Home Forums Discussions General Discussion Getting labs ahead of visit

I know several practices have the patient get the labs ahead of a visit, and certainly this makes sense in terms of efficiency. My problem is that I frequently don't know what labs I am going to want until the visit, necessitating a second draw if I do this. To get even close seemed to require a chart review, making me do the same job twice. Even the simplest things... say, an annual wellness exam, or followup on methotrexate therapy... often have some other issue thrown in to complicate matters; certainly often enough that I just could never get this system to work, and I rely instead on UpDox to send the lab results with comments to the patient after the visit. So, the question from me is this: How do you all make the "lab before visit" work?

I try to review the chart at the preceding visit. As much as possible, for monitoring labs for the management of chronic medical problems, I try to order them in advance at the preceding visit to be drawn 1 week before the next follow up visit, and then I review them with the patient at that follow up visit, modify my therapy as indicated, and use the Updox portal to send a clinical summary to the patient immediately thereafter that automatically has the labs, but they have already heard the interventions if any from me at the visit. Even if the patient is reluctant to schedule a f/u for a chronic problem, I hand them the appropriate lab requisition at the end of every visit to get done 1w before the next visit they do decide to later schedule. The key for me is not to let patients leave without a thought out decision of when they need to come back so I can plan for that return visit. When patients at visits dedicated for f/u of chronic problems introduce new problems requiring different labs, I handle that separately just as if they made an unscheduled visit for a new problem as below.

For FFS patients coming in for new problems of which I know nothing in advance, I'll order the appropriate labs during the first visit and suggest a follow up visit at an appropriate interval to review the results.

I try not to have results coming in after a visit without a follow up visit to act upon them and generate the reimbursement for the time spent doing so.

For capitated patients I will sometimes alter this when it is clinically acceptable to do so, and generate appropriate monitoring lab requisitions with future dates instructing patients to call 1w thereafter for results. As about 80% of my lab results show stability not necessitating a change in therapy, when the results come in, I annotate a message to the effect "no new intervention required" and when the patient calls, my staff immediately gives the inquiring patient that message without a second call back. We let the patient know it is our expectation that they will call us for all lab results not preceding a scheduled appt - that way if they don't call, we don't worry about not informing them of normal results, and just chase the abnormals. I'll use this method as well for patients wanting to avoid a second copay where the patient and I were just seeking the reassurance of normal results ruling out a rarer cause of a more common self-limited problem, and for infrequently seen patients for routine physicals whose labs almost always return normal. When unexpected abnormal results return, my staff call the patients to schedule an appointment to address them.

We use the same approach for prescription refills. At every visit, the appropriate interval f/u is recommended, and all prescriptions needing refilling before that f/u visit are done before they leave. In this way, we try to minimize calls for refills to only those patients who elect not to make a recommended interval f/u appointment - and those patients are told they need to be seen. We also do not give out our fax number to any pharmacy or accept calls from pharmacies for refills - only from patients. 99% of our pharmacy calls are for expired prescription numbers that have already been renewed at a recent visit and are in the pharmacy's database, but the pharmacies uniformly don't bother to check. Most of the time the patient has already picked up that renewal and it is just an automated fax trolling for a refill not requested by the patient. I deny every NewCrop refill request with the response "have the patient call". I also try to synchronize all prescribing of medications for stable problems to once a year on the same date, and any later added medications are refilled just enough times to synchronize with that yearly refill date. Of course it doesn't work every time, but we have cut our phone calls and faxes by a lot. The challenge is to educate the patients to tell the pharmacy to check for the new renewal, not old prescription number.

We used to respond to those refill faxes. Now we have an electronic stamp that says "please check original number of refills. If no more refills, patient must contact office." After sending the fax back to the pharm, maybe half of those patients actually call to ask for a refill. I love cutting down unnecessary work.

I am planning to respond to this later in between patients, but I want to say I am very interested in how these processes work. I hope many log in to share their strategies. If we learn from each other, and what is really possible with workflow, we may all be able to improve efficiency. I get several refill requests per day for which I must respond. I used to have a goal to only refill at appointments, but practically speaking, I have never been able to make this work. The above gives me new hope. I worked at an office as a resident where a sign was posted that refills would only be given in the office. I know other doctors that spend hours every day on these kinds of tasks. It is minimal for me, as I used NewCrop, but an improvement would be welcomed.

I would echo almost exactly the well thought out response of SoCalFP. I have found it much more efficient to order the labs in advance of a routinely scheduled follow up visit, so that the patient and I may go over the labs at the visit, have a real time discussion about them, and make any adjustments to the plan before the patient leaves. This is much easier than trying to track down the patient after the visit, and much more convenient than having the patient come in for a follow up visit to go over the labs.

Like SoCalFP, I think about the interval for the next follow up visit before the patient leaves my office. I think about what tests need to be ordered and give them a lab order sheet. I tell them to get the blood work a few days prior to their visit with me. Our lab keeps the blood work in the freezer for 6 days before discarding, so if a test needs to be added, it can usually be added on to the blood work that has already been done, rather than collecting a new sample.

That being said, it is sometimes the case that we have to send the patient for new blood work if a new issue presents itself at the visit.

If it is a new patient, or a visit for an acute problem, we usually do not get the blood work in advance of the visit.

Most of my patients like this system. Since they have been doing it for a while, I think going back to the days of getting the blood work at the time of the visit would seem strange to them.

With regard to prescription refills, this is still a problem at our practice. I do not try to coordinate the refills with the visit. I tried to do this, but I think this is almost impossible for a whole variety of reasons. My philosophy is not to charge a fee to refill the Rx, though other practices do. For me, as long as the patient is current with their visits, I will do the refill. My preference is for the patient to call the pharmacy directly for refill requests. This part of it solves the issue of the patient calling our office when they still have active refills on the prescription. If there are truly no refills, then the pharmacy sends an electronic (usually) or faxed (less frequently) request to us. These are somewhat cumbersome, but still much easier than the old days as they come in the refill request que of AC and can be dispensed with in a few minutes.

I am curious to hear what others do.

When possible for scheduled visits it is much better to get the labs drawn ahead of the visit. Better to discuss the results face to face than on the phone later. If meds need changing or more patent education, this works best.

Obviously does not work for everyone, some labs needed for acute problems or some patients have trouble with travel and we do everything we can at the visit, but then chasing down lab results later is harder.

As far as refills, I try to keep them refilled at the visit but will refill them outside of a visit. For compliant patients will try to give them a years worth of refills. Other patients may not show up if the don't need to come in for refills and we use that leverage.

Greg

I think this lab draw issue is most interesting. One caveat is that I draw all the insured patient's labs in the office, as we make some money on these, and most of the Medicare patient's labs at the hospital, as we are not reimbursed and it takes a significant amount of nursing time to draw and process. I see two scenarios:

#1
Mr. Jones comes in on Tuesday for a blood draw only. I have to have the orders in ahead of time and think about what needs to be drawn. Doing this at the previous visit may save time. If it is a Medicare patient, they may lose the order sheet, or forget to have them pre-drawn completely. On Thursday, Mr. Jones comes in and we do his annual exam and review the lab results in hand. He may have additional complaints that would prompt a second needle stick and labs, and results may require yet another follow up.

#2
Mr. Jones comes in on Tuesday for his annual exam. We review labs from last year and add any additional labs needed based on complaints or concerns. We draw blood before he leaves. On Thursday the nurse calls and tells him all the labs are normal, or perhaps we send it to the portal. (Patient being computer literate is always an open question.)Or, he has abnormalities and the doctor calls to discuss, or we set up a follow up visit to go over abnormalities and possible treatments.

Does this summarize the options well? I am looking at benefits and problems with each.

Thanks for the insights. I can see a couple of differences. For one, I rely fairly heavily on the patient portal to discuss results (90% normal, or no change needed) and field limited questions. I don't get paid for this, but figure it is an extention of the initial visit. Surprises do warrant a separate visit, true, but I like that; it lets me shift mental gears to address the problem. The vast majority of our patients use the internet, so this works ok. There are some outliers.

That said, I may try it again. I do give lab slips for advance labs when I know for sure I will be needing it, or have the patient call to get a slip, e.g. for a hemoglobin A1c. I just don't think I can do as Mike suggests and review the chart a few days ahead of time. I am resistant to doing the same job twice and getting paid once.

We don't do many phone prescription refills. We are pretty meticulous about giving the amount of medication needed before the next visit. When a patient decides (s)he wants to change pharmacies and have all 12 prescriptions re-written, I usually ask for a visit to review medications. I don't feel that having an insurance company find a way to save money should cheat me out of reimbursement for honest work done.

I completely agree with the sentiments of dgrauman with regard to all the refills, especially if a patient decides to change pharmacies midstream. I just haven't had the fortitude to follow this practice in my own office.

David,

A couple of extra thoughts I had, oftentimes for the annual wellness visit labs I will right click on the name under summary and look under all of the diagnosis codes to make sure that I have the appropriate diagnosis codes to order a hemoglobin A1c, TSH or lipid panel, which requires no additional review of the chart. Also we primarily use Quest and send the orders over electronically to the phlebotomist whether they are Medicare, private pay or private insurance. In the best of all worlds, ideally, I'd like to get the lab drawn 2-3 days before the visit, send the results through the patient portal so the patient can review and come up with any questions they may have at the time of the visit, and if we need to add any additional labs Quest will hold the blood work for a total of 7 days so extra lab work can be added without an additional blood draw most of the time.

I use the Gestalt method with refills. If I see the name for a request, my little inner voice will tell me if they need to come in or not, which is usually confirmed with a quick check when the last visit was. The frequent flyers that keep the place open, usually do not require a cursory review.

I also have patients do the labs 1 week before their follow up visit, based on "today's" visit. I give them the form or post it to Updox (this decreases the "lost form" phone calls) The can print them from Updox as needed. However I do not post the results prior to the visit as I have some patients that would then cancel their appointment and try to discuss them via the portal.
One benefit is that if there is an abnormal lab such as a newly elevated glucose or TSH I often have time to have the lab add an a1C or T4 prior to the visit, making the visit more productive.
Interestingly some patients have the lab send them a copy of their labs, which they bring to their visit.
Most of my patients are now used to my system and get the labs done as I request.

Theo also touches on an interesting point...

I am continue to prevaricate on how to integrate electronic communication into my practice. On the one extreme is the government hype that much of what we do can be done without an office visit; I can, for example, train my patients to take their own blood pressure, and could easily adjust medication by remote control. But, of course, there is no reimbursement for that. Still, if I think of myself as the patient I would certainly appreciate not having to take time from work to sit in a waiting room for a 15 minute meet and greet that I could have done in the evening from my laptop.

I guess if we are all eventually on salary this will settle out. But, I have to say I do feel a little guilty having a patient miss a good portion of a day's work for something that really could be handled by e-mail.

David, just for clarification I was actually referring to patients that have multiple labs such as their yearly labs done, and then want to discuss them over the phone rather than come in for their physical. For follow up of a particular lab I may post results on the portal, often with a brief note (example - "Your TSH is now normal with your new dose of synthroid - print the lab form that I have posted and repeat it again 1 week before your next appointment in x months").
Some patients can have part of their care managed by using the portal, and some I bring in. It is based sometimes more on the patient than the actual care. I would compare it to how some patients can follow a sliding scale to titrate up their daily insulin, while others (not based on their age) never seem to get it right and need to be seen more often.
Using the EMR with Updox I find that I am continually refining and adjusting how I practice in order to balance my schedule (and actual income) while maintaining our patient load (and potential income), as I see what works and what does not work (i.e. the usual trial and error system).

Hi everyone,

This is a response to David's original question, which started this thread.

I am approximately 50/50, concerning labs in advance or ordered at the visit. Will I echo David's sentiments, my ability to predict the labs needed at the time of the next visit is sometimes good, sometimes not.

How ever, I also have a very practical concern with ordering labs four or six months in advance. Very often, the patient will lose the order, and call a week before the visit requesting a new order. I find reprinting an order very cumbersome and time-consuming. Perhaps if AC had a two click process to reprint the orders, I would do this more frequently. If I'm missing something, please let me know, but I pull up the last note, and reselect the tests, one by one, then reprint the order.

If labs are ordered at the visit, I typically send patient a brief letter with results and recommendations. I may be the only AC user left not using Updox. My patient population is much older, and I think the percentage willing to go online for results would be rather small. So we actually mail a paper letter to them. The letters typically will be three types.

First, is a simple "Everything was excellent", and I typically will list values for sugar, total cholesterol, HDL and LDL.

The second is a letter with simple instructions. "Your thyroid was low, please increase your thyroid medication from 88 ?g to 100 ?g, and have repeat blood work in two months. I enclose a prescription for your new dosage, as well as for bloodwork in two months."

Finally, for a complicated issue, "Your A1C is very high at 9.5. Please schedule an appointment at your earliest convenience so we can discuss this further."

Gene

Part of my question was triggered by several articles by Christine Sinsky MD from the Institute of Medicine relating to maximizing efficiency and pleasure in practice and published in the Annals and elsewhere. She strongly encourages the "lab ahead" method. However, she also encourages the use of an RN rather than a medical assistant to handle a lot of basic decision making, and has had the good fortune to have hired some talented help that could do things like figure out the needed labs autonomously. Although our MA's are good, that sort of decision making is largely beyond them and our talent pool is not that big (nor our budget). That task does seem like something just begging to be delegated.

Mike,
You're brilliant!! I already order labs the way you do. I love the idea about your prescriptions because that way the fax isn't cluttered up with refills unless the patient really needs them. Some of the big chains that start with W send out requests for refills on medications every month whether the patient wants them or not. This can be problematic and can end the patient up with 2 or more meds in the same class because the older medication was not cancelled.

How much of your telephone time does this take. Seems so much nicer to be dealing with the patient instead of the the big box.

Thanks for taking the time to share your experience.

Do you have phlebotomy inhouse? That helps so much.
Even for annual exams, if you have the labs ready for the visit, after that visit, you should be OK. Our patients get a copy of their lab order so they know if there is something else that is bothering them, they can call us and we can add it on.

Vicki, we do have a phlebotomy station in the building.

Reviewing all your answers, I think for me it would be a wash which way I go. I can 1) put in the time to review the chart ahead of time, order labs ahead and review at the visit, or continue with 2) don't review the chart ahead thereby not wasting time on no-shows, order lab at the visit, then spend the extra time to send a good explanation with a lab copy via UpDox the next day, and have occasional surprises that need a repeat visit.

And Mike, you are spot on on the refill issue.

These interchanges are so helpful for managing my practice

Do you also only give refills at an appointment?

Not 100% rigid... there are exceptions... but yes, in general we try hard to give the correct quantity and refill at an appointment time. No more refills = we wanted to see the patient again.

This is our policy

Rough estimates:
Each day I get about 2 Newcrop refill requests which I deny without looking at them, with the reason "have the patient call".

I probably overhear my receptionist fielding a call from a patient resulting from the denial about every other day - granted I'm in exam rooms not listening all the time.

Every such call from the patient is a welcome opportunity to (re)educate them to ask for the new renewal we previously sent, not old prescription number, otherwise we can count on such pharmacy requests ad infinitum. Or if they are overdue for an appointment, gives us the opportunity to capture an appropriate revenue generating visit. It also allows the few patients who just want refills for life without the expense of ever coming in to decide to move on to someone elses practice and open room for new patients whose expectations are a better match for the service we offer.

I'm guessing some pharmacies ignore my denial without contacting the patient, some contact the patient who remembers our last instructions and solves the issue themself, and a few call us as above.

I'm hoping some pharmacies will reflect that this is a hassle and look for the renewal previously sent instead of just sending a request for an expired prescription number.