Ordering Labs as a Team

THE INNOVATION

Assigning too many clinical tasks to the clinician creates excessive cognitive burden and diverts attention from other critical work, leading to less-effective processes and the potential for error. In our clinic, we altered our laboratory ordering process from a clinician activity to a team-based process to test this hypothesis and with the goal of improving our effectiveness and efficiency in ordering laboratory tests.

WHO & WHERE

At Iora Health, health coaches remain with their patients in the exam room throughout the clinician portion of the visit, allowing for an opportunity to document and place orders as a team. Health coaches are not required to have a specific background or certification; they learn on the job by extensive overlap in the room with clinicians. The innovation described here could be adopted by medical assistants in other settings.

HOW

The adoption of electronic medical records has altered the workflows and division of labor within health care teams.^1,2 These new workflows often rely on the clinician to perform multiple tasks, sometimes simultaneously. In many organizations, the clinician is responsible for entering a laboratory order into an electronic order entry system, either in front of the patient or after leaving the room.

Using plan-do-study-act cycles, we developed a team-based laboratory ordering process in our clinic. The health coach, clinician, and patient sit together as the clinician interviews the patient. If the clinician decides to order a laboratory test, she tells the health coach verbally what she’d like to order (which notably also gives the patient an opportunity to ask questions and be an active participant). The health coach initiates but does not complete the laboratory order. As the visit progresses and more health issues are discussed, laboratory tests may be added or removed from the laboratory order. Importantly, the health coach captures the intended laboratory test into an order as the clinician is having the thought of what test she’d like to order, decreasing the likelihood an intended test will be forgotten. For example, while discussing a patient’s hypothyroidism, the clinician decides she’d like to order a thyroid-stimulating hormone (TSH) test. The health coach immediately captures this order in the electronic system (and links the order to the proper diagnosis). As the visit progresses into a discussion of the patient’s diabetes, the clinician decides to order a hemoglobin A_1c test and a metabolic panel. This thought is also captured real-time by the health coach. When the visit is winding down, the clinician quickly reviews and signs off on the laboratory order created by the health coach.

Our health coaches were initially uncomfortable with being an integral part of the laboratory ordering process. After a weeks-long trial, though, they reported feeling competent at the process and more knowledgeable about laboratory screening in general. They began predicting which tests would be ordered under what circumstances, adding an extra layer of protection from the clinician inadvertently forgetting to order a test.

LEARNING

The success of this new process, like any team-based workflow, depended on the engagement of the team, so we adopted a “growth mindset,” assuming that team members would enjoy taking on new roles if they were learning and being supported. “When entire companies embrace a growth mindset, their employees report feeling far more empowered and committed; they also receive far greater organizational support for collaboration and innovation.”³ In our experience, a team-based laboratory ordering approach is more efficient, more effective, and more engaging to nonclinician team members than a clinician-driven approach.