CLN - Focus on Laboratory Stewardship
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They go by many names – MISCREF, miscellaneous test, MISC - but regardless of what you call them, miscellaneous tests present a unique challenge to laboratories. Providers need a mechanism to request a test that is not defined in your institution’s laboratory information system (LIS).
However, these requests are wrought with challenges due to lacking or unclear information in the order. Miscellaneous orders often confuse everyone: the phlebotomy team who must navigate the appropriate sample collection in a timely manner; the laboratory send-out team who must process the request and determine the appropriate reference laboratory to perform the testing; and the ordering provider who must write a free text entry field, which can lead to order-entry errors.
Here, we describe three different ways to improve how laboratories handle MISC orders.
Using Epic’s “follow-up worklist” feature, we created a hold process for two types of orders: miscellaneous lab request and miscellaneous – genetic test request. Both require review and approval from one of four genetic counselors or one of four doctoral level consultants before coordinating.
After the order is placed in the follow-up worklist, the send-out staff create an entry in a separate web-based application. The orders then enter one of two review queues, depending on whether they are designated as a genetic or non-genetic test. The reviewer evaluates the test for order errors and medical necessity, including whether the test built, if it is a preferred lab, whether preauthorization is required, and if we approved this test before. If it is a new test, we ask the provider to complete the new test request form for additional evaluation and we discuss it at the Lab Stewardship Committee meetings.
We evaluate approximately 80 cases per week, with about a third of those being non-genetic requests. About 75% of cases are approved as-is, and for those that are modified or canceled, the most common modifications are updating the reference lab or recommending an alternate test.
The MISC test process at Kaiser Permanente Northwest has evolved over the years. It’s now a much more streamlined process than it was in earlier days. Like the example above from Seattle Children’s, it also relies on an Epic software feature, but with a few twists.
When a Kaiser Permanente clinician orders a MISC test, an alert immediately fires in Epic telling them that the test needs to be reviewed by our Lab Utilization Action Team (LUAT) (Fig 1).
An Epic message then drops into our lab client services shared email pool. Our client services team evaluates the MISC order and determines whether the order is on our formulary. Our formulary is simply a shared Excel spreadsheet listing all our approved send-out tests and which departments are authorized to order each test.
If client services finds that the requested MISC test is on the formulary, no further action is needed and the lab processes the test. If the test is non-formulary, clients services emails our lab genetic counselor if it’s a genetic test or to one of lab directors for non-genetic tests. These reviewers will either approve or deny the request and send the decision back to the ordering clinician using an Epic message.
We receive approximately 600 MISC tests per month. Of these, roughly 25 per month are non-formulary and require review. In 2024 we cancelled 14.8% of our non-formulary, non-genetic MISC test orders as ‘not medically necessary’ and redirected 9% to more appropriate labs. For the genetic tests that required review, 24% needed intervention and were modified.
Another approach to managing miscellaneous requests is to reduce their overall burden by building more tests. At UCLA Health, the lab recently began retrospectively reviews of miscellaneous send-out test orders to identify new tests for inclusion as discrete orders in the electronic health record (EHR).
The process began with preparing a report of MISC orders placed in the previous calendar year. The lab then delegated the 100 most frequently ordered tests to faculty subject matter experts in the laboratory medicine division for review. This expert group included faculty from clinical chemistry and immunology, toxicology and therapeutic drug monitoring, and microbiology, among others.
These experts provided feedback about the general appropriateness of the tests and whether there are any comparable tests already available, either in-house or built in the EHR to go to preferred referral laboratories.
In 2024, the lab used this process to identify and build 37 new discrete send-out tests in the EHR. Providers who had previously ordered those tests as MISC received targeted e-mail notifications about the newly built tests.
UCLA Health plans to continue this retrospective MISC review and new test build process every 6 to 12 months, with a goal of reducing MISC test volumes to the point that the lab can reasonably review the orders in real time. While a separately available “miscellaneous genetics” test order has not been included in this process, those orders are already reviewed in real time by our molecular diagnostics laboratory directors and laboratory genetic counselor when they are ordered for inpatients.
Separately, we have established a process for providers to request new send-out tests to be built in the EHR. This process helps us to identify newer tests that are not yet identified by our retrospective review process of high-volume tests. The requesting provider must first fill out a digital request form with basic information about the test as well as general medical justification and intended patient population. The UCLA Health Laboratory Stewardship Committee reviews these requests for approval decisions and EHR build prioritization (1).
There is a twist on the old adage that says, if you’ve seen one way to do something, you’ve seen one way. That sentiment certainly holds true for the manual systems required to handle undefined tests.
However, these three examples share common elements, including having medical director oversight in defining a review process and a specific process for first-time requests. Perhaps more comforting is knowing that this is a common struggle, and we can learn from each other on how to manage the miscellaneous lab requests.
Most importantly, in our experience, such systemic approaches help ensure patients receive the best testing for their unique circumstances while avoiding financial toxicity from potential miscommunication with payors.
Kevin Foley, PhD, DABCC, MT(ASCP)SC, is the director of clinical pathology at Kaiser Permanente Northwest in Portland, Oregon. +Email: [email protected]