The Impact of Poorly Designed Test Requisition Forms

As a healthcare information technology leader, you face many challenges with the collection and processing of data. While meaningful use standards have increased the adoption of electronically delivered health information, the industry is still trying to catch up to the ever-changing landscape. Most IT leaders assume the main challenge with test ordering is technical – chasing the never-ending dream of 100% electronic orders. With petabytes of data being streamed to the cloud, filling data lakes with information for big data analytics, it's no wonder we think our main challenge is of a technical nature. Although the genomic industry is exploding with endless amounts of data, the biggest data challenge is not digital, it's physical.

Paper is your problem!

The Test Requisition Form

Every specimen entering your lab includes an often overlooked, but important piece of paper – the test requisition form. This form contains critical information about the patient, ordering physician, ordered tests, and insurance data. Properly designing your requisition is a balancing act between capturing enough information and encouraging completion and accuracy. A poorly designed requisition form can lead to laboratory inefficiencies, compliance concerns, customer dissatisfaction, billing denials, and worst of all, medical errors.

As of now, the burden of filling out these forms has been put on the ordering physician, as a quick-fix solution. This is because the physician is busy and doesn't have time to complete a complex five-page test requisition while the patient anxiously awaits care. Furthermore, rapid developments in knowledge and the information available create constant challenges in the laboratory and for ordering physicians.

It's no question that there are a number of hurdles to consider when it comes to the test requisition form.

The Challenges

The paper requisition or it's digital representation serves as the entry point to your business. There are eight main challenges that must be addressed.

1 - Missing Information

At a fundamental level, there are specific pieces of information you need to collect before you can analyze a sample. Garbage in, garbage out! Missing or incomplete information can lead to false or misleading data, misidentifying a sample, and other laboratory inefficiencies.

2 - Incomplete or Unclear Information

Requisitions are not electronic and have no way for you to enforce required fields for mandatory data. The requisition could be missing a date of birth, patient name, or other necessary information. Even if the information is filled in it can be difficult to clarify ambiguities in handwriting.

3 - Inherent Complexity

Today's testing is more complex than ever. Communicating the vast available options to the ordering physician is difficult. Beyond primary testing options, is the reflex testing process clearly outlined? Are you able to communicate which data is necessary to perform the test?

4 - Outdated Delivery Methods

Even with all the existing technological advances, a test requisition can be delivered with 40-year-old technology via a fax machine or traditional mail. A human completes a paper requisition with no way to enforce proper procedure. Let's move away from using fax machines! The problem is faxes have unique properties that can be hard to replicate with alternative delivery methods. For example, some countries will not allow digital signatures and require a paper copy. When compared to email and other digital delivery methods, faxing is difficult to spoof. These characteristics make faxing an appropriate solution for HIPAA compliance.

5 - Compliance Pressure

The industry is shifting the responsibility of medical necessity to the clinician and the laboratory requiring additional information to be present or collected on the test requisition. Finding space to add Current Procedural Terminology Codes (CPT), Advanced Beneficiary Notice (ABN) information, and Letters of Medical Necessity is difficult. All this additional information can be confusing.

6 - Limited Space

With limited requisition real estate, responding to advances in the industry and regulatory pressures are more difficult. The fewer the pages the better, but the need to collect more and more data makes designing requisitions that fit on one or two pages very challenging.

7 - Rapid Innovation

The industry is in a constant state of change. To remain competitive, you have to update your test menu frequently. Unlike making a change to your website, replacing all test requisitions at all of your clients can be a daunting task. Even if your customers are notified in a timely manner, you need to support multiple versions of the test requisition because you can't guarantee all were replaced– and you don't want to impact the expedited care of the patient.

8 - Time Consuming EMR Interfaces

Implementing an electronic interface is a lengthy process filled with many idiosyncratic requirements different between vendors. Proper implementation of a fully integrated electronic interface can take a year to implement. During this time, the business is losing money and the patient is unable to receive the best care possible. This makes the paper requisition equally important to the forthcoming EMR interface.

The Impact

All eight challenges lead to problems. To stay competitive, you need to find a way to keep up with technology while continuing to provide safe care. While filling out the paper requisition may be easier for the ordering physician, it can cause a series of challenges throughout the process when compared to electronic methods.

Implementing timely, 100% accurate, electronic health records is the goal. However, the rapidly changing test compendium and constant technology breakthroughs make it nearly impossible to accommodate all of the available electronic medical record systems. Although electric interfaces are the ultimate goal, a lot of providers will continue to use paper, requiring labs to have a dedicated team inputting information into a Laboratory Information System (LIS). By having human touch points, you introduce the opportunity for errors.

When data is inaccurate, misleading, or missing altogether, it can:

• Block the ability to process a sample altogether

• Lengthen turnaround times beyond industry standards lowering competitive advantage

• Increase denials and complicate the reimbursement process

• Order and run a test unintentionally

• Add additional compliance risk to the business

• Affect the delivery of timely and accurate results impacting patient care

• Create conflict with ordering physicians due to constant follow-up for missing information

• Result in a mislabeled or lost specimen

• Complicate Quality Control and Data Analytics

• Expand the complexity of reporting

The Solution

The goal is simple. Create an easy-to-use requisition form that can be completed in minutes while meeting all quality and regulatory demands. Easy enough, right?

The first item to address is that human involvement can enhance the overall user experience. You should apply the same principles to your test requisition form that you apply for the user experience of your web page or internally developed systems. You can never eliminate the overall complexity of test selection, however, you can turn it into a competitive advantage by creating clear and engaging test requisitions for our clients. To obtain usability and completeness, you need to request enough information while not overwhelming the ordering physician. By extending your user experience to the requisition you can turn your requisition into a business advantage.

• Ensure patient demographics fields are clearly marked

• Clearly identify diagnostic information fields

• Highlight any missing data that could block a sample from running through the laboratory

• Encourage the ordering of specific tests and panels by locating them in prominent areas of the requisition

• Ensure all barcodes are legible when scanned or sent through fax machines

• Eliminate all unnecessary information

• Limit the number of available options while also limiting the amount of test write-ins

• Avoid the use of paper requisitions by transitioning to a web-enabled form

Following these guidelines will help you get the most out of your requisition forms. Look around and compare forms from different companies and you will find not all forms are created equally. Which form with your customers choose?

What's Next?

It's important to know that paper and electronic interfaces are here to stay. The second realization is that both will continue to change. The look and feel of paper requisitions will adapt as the industry changes. Data formats and information interchanges will be updated to support new testing methods. With this in mind, you can increase the usability and accuracy of each. Digital isn't the only future - don't forget to innovate on both types of data collection methods.

The next evolution for paper is to offer print-on-demand custom requisitions for specific specialty groups or physical locations. These are tailor-made to the ordering practice allowing you to hyper-focus on the needs of the client. By doing so, you help eliminate bad practices and encourage good practices. The requisition can contain only necessary data in a format conclusive to the ordering physician. In addition to helping collect accurate data, offering custom requisition can help maintain and strengthen business relationships by including your customers in the design process.

The industry continues to work towards better standards for exchanging healthcare information electronically. Be willing to implement and offer multiple industry standards from HL7 to the newer JSON-based Fast Healthcare Interoperability Resources Specification (FHIR). Standards are good but do not limit yourself to only supporting industry standards. Be willing to offer multiple options and custom data exchanges.

The overhead of constantly enhancing the user experience is worth it if it leads to more accurate and safe care for your patients.