The laboratory is a key ancillary with a large amount of data that can be incorporated into population health management (PHM). With an understanding of PHM, the lab can play a more active role in communicating results and coordinating care. The lab is the “gatekeeper” for patient data that can identify patient populations that can benefit from screening tests or require chronic disease monitoring.
POCT Increases Patient Engagement
One area where laboratory professionals can contribute to PHM is in the oversight and proper implementation and integration of point-of-care testing (POCT). It is widely recognized that POCT, in the appropriate scenarios, can improve patient satisfaction and patient engagement. Because patient engagement is vital to an effective PHM program, it is prudent for a healthcare organization (HCO) to rethink where POCT can best serve its patient population, and to make sure those results are integrated into analytics for PHM risk stratification. Laboratorians have an opportunity in regards to POCT implementation by being the expert voice that aids in deciding when and where POCT can have a positive influence on an active PHM program.
Help Providers with Quality Measures
The shift in provider reimbursement also creates an opportunity for labs to help providers meet quality measures, simultaneously improving quality of care for patients. The lab is “data rich,” and therefore has much to contribute to quality reporting. Labs can use their LIS to collect population-level data to support PHM and QPP measure reporting for providers. Specific measures in the quality domain involve determining if clinical services, such as lab testing, and preventive services are used properly so that improvements in population health occur. Included in this domain are process measures that focus on prevention of disease by screening for early detection. Laboratories can use LIS data to determine patients for whom preventive testing would be beneficial based on evidence-based guidelines (e.g., identifying women eligible for HPV screening by age groups).
Lab Analytics for PHM
A fully integrated LIS-EHR combined with claims data can be a foundation for the risk stratification and predictive modeling process. The LIS provides a vital connection between the EHR’s CPOE process and the analyzers and then back to the EHR, with a vast amount of patient clinical data that has been carefully processed and assessed for quality and accuracy that is important for population health analytics. Data stored in the LIS and communicated to the EHR in a structured manner can be extracted and manipulated to generate analytics that provide insight to the population’s overall health status and to earmark certain populations with diseases that require more expensive care.
For those in early stages of PHM development, lab data can pinpoint high-risk patients that can benefit from follow-up care (e.g., patients with Hgb A1c greater than 9) and match them with a care coordinator who can connect with the patient. Taking the consultation concept a step further, laboratory professionals who are experts in lab test orders and results can be integral in the development and implementation of appropriate EHR reminders that identify opportunities for preventive or follow-up care. To be most effective, data must be integrated and formatted into useful analytics and displayed for the provider in the form of decision support tools and risk stratification. The lab can be involved in committees that determine appropriate evidence-based clinical decision support rules and decide which EHR alerts are appropriate.
Key areas where the laboratory can support a PHM program include development of analytics and algorithms that involve lab results; involvement in POCT implementation where it can support patient engagement; as clinical consultants and/or active members of a PHM team defining EHR rules and other triggers to identify patients in need of care management attention; and by supporting providers in Quality Payment Program (QPP) measure reporting (see Figure).
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