predict what the lab testing is that the patient would need.
By doing the lab ahead of the appointment, then the appointment is more effective. The patient gets to ask their questions to the physician face to face. The physician gets to interpret the laboratory values with the patient. Together, they can craft a plan for how to respond to those laboratory results. It's also more efficient, because all the work for that appointment can be completed at the appointment.
Now, this is in contrast to the much more usual situation where the patient comes for their appointment. The physician and the patient review labs from six to 12 months ago. Then, at the end of the appointment, the patient is sent to the lab for their laboratory testing. Then, those results come in over the next several days. At that point, that becomes additional work within the physician's inbox.
The physician is left trying to reconstruct who that patient is. What were the particulars of their situation? What were the medications? What were their previous labs? There's a lot more work involved in reconstructing the patient scenario.
Then, the patient has to be contacted by either the physician or the team and given instructions for what to do in response to their lab, but that's a one-way conversation. The patient really doesn't have an opportunity to reflect back to the physician their own input about how that management should be. If you do the lab ahead of the appointment, you've been able to close the loop of care at the visit itself.
Unger: What about from a financial standpoint? How can previsit labs help your practice financially?
Dr. Sinsky: Previsit lab is good for patients, but it's also good for the clinic's financial bottom line.
One organization, the Massachusetts General Hospital in Boston, published results that showed that they had decreased the number of phone calls around lab results by 89% by doing previsit labs. They decreased the number of letters required for communicating around the lab results by 85%. And their patient satisfaction improved. They also found that they saved $26 of overhead costs per visit.
That overhead would include the call center, where staff are hired to respond to those incoming calls where patients are asking for their lab results or giving feedback about the instructions they've been given over the phone. It also includes the time of the clinical care team, who also have to respond to those incoming calls.
All of that churning, all of that extra work—where the patients have to call in for the results, or call in with questions about the management that had been delivered to them over the phone—all of that can be eliminated when you complete all the work of that patient care at the visit.
Unger: That sounds like something all practices should consider. What would be the first step toward implementing it?
Dr. Sinsky: One of the first steps toward implementing previsit lab testing is to recognize what you're doing. We picked up a mantra from another organization, Data Care in Wisconsin, “The next appointment starts today.”
In this model, we start thinking about the next appointment at the end of today's appointment.
If, today, you were seeing a patient for hypertension, diabetes and congestive heart failure, at the end of the appointment, you would think, "Well, in three months, I'd like to see you back. And we'll need electrolytes, and we'll need an A1c."
You schedule that previsit lab at the end of the previous appointment. That way the next appointment starts today. You've already done the work of planning the next appointment today.
Unger: What's the best way to arrange a patient's next appointment and lab test?
Dr. Sinsky: At the end of each visit, it's helpful for the physician to think about what the patient will need at their next appointment, and to schedule that next appointment—in three, six or 12 months—at that time and schedule the lab that will accompany that visit at that time.
In many practices, physicians use a checklist, like a paper checklist, to check off the labs that they would like done prior to the three-month appointment or the six-month appointment. Then the staff person is assigned to the task of translating that into the computer.
It takes a matter of seconds to check off the next lab tests on a checklist, but it can take two to three minutes to do that same work in the electronic health record through computerized order entry. The most efficient practices assign the decision making to the physician, but they assign the clerical task of converting that decision-making into the future order to a team member who is completely capable of doing that work.
One of the great advantages of doing previsit lab is that it markedly reduces the volume of inbox messages that the physician must manage every day. The average physician has 77 inbox messages per day in primary care specialty. By doing previsit lab, you eliminate a good number of those inbox messages. That saves a tremendous amount of time.
Unger: What are some additional things to keep in mind as you try to roll this out in your practice?
Dr. Sinsky: In the most effective models of previsit lab, there are organizational changes that help support this process. One of those organizational changes is the ability to hold future orders for longer than a three-month period of time.
For example, in many practices, the institution has developed the capacity to hold orders for 12 months or further into the future. That allows the physician to set up, at today's appointment, an appointment a year from now. When I see a patient for an annual comprehensive care visit, I can set up their next appointment a year from now and can set up the mammogram and any other lab testing that may be required at this point. Then no one needs to touch that, between now and then, if nothing changes for the patient. It's incumbent upon the organization to have the ability to hold those future orders for that period of time.
Unger: Great. Do you have any final thoughts or tips to share on this?
Dr. Sinsky: The most effective form of previsit lab also includes teamwork. In my practice, for example, when the previsit lab comes into the electronic health record, those results are directed to one of my nurses. The nurse reviews those. If anything is critically abnormal, she will bring that to my attention before the patient's appointment. Otherwise, the only time that I will need to see those lab results are at the time of the visit. That's a form of efficiency, to review the labs only once, and only in the context of seeing the patient. Then, we have a safety mechanism where the team has filtered those tests for anything that would be significantly abnormal, where we can respond to those ahead of time.
Previsit lab also allows you to advance the care for patients in a way that we couldn't do if we didn't do previsit lab. For example, if during the previsit lab the patient was found to be slightly anemic, that allows us a chance to review the patient's situation, give the patient a call, find out what's been going on and order the second round of testing that's appropriate for that patient before their visit.
By another example, if a patient had electrolytes before their appointment, and their potassium returned low, my nurse would review that. She would call the patient. She would find out if they've been taking their potassium supplementation. She'd find out whatever else had been going on. Then, she would bring that to me as an efficient message that we could review and manage prior to that patient's upcoming appointment.