Even Small Labs Can Yield Big Results from Simple, Low-Cost Informatics Strategies

Big Data, informatics and information systems are critical topics for the health care industry as reforms emphasize coordinating care, increasing quality and reducing costs. Capitalizing on the volumes of data generated and collected is a challenge for every laboratory. But the task can seem overwhelming to smaller labs with fewer resources and smaller technology budgets. Even small and midsized labs, however, can find ways to make data work for them. Doing so can help the lab’s bottom line by improving efficiencies and finding ways to trim costs.

Gary A. Letts, MD, MBA, FCAP, founder, president and medical director of Corium Diagnostics, a Connecticut anatomic pathology laboratory, learned the importance of clinicians being involved in the development of lab information systems while establishing his own anatomic pathology laboratory and implementing information technology solutions. G2 Compliance Advisor talked with Dr. Letts to get some insight on how start-ups and smaller labs can leverage data while minimizing their investment.

Q: Informatics can be an overwhelming term. But you have explained that it should not be intimidating. How do you define informatics in terms of lab and pathology operations?

A: Informatics is variably defined because of the scope of the topic. For example, if you ask Google to “define Informatics” you will get about 4,860,000 results and a general or basic definition that encompasses “the science of processing data for storage and retrieval.”¹

Practically speaking, informatics includes simply the act of measuring some aspect of operations and using data in some way; and many laboratories may already be implementing an approach to practical informatics in their lab even if they do not think of it that way or aren’t fully cognizant that it is informatics. For example, when a laboratory wants to improve its turn-around times (TAT) and gathers details regarding its current history of returning results, the data collection and analysis used to make some conclusions about TAT and problems with it, is a practical application of informatics. Informatics helps labs and pathologists identify the low-hanging productivity improvement fruit—that is, measure the parameters of a function that needs improvement. So, many lab managers and directors are already using informatics when they are assessing productivity levels against those promised by new technologies or benchmarking against industry standards, for example. Labs necessarily also need to know current metrics to bring to the table when talking to vendors so they can then identify appropriate technologies including software, that will allow for improvements on those metrics.

Q: Why is informatics so important to managers and directors of laboratories of all sizes?

A: I embrace the assumption that computers can be more efficient at some tasks than humans and should always be used for said tasks whenever possible, so that humans can focus on the things that computers can’t do as well. We are in essence in the information business and diagnostic pathology includes information gathering, analysis and dispersal. We are therefore informaticians, by definition, at least by the definition above. I am drawn to and I seek out every possible way in which computers and information management can enhance my diagnostic accuracy and precision as well as the work processes required to manage all aspects of our interaction with a case, all the way to getting the diagnosis back to the treating physician. Focusing on productivity and quality was critical to surviving in the market place after the big Medicare reimbursements payments reduction for CPT code 88305 in January 2013—our lab was no exception. In the end, as the owner or manager of any company, you are always seeking to achieve maximal efficiency in the various tasks and systems required to run a quality-focused organization. Informaticians buy into the idea that this amorphous and evolving discipline can improve productivity and reduce cost while maintaining quality.

Q: Why should lab leaders and pathologists have some understanding of and involvement in informatics and IT issues—why not leave those issues to the IT professionals?

A: Laboratory professionals that have a common language with IT professionals, vendors or other external partners can increase the likelihood that the services and products that they purchase, and use, will meet their needs more specifically and at an ideal price point. The more you know, the better you can define what you want, understand what is being sold and negotiate the price based on value in your own organization and industry value standards. In the worst-case scenarios, if unneeded services and products are purchased or leased, they can actually degrade your productivity with no meaningful or recognizable tradeoffs. Flawed implementation and inappropriate tools can create productivity black holes that often lower morale of otherwise motivated staff in your organization—sometimes it is impossible to recover from this without significant or key staff exodus. Input from every rung on the staff vertical is therefore critical and can help to assuage new unsuspecting foci of shifted bottlenecks during implementation. Familiarity with the experiences of others through user groups and conference sessions should not be underestimated. You would be surprised how willing some managers are to share their hard earned knowledge, particularly if you are willing to do the same.

Q: How did IT help you improve overall compliance?

A: We did not have a digital data exchange between our LIS and billing software, so we started with a Quality Management program to monitor and improve data entry, in my mind, one of the low hanging fruit. By simply documenting, tracking, and categorizing our data entry errors across all protocols in the laboratory, using an excel spreadsheet, we were able to monitor our progress and focus on specific areas that were easy to address but yielded tangible results. Establishing baselines for speed with accuracy in various departments or tasks, and focusing on increasing speed without compromising accuracy and precision (efficiency) are relatively easy and painless undertakings. (Digitally captured data will continue to abolish the paper trail in theory and effect; and eventually helps to reduce issues directly related to poor data entry and improve compliance.) Data interfaces can pay off handsomely, but depend on your labor cost and your capital, especially in the early stages of your laboratory. They are unnecessarily expensive and may have recurring charges.

We outsourced the lion share of our billing after executing a rigorous Business Associate Agreements with input from our attorneys. We then familiarized ourselves with the various reports available in the software as a first step in understanding indicators of compliance or lack thereof. We worked with the LIS developers to build rules for CPT coding and ICD9/10 selection and assignment and created rules for error checking and flags after manual entry of codes, that would block the sign-out of a case if, for example, there was an inappropriate combination of codes (e.g., Nail for PAS gets an 88300 instead of 88305 along with the 88312 or Coding for multiple IHCs on different blocks on the same specimen is a common error and can be checked automatically and significantly minimized.) Our software modification would return an error with a “fix it” button that takes the user directly to the failure point for review and correction. We invested in a solution that made transition to ICD-10 less painful, but continued to monitor items flagged in the system or flagged by the billing consultants, and continually updated misused or discontinued or replaced codes systematically returning us to our ICD9 baseline of clean code submission shortly after transitioning to ICD10.

Now, with PAMA implementation imminent, our billing system allows for reports that would contain the required data to meet reporting requirements. In addition to our standard reports, we have requested read only access to numerous fields in our LIS and Billing Software that would allow us to combine the data present in any manner we desire. Our previous system allowed us to query the entire database with basic SQL queries. This is a very powerful feature that is often overlooked by users or just not present in many software solutions.

Information systems can also help monitor compliance with regard to relationships with referral sources. Reports stratified by clients, payers and reimbursement rates are often monitored to drive sales and disburse commissions. After a pattern is established for a given client, trends and shifts can be easily recognized by plotting the data output at regular intervals using excel. One might observe different ordering patterns and payor mix simply because clinicians accept new insurances that might cover a different demographic, but such changes could also signify compliance issues to be further investigated.

Q: What should labs look for in hiring a high level IT person?

A: Hiring can be one of the greatest challenges in running a laboratory. Some technical staff can be easily tested on the bench before you hire them, administrative staff should have a stellar track record. IT professionals come with varied skill sets and focus and often will try to apply the law of the instrument in their decisions on how to approach a problem, if you are not looking carefully you could go down a path that is efficient for them but not the best for your organization. One way around this is to seek out vertical specialization by focusing on professionals that have specific experience in the laboratory space that you occupy or with problems that you are trying to solve. This is a very common issue in selecting a coding platform for product development. One has to consider cost, scale and technical expertise necessary for continuity and transferability and the natural conflicts and contradictions between them. Finding the right person to take over a complex home grown system can be a major pitfall in using the economical route or a niche platform. After you hire your IT professional, ensure that you require them to document their work and decisions exhaustively. This can be a life saver for them and for you, and for anyone who might need to master and take charge of your systems. Consider having an understudy or back up personnel to shadow your main IT contractor or staff from time to time and ensure that your contractors are open to a smooth hand-over process by discussing this ahead of time, early and often, including verbiage in your contract to that end. Consider asking for a reference with whom you could speak, that successfully transitioned away from the contractor you are considering to use. Lastly, ask your potential IT hire to tell you about other companies where they have implemented similar or different systems, before you hire them, get input from those companies’ managers, even if they are not in your same lab space, and talk to them about their pain points as well as the reliability of the IT support they received. The down side of doing IT support yourself is that from time to time one can get stuck, deeper than where the original problem occurred—even IT professionals can get stuck occasionally—so backup is key. Your IT person should have an understudy who is familiar with your platform and architecture.

Q: Why should we even invest in developing our informatics capabilities if we are already making money?

A: The future of healthcare reimbursement is unpredictable and small laboratories are disproportionately susceptible to stroke of the pen risk around rate reduction by Medicare and the third-party payers whose rates are often tethered to CMS or who follow Medicare with reductions themselves within weeks to months. If you end up for sale, your suitors might be willing to pay more for a well-oiled and efficient operation than for one with operational or quality problems. Great solutions and operations that can be transferred to a new parent company, can potentially increase the goodwill value of an acquisition and certainly would increase the likelihood of staff retention in a merger.