An Automated Clinical Laboratory Decision Support System for Test Utilization, Medical Necessity Verification, and Payment Processing

Physicians could improve the efficiency of the health care system if a reliable resource were available to aid them in better understanding, selecting, and interpreting the diagnostic laboratory tests. It has been well established and widely recognized that (1) laboratory testing provides 70%-85% of the objective data that physicians use in the diagnosis and treatment of their patients; (2) orders for laboratory tests in the United States have increased, with an estimated volume of 4-5 billion tests per year; (3) there is a lack of user-friendly tools to guide physicians in their test selection and ordering; and (4) laboratory test overutilization and underutilization continue to represent a pervasive source of inefficiency in the health care system. These inappropriate test orders not only lead to slower or incorrect diagnoses for patients but also add a significant financial burden. In addition, many ordered tests are not reimbursed by Medicare because they are inappropriate for the medical condition or were ordered with the incorrect International Statistical Classification of Diseases and Related Health Problems, Tenth Revision diagnostic code, not meeting the medical necessity. Therefore, current clinical laboratory test ordering procedures experience a quality gap. Often, providers do not have access to an appropriate tool that uses evidence-based guidelines or algorithms to ensure that tests are not duplicated, overused, or underused. This viewpoint lays out the potential use of an automated laboratory clinical decision support system that helps providers order the right test for the right disease and documents the right reason or medical necessity to pay for the testing.