Integrating Laboratories Into Patient-Centered Medical Homes

Clinical laboratories have numerous opportunities to play a role in patient-centered medical homes (PCMH), a new health care model intended to establish a foundation for primary care that achieves the Institute for Healthcare Improvement’s threefold aim of better health, better care, and lower costs. According to a new white paper from COLA, there are numerous opportunities to integrate labs into the PCMH model. Specifically, lab personnel can take the lead in establishing practices that align with PCMH standards in three key areas: Controlling utilization; identifying risks and controls for all phases of laboratory testing, including pre-analytic, analytic, and post-analytic; and coordinating lab results among primary care providers, other providers in the PCMH “neighborhood,” and the patient. Controlling Utilization COLA notes that inappropriate testing can take two forms—overutilization and underutilization. Ramifications of overutilization go far beyond lab costs, unnecessary sample collection, and burden on health care resources. Downstream effects include increased likelihood of false results leading to incorrect diagnoses, unnecessary prescription drugs, longer hospital stays, and additional medical or surgical interventions. Lab utilization controls that could be implemented by physician office labs include physician education on lab test costs and evidence-based medicine, and restricting and auditing test ordering. Identifying Risks and Controls The total test process (TTP) is composed of three phases—preanalytical, analytical, and post-analytical. The preanalytic phase has the greatest estimated contribution to TTP errors (46 percent to 68 percent), followed by the post-analytical (18 percent to 47 percent), and the analytical (7 percent to 13 percent). Labs operating in a patient-centered practice should follow the concepts of total quality management to ensure quality in the testing process. Accreditation agencies require POC labs to have a quality-management system and evidence that they are competently applying their quality system to the TTP. Coordinating Lab Results The increasing use of health information technology (HIT) is key to the success of a patient-centered medical home. HIT enables the practice of capturing and documenting the entire POC testing process in the patient records, including test and quality control results, billing, and the clinician’s response to test results. Best practice quality system policies and procedures for reporting test results should, at a minimum, address receipt of results, review of results, backup reviewing, reporting and confirming receipt of results by the patient, handling of abnormal results, reporting time frame for critical as well as normal results, qualification and training requirements for results reporting, and quality plan for reporting process audits. Takeaway: Given that laboratories perform work that impacts about three-quarters of diagnostic decisions affecting patients, the ultimate success of the PCMH depends upon successfully integrating labs into the model.