Problem Addressed

• Growing desire to receive tests without office visit, physician order: Consumers report increasing interest in receiving certain laboratory tests and results without a physician office visit and order.¹ Several factors are fueling this demand, including convenience and financial concerns. Busy consumers often feel they do not have time to go to the doctor but would still like to monitor certain aspects of their health, such as cholesterol levels. In addition, many uninsured individuals and the growing number of people with high-deductible health plans may be deterred from seeking tests due to the added cost of the incremental office visit required to receive the order.²
• Failure of providers to meet demand: Although the volume of consumer-ordered laboratory tests is increasing by roughly 15 to 20 percent a year,² relatively few (approximately 10 to 15 percent) hospital-based and commercial laboratories offer this option to patients.³

Description of the Innovative Activity

• Order form with waiver: Patients can obtain the order form at a physician’s office (it's included in a brochure in the waiting room) or download it from Sentara's Web site. The form includes a checklist and description of available tests, instructions on how to obtain them, a list of testing locations, a waiver, and space for the patient’s mailing address.
  
  • Choosing tests: Patients check off the test(s) they would like from a list of approximately 20 routine tests often used to monitor health between office visits. Offerings include a basic and complete metabolic panel, blood alcohol level test, various cholesterol and lipid tests (total cholesterol, high-density lipoprotein, complete lipid profile, triglycerides), complete blood count, drug testing, glucose and hemoglobin tests, ferritin test, high sensitivity C-reactive protein test, pregnancy test, prothrombin time test, prostate-specific antigen test, thyroid-stimulating hormone test, urinalysis screening, and measurement of Vitamin D levels.
  • Waiver: Patients sign a waiver (on the back of the form) that includes the following: an explanation of laboratory blood testing and its limitations, a statement releasing Sentara from liability associated with the tests, an explanation of the patient’s responsibility to see a physician for a medical examination and interpretation of test results, a note explaining that results will be included in the patient’s electronic medical record (EMR) if available, and a statement emphasizing the patient's sole responsibility for seeking followup regarding results. The waiver also lists the toll-free telephone number for Sentara’s physician referral service.
• Payment and specimen collection: The patient takes the order form to a testing location. Because third-party insurance carriers typically cover only tests ordered by a physician or other provider, patients generally must pay out-of-pocket for the tests; costs range from $9 to $54. Patients currently pay at the testing location, although Sentara is in the process of upgrading its Web site to allow online payments by credit card. After paying for the test, patients have their blood drawn for the test(s) they would like.
• Results reporting: All patients receive the results in the mail. Those who subscribe to Sentara’s patient portal (called MyChart) can also retrieve results online. These communications emphasize the importance of patients' sharing and discussing all test results with their primary care physician and other health care providers.
• Personal call for critical results: For a defined set of tests, a Sentara pathologist calls patients with critical results that fall outside the normal range, indicating the potential for significant health consequences and the need for timely followup care. Not all abnormal results generate a phone call; for example, glucose test results that fall outside the normal range may generate a call, while an abnormal urinalysis result will not.

References/Related Articles

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Innovator Disclosures

Results

• Enhanced access for small, growing number of patients: In 2011, approximately 1,700 of the system’s 7 million laboratory tests came through the SelfTest program. Although a very small proportion of all tests, the number of self-referred tests continues to grow rapidly, increasing by 25 percent between 2010 and 2011, with year-to-date results suggesting a similar increase in 2012.
• Positive feedback: Patients who have received tests through the program report finding it beneficial and express gratitude for the ability to receive tests without first going in for an office visit or otherwise securing a physician order.

Evidence Rating (What is this?)

Context of the Innovation

Planning and Development Process

• Obtaining approval to explore idea: The laboratory director pitched the idea for the program to the executive in charge of laboratory services (her direct supervisor), securing approval to explore the idea.
• Consulting with legal department: The laboratory director consulted with the health system’s legal department to ensure that State law permitted self-referral for laboratory testing and to determine which tests could be included in the program.
• Reviewing similar programs at other sites: The laboratory director researched other programs across the country to identify best practices, such as requiring patients to sign a waiver. She used her findings to design the order/waiver form and then submitted it to the legal department for review and approval.
• Determining available tests and pricing: The laboratory director and other staff worked with several health system pathologists to determine which tests should be offered. A proposed list was then vetted by the system’s two pathology groups. The group set prices based on the cost to perform the test, typical third-party reimbursement, and the prices charged by other similar programs.
• Designing print materials: The laboratory director and other staff designed posters and brochures that included the menu of available tests, waiver form, and general instructions for patients.
• Estimating financial impact: The laboratory director conducted an analysis to estimate the financial impact of the program.
• Addressing process issues: The laboratory director and other staff outlined the ordering process and worked with relevant stakeholders to address related issues, such as testing site collection of payments, needed adjustments to the EMR, introduction of the form and process to laboratory staff, and mailing of results to patients by the client services department.
• Obtaining formal approval: The laboratory staff made a presentation to the health system’s executive team, sharing the order form, describing how the program would work from a process perspective, and reviewing the estimated financial impact. Medical staff executives at Sentara Norfolk General Hospital, Sentara’s flagship institution, formally approved the service.
• Marketing: Physicians learned about the service through health system newsletters and a monthly update letter. The public relations department sent out a press release to spread the word throughout the community, and program leaders made presentations to key executives at other Sentara hospitals and to large physician groups. Marketing continues on an ongoing basis; the system plans to use social media in future marketing efforts once online ordering and payment is available (expected in the third quarter of 2012).
• Ongoing review and revising of test menu: Program leaders periodically consider adding tests to the available options, often in response to requests from patients and physicians. Whenever they do, they poll physicians from relevant specialties to elicit their opinions and guidance.

Resources Used and Skills Needed

• Staffing: The program required no new staff, as existing staff incorporate it into their daily routines.
• Costs: The program required minimal financial outlays, either for upfront development or ongoing operations. Upfront costs consisted primarily of staff time to make adjustments to the EMR and patient portal, and the main ongoing expense is for printing the order/waiver form.

Funding Sources

Getting Started with This Innovation

• Address initial physician skepticism: Physicians may initially express skepticism about patients being able to request and receive laboratory tests on their own. To address these concerns, emphasize in internal communications the benefits of increasing patient access to testing services, the existence of other similar programs, the involvement of physicians (especially pathologists) in designing the test menu, and the program's reliance on personal contact with patients with time-sensitive or critical results.
• Prepare staff: Introduce the new system to all staff who will be involved, especially those who will have direct contact with patients who order tests. Staff should be made aware that these patients will come in with the order forms and pay for the tests, and that they need not show an insurance card.

Sustaining This Innovation

• Continually reevaluate test menu: Review the tests offered on an ongoing basis and evaluate requests from patients and physicians to add new ones. All requests should be reviewed in the context of state legislation that defines which tests can be self-referred.
• Use social media: Consider the use of social media (e.g., Twitter, a hospital Facebook site) to advertise the service to patients. These options were not available to Sentara when it first launched the service.

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