The Tests Every Practice Should Have

By Jim Poggi

When I began thinking about how to write the most pertinent and useful article on the topic of tests every physician practice should have, I obsessed over how to introduce the test menu. There are just so many good choices.

Then the light bulb went on. Trying to decide the list of tests every practice should have is like trying to determine who is the best doctor in town. It all depends on who the patient is, and what the clinical conditions that need to be treated are. In the end, practice specialties will be different since the types of patients and the typical healthcare needs of different patient populations they see will differ. This will determine the test mix to a large extent.

But, the constant is always the same. The tests each practice needs are the tests needed to initiate or modify a patient treatment program. I am so confident this is true, that I’m thinking of getting a tattoo of it.

If the clinical need of the practice was the sole decision criterion, life would be very simple. Every practice type would use the same tests every day, patients would be treated quickly and effectively on a timely basis, and we would all live happily ever after. But, life is quite a bit grittier than that.

The other classic parameters that come into play in determining the tests likely to be performed in the physician practice include overall practice objectives, skills and attitude of the staff, CLIA license, practice work flow and efficiency needs, training and experience of the physicians and staff with lab tests and available space.

Finally, we can’t forget MACRA, which aims to improve patient outcomes, reduce costs to the healthcare system and improve patient satisfaction. While MACRA presents a daunting challenge, we can all agree that testing and treating during the patient visit meets the general requirements of improving patient care and satisfaction. One visit, rather than several, also saves both the healthcare system and the patient time and money. So, you see, MACRA is our friend.

In order to simplify a useful guide to tests needed every day, I have based my testing suggestions on a model of a fairly typical independent suburban physician practice: 10 physicians, 3 PA/NP personnel, an office manager and typical nursing and support staff. Their patient mix includes children and adults, and spans a range of chronic and light acuity conditions, such as flu, strep, sprains and minor orthopedic injuries. They have a Medicare and private insurance payer mix. They have a CLIA moderate lab license.

 

What are the core tests this typical middle of the road mixed specialty practice needs?

What’s the test?	Why?	CLIA Category	Comments
Hemoglobin	Quick check for anemia	Waived	Fast, easy, accurate
hCG	Pregnancy can happen at any time	Waived	Important for nutritional needs, pre-natal care and before imaging studies
Urinalysis	Fast, easy, non invasive health screen	Waived	Should be part of every annual physical
Mono	Adolescent health	Waived/Moderate	The new waived tests are easy and accurate
Glucose	Diabetes, especially type 2, is on the rise worldwide	Waived	Treatment can’t begin without a good diagnosis; use an accurate quantitative test
CBC	Infection, anemia, general health	Waived/Moderate	Next to glucose, UA and hCG, the best tool in the general use lab tool belt
CMP	General metabolic assessment	Waived/Moderate	Tells the story of overall patient status in health and disease
BMP	Limited general health assessment	Waived/Moderate	Less data; typically, no liver function tests
Lipid profile	Lipid disorders lead to serious complications and are often related to diabetes	Waived/Moderate	Use of statins has made lipid tests fundamental in adult medicine
A1C	Knowing average glucose level over time	Waived/Moderate	Are Ward and June sticking to their diet? How well controlled is their diabetes?
Flu	Know what you are treating	Waived/Moderate	Only about 30 percent of all flu tests are positive; ever wonder what the other causes are?
Strep	Prevent very dangerous complications	Waived/Moderate	Before antibiotics, strep was a serious cause of illness and death
RSV?	Some practices love it; others want it done in a more sophisticated lab	Waived/Moderate	This test has arguments for and against in house testing; new, molecular tests make it a better in office test choice than ever
FIT/FOBT	Colorectal cancer is highly curable if detected early	Waived	Colonoscopy has left these tests “behind” to a large extent; they are still important

 

Additional useful tests based on patient population

What’s the test	Practice type/patient type	CLIA category	Comments
Lead	Pediatric	Waived	Can prevent serious neurological damage via early detection
TSH	GP/IM/OBG	Waived/Moderate	Useful at annual physical
Free T4	GP/IM/OBG	Moderate	Reflex with abnormal TSH
PSA	GP/IM/URO	Moderate	New, multiple assay tests including PSA are better than ever
PT/INR	GP/IM/Cardio	Waived/Moderate	Important follow up for clotting disorders
BNP	GP/IM/Cardio	Waived/Moderate	Detect/follow up on heart failure
B12/Folate	GP/IM/OBG	Moderate	Differential diagnosis of anemia
CRP	Rheumatology	Waived/Moderate	One tests in a tricky differential diagnosis panel
ANA	Rheumatology	Moderate	Typically done with or after CRP; autoimmune diseases are among the toughest disorders to diagnose and treat
Vitamin D	GP/IM/OBG/Etc.	Moderate	Depending on who you believe, either everyone or no one has a Vitamin D deficiency

So, what’s the bottom line? Essentially, it’s to know your customer and their needs, and understand their practice in every detail. What are their objectives? Does their staff love or fear lab tests? What patients and clinical conditions do they see every day? What pressures is the practice under?

Seventy percent of all medical decisions involve a lab test, but only if it’s ordered and used to initiate or modify a patient treatment program. There is no better place to perform lab tests than the physician practice, and no better time to perform them than during the patient visit.