An Automated Clinical Laboratory Decision Support System for Test Utilization, Medical Necessity Verification and Payment Processing.

Abstract

Unstructured: Physicians could improve the efficiency of the healthcare system if a reliable resource were available to aid them in better understanding, selecting, and interpreting the diagnostic laboratory tests. It has been well established and widely recognized that (a) laboratory testing provides 70-85% of the objective data that physicians use in diagnosis and treatment of their patients, (b) orders for laboratory tests in the U.S. have increased with an estimated volume of 4-5 billion tests per year , (c) there is a lack of user friendly tools to guide physicians in their test selection and ordering, and (d) laboratory test overutilization and underutilization continue to represent a pervasive source of inefficiency in healthcare system. These inappropriate tests ordering not only lead to slower or incorrect diagnoses for patients but also add a significant financial burden. In addition, many ordered tests are not reimbursed from Medicare because they are not appropriate for the medical condition or were ordered with the wrong ICD-10 diagnostic code, not meeting the medical necessity. Therefore, current clinical laboratory test ordering procedures suffer from a quality gap. Often providers do not have access to an appropriate tool that uses evidence-based guidelines or algorithms to make sure that tests are not duplicated, over-, or under-utilized. This viewpoint lays out potential use of an automated laboratory Clinical Decision Support System (CDDS) that helps providers to order the right test for the right disease and documents the right reason or medical necessity to pay for the testing.