Airtight order entry: How an oversight led one pathology group to upgrade its ordering system
Delane A. Wycoff, MD
"Dr. Wycoff, we don’t like your
computer ordering system!" It was Julie, the lab manager in a clinic about 100 miles away for which our laboratory provides reference testing services. I had asked Julie if she was happy with the direct computer ordering system we had recently set up in her lab. Julie’s disappointment with the system was troubling. Where had we gone wrong?
Our pathology practice serves numerous clinics and rural hospitals within a 150-mile radius of North Platte, Neb., and covering parts of Nebraska, Kansas, and Colorado. Testing is performed in our local hospital lab or our independent reference lab, which are linked together through a laboratory information system interface, permitting referrals in either direction. These labs are also interfaced to outside testing sources at university and national reference laboratories. The clinics and hospitals that we serve have been receiving all of their clinical pathology and anatomic pathology reports via direct teleprinter services for 22 years. We recently had begun providing direct electronic reporting interfaces to medical records systems in some of these clinics.
The impetus for our direct computer
ordering system was a need to improve on our manual paper requisition process for ordering lab tests. We had ongoing problems with illegible handwriting and incomplete information on the paper reqs, which we felt might improve if we put computer ordering in the hands of our customers. We had done this with apparent success in three clinics and one hospital before providing Julie’s lab with the same service.
When we set up Julie’s lab for direct computer entry, we provided the same computer screens and ordering functions used in our own laboratory. The ordering screens looked like ours—character user interface, or CHUI, screens running on a telnet session. These entry functions worked well in our lab, but some of Julie’s staff refused to use them. We soon realized that the screens worked well in our lab because they were ideal for "heads-down," high-volume key entry, and our staff processed hundreds of orders per day. However, they were not user-friendly for our clients who did not spend all day doing this type of work, such as Julie’s lab. Julie’s staff expected graphical user interface, or GUI, screens with features convenient enough for novice users.
I invited Julie and her staff to help us develop a better system. Using suggestions from her lab and other laboratory clients, we developed ideas for a direct ordering system using Web browser technology. We already had a secure Web site for looking up lab results. This was the nudge we needed to complete our previously planned lab-ordering capability. We implemented a new Web-based ordering service in 10 weeks. We then spent four weeks refining the system, which has worked successfully for the last 10 months.
The new system was easy to use.
Nurses and laboratorians needed less than an hour of orientation, usually over the telephone. Some of our clients had even begun using the system successfully without any instruction from us. Furthermore, customers used words like "neat" and "fun" when describing their experience with the system. In fact, the system proved so easy to learn that we are now training our own new employees on Web browser-based ordering in lieu of traditional order entry.
We also benefitted when outside clients ordered directly from our Web site. These pre-ordered requests were processed more efficiently, requiring only entry of "date/time of receipt" to complete the request.
Additional benefit was gained by our billing office. With improved validation of billing information during order entry, billing workload and the volume of phone calls requesting billing information declined. When our billing office lost two employees, the billing manager announced that there was no immediate need to replace them.
Design decisions focused on customer convenience also contributed to our success. We view the direct computer ordering process as optional. We tell clients not to use it unless they find it helpful, and we emphasize that we will always accept paper requests.
Why did our laboratory clients like the new system?
- It was faster, on average, than paper requests.
- It simplified the lab request process.
- It had fewer problems than the old system.
We achieved "faster" in several ways. We designed for the worst case scenario—that is, users with a dial-up modem connection. We kept our screens fast, despite slow connections, by designing Web frames and pages with no images.
Using pure HTMLkept the data thin and the responses snappy. We also avoided using .pdf files for computer-generated specimen packing slips and advance beneficiary notice, or ABN, forms. (While commercial vendors of Web-oriented lab-ordering systems sometimes use this technique, we found it unnecessary and counterproductive when speed was the objective. It is possible to exactly duplicate the government-mandated ABN form using only HTML if clients have arial and arial narrow typefaces on their computer and appropriate margin settings on their printer.)
We also minimized keystrokes and mouse clicks and avoided unnecessary page changes. We prepopulated all patient demographics and insurance information whenever previous information was in our database. Because 80 percent of our testing is on returning patients, this feature alone made the computer ordering process faster than handwriting a paper request. Furthermore, we included such features as a check box to duplicate addresses from responsible party to patient or vice versa; client-specific pull-down menus for ordering physicians; client-specific and physician-specific pull-down menus for the most commonly ordered tests and most frequently used diagnosis codes; two- or three-letter abbreviations or zip codes to designate city, state, and zip code; and acceptance of almost any date format, including T (today) or T-1 (yesterday).
We made the ordering process easier by giving users options for key word text lookup of insurance company codes, test codes, and diagnosis codes. The desired selection could then be entered automatically with a single mouse click. Test lookup displays were further enhanced with information on specimen type and testing location and a Web link to the online directory of services. If the test was sent out from our laboratory, it was linked to the reference laboratory’s Web site to display that lab’s directory information for the test in question. We provided special pages for ordering Pap exams, non-gynecologic cytology, and surgical tissues, which streamlined entry of these requests.
Finally, our direct-entry process was better because we checked information during the ordering process to assure that billing information was complete, Medicare or Medicaid numbers were valid, insurance ID numbers and group codes were in the correct format for the most frequently used insurance companies, and additional requested information, such as urine volumes, culture sites, and patient weight, was included. We initially received a few concerned comments from users regarding their need to provide information that they had previously ignored, but the immediate feedback helped them to learn quickly, and they soon recognized, and appreciated, that this led to fewer phone calls from our laboratory seeking missing information.
We also made sure that we requested only pertinent information. In one case, due to an initial oversight, a customer was quick to remind us, "You shouldn’t need that information on this order." We immediately corrected our ordering rules.
Online checking and validation of Medicare medical necessity are now offered as well. The ease of this process and the immediate feedback on passing and nonpassing codes were praised by users even before they discovered that the system allowed them to print a completed ABN form. We also provided users with a secure "lab only" messaging service on our Web site. This allowed users to easily exchange information protected by the Health Insurance Portability and Accountability Act and provided an easy way to answer questions that didn’t warrant a phone call. Fur thermore, we included a Web-based method for ordering lab supplies.
We achieved success
with our direct order-entry system because we listened to our customers. For example, one of Julie’s first complaints was that a stool specimen with orders for culture, ova and parasites, and Helicobacter pylori antigen required three separate orders on the old system. Consequently, we made sure the new Web service allowed any combination of testing on the same specimen. We continued to use operator feedback to tweak or enhance the system. What we learned during this process applies to hospitals that want to implement Web-based lab orders for outreach services and to reference laboratories not yet providing Web-based direct ordering.
Anyone considering a Web-based enhancement to their system, or middleware that provides similar functionality, should keep in mind that:
- Busy people don’t have time to wait—speed is everything. We made sure our system ran at an acceptable speed, even when limited to low bandwidth. The system operates satisfactorily on a laptop connected by cell phone modem and operating at a data rate of only 19.2 kbps. This data rate would be intolerably slow for most pages found on the Web, but it is fully adequate for our image-free pages. This means that users with broadband connections enjoy almost instantaneous response times.
- Efficiency and convenience are paramount. We streamlined and provided convenient features whenever possible. These features were not necessary to operate the system successfully but were easy to learn and helped users become more efficient. We also minimized page changes to maximize efficiency and clarity.
- Getting information right the first time saves work for everyone. We applied a rigorous set of client-specific validation rules to our billing information, where applicable, in addition to the usual checks to validate dates, physicians, test and diagnosis codes, additional order information, and medical necessity checking. Consequently, more than 95 percent of our orders passed from our lab system to electronic claims submission without being reviewed by the billing department. The reduction in phone calls to clients as a result of incomplete or incorrect billing information was as much a boon to our customers as to our own laboratory.
- Users readily accept a system that makes sense. Conversely, they will reject a system that encumbers them with functionality they consider unnecessary. A system must give users sensible responses, including help for user entry errors, or it will be ignored.
We have been seeking medical
clinics and hospitals that are interested in implementing a direct ordering interface with their medical records system. Direct, or computer-to-computer, links can be an even more efficient way of handling lab requests, particularly patient addresses and insurance information. Yet we’ve had no takers.
Even though some of our clinic-based customers like to receive lab reports electronically, they seem reluctant to undertake an ordering interface. It appears that it is easier for them to print a computer- generated label request or a label they can affix to a paper request. Even so, at least one of the clinics that used printed labels on paper requests has opted for Web-based ordering.
In summary, our experience with direct Web-based ordering of reference lab testing by clinics and rural hospitals has been invaluable. Web pages that are functional and well designed are more appealing to clients than are paper requests, and they offer greater efficiency and fewer errors. More importantly, Web-based technology makes direct ordering readily accessible to a broader scope of laboratory customers than systems that depend on computer links, while providing many of the same benefits.
Dr. Wycoff is clinical pathologist, Pa thology Services PC, North Platte, Neb.