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5 Ways to Improve Diagnostic Services to Boost Care

Contributing Lab Leaders: Les Duncan; Michael Astion, MD, PhD, HTBE; Patti Jones, PhD; and Jason Bhan, MD

5 Ways to Improve Diagnostic Services to Boost Care
CLINICAL

Article highlights:

  • ACOs use diagnostic data and services to improve cost-effective care and patient outcomes
  • Five key opportunities exist for laboratorians to enhance diagnostics and contribute to ACO success

To reduce health care costs and improve population health, accountable care organizations (ACOs) rely heavily on diagnostics. Improvements in the efficiency, cost effectiveness and clinical utility of diagnostic services can go a long way in helping ACOs achieve their goals.

Diagnostics is an area where laboratorians can add immense value, especially during pre- and post-analytical test phases. In this article, our ACO experts explore five areas where labs might make a positive difference.

Build your ACO expertise one step at a time, beginning with these key articles:

Opportunity #1: Data Disharmony

 

ACOs are vast. In the case of River Health, where Les Duncan is Vice President for Accountable Care Initiatives, their network includes over 350 health care providers (HCPs) in a 16,000 square-mile area. Within that space, all sorts of different labs operate: hospital, private, commercial, national-level…you name it.

Those labs produce a chorus of data. But the data are often discordant. Labs use different scales, equipment and reference ranges. This means there is little data standardization.

Primary care physicians (PCPs) need to know about this data disharmony. They’re the quarterbacks directing patient care in an ACO. Accurate data must flow to them and inform evidence-based medical decisions for each patient.

Laboratorians can help PCPs understand:

  • Not all lab data are the same—a value from one lab does not necessarily correspond to a value from another for the same test
  • Data must be interpreted against each lab’s specific reference range (available in electronic medical records, or EMRs, and printed results)
  • The value of working with labs to interpret data from complicated tests

A few of today’s tests are relatively well harmonized, such as glucose, calcium and sodium. But achieving greater data harmony in more areas will be a daunting task, given the variety of tests available and the multiple ways many can be ordered. This makes the role of laboratorians even more important in raising awareness of the issue and assisting PCPs with practical solutions.

Michael Astion, MD, PhD, HTBE

Division Chief of Laboratory Medicine, Clinical Professor of Laboratory Medicine

Seattle Children's Hospital

Opportunity #2: Test Utilization Management

 

Solving the dual problems of over- and underutilization of tests requires lab expertise. A reduction in unnecessary tests and an increase in proper test ordering will help ACOs control costs and improve care.

Multiple opportunities exist for laboratorians to step in and help optimize test ordering. Labs can provide tremendous value in any of the following ways: 

  • Create standardized order sets—in the case of Celiac disease, for example, labs might narrow testing options down to one or two
  • Join utilization management committees—many ACOs have formed such committees in an effort to mitigate the risk of over- and underutilization
  • Participate in subcommittees tasked with specific challenges—like devising a test order set for post-surgery transplant care
  • Inform technology solutions—get involved in front-end development of test-ordering systems akin to EPIC or Cerner, through consultation
FAQ

FAQ

Underutilization occurs due to:

  • Access: Patients not coming in for scheduled tests (most common)
  • HCPs failing to order the appropriate tests (far less common)
  • Slow adoption by HCPs of new tests that are better than older ones (such as anti-CCP vs. rheumatoid factor in rheumatoid arthritis)

Overutilization occurs due to:

  • Lack of physician education about proper test ordering
  • Too many tests to choose from, as in the case of Celiac Disease, where just one or two tests may suffice
  • Breadth of symptoms associated with diseases of the thyroid, which lead to over-ordering of thyroid stimulating hormone (TSH) tests

Michael Astion, MD, PhD, HTBE

Division Chief of Laboratory Medicine, Clinical Professor of Laboratory Medicine

Seattle Children's Hospital

Opportunity #3: Expert Consultancy

 

Let’s say there are about 50 lab tests that are considered commodities today. Where those tests are performed doesn’t matter so much: the data will be harmonious and therefore actionable.

But what happens when patients in an ACO become really sick and the commodity tests no longer apply? When therapeutic drug monitoring is called for, reference ranges change, testing methodologies differ and the odds of HCPs ordering the wrong tests increase.

Laboratorians can add value by providing consultative services to assist HCPs with complicated test ordering. Genetic testing, for example, is a hot new area of opportunity. For many genetic tests, reference ranges do not yet exist. As a result, there is an enormous need for consultative services with both pre-analytical test ordering and post-analytical data interpretation.

 

Case Study: Achieving Safety and Savings through Genetic Test Guidance

 

Here’s an example of how a joint effort to optimize genetic test ordering helped improve safety and save money for a hospital, patients and payers. It’s adapted from the experience of Michael Astion, MD, PhD, HTBE, Medical Director for the Department of Laboratories at Seattle Children’s Hospital.

 

The Problem

  • Genetic testing was poorly covered by insurance
  • Patients were charged thousands of dollars for unnecessary tests
    • Many patients simply couldn’t pay the out-of-pocket costs
  • Seattle Children’s Hospital ended up shelling out millions to cover the tests

 

The Program

  • Hospital leaders launched a grassroots effort to solve this issue
  • They formed a group called the Pediatric Lab Utilization Guidance Service (PLUGS)
  • PLUGS analyzed the problem and found:

    • 1/3 of tests costing >$700 were ordered incorrectly

    • 11% of those could be cancelled

    • 6% were medical errors

    • The rest were expensive, bundled tests of questionable quality

       

The Progress

  • PLUGS created test utilization management systems for all its members
  • Those systems consist of policies, procedures and tips for:
    • Using consultants such as genetic counselors, pathologists and chemists

    • Adjudicating test cases

    • Flagging expensive test orders in EMRs

    • Collaborating with HCPs to order the correct tests

 

The Payoff

  • Millions of dollars saved over 2½ years
    • ½ accrued to the lab
    • ½ accrued to patients

The PLUGS Program has been very gratifying. It’s a place where patient safety meets cost containment. We no longer pay for costly tests we don’t need. It’s very helpful for the participating labs.

Michael Astion, MD, PhD, HTBE

Division Chief of Laboratory Medicine, Clinical Professor of Laboratory Medicine

Seattle Children's Hospital

Patti Jones, PhD

Clinical Director, Chemistry

Children's Medical Center Dallas

Opportunity #4: TAT Acceleration

 

Fast turnaround times (TATs) on lab tests are vitally important to ACOs. Effectively managing wellness requires HCPs to take advantage of every “teachable moment” with patients. Currently, patient adherence to annual wellness visits is low (see Why Success Hinges on Infrastructure). When patients do show up, having lab results on hand makes interactions with HCPs far more productive.

In an ideal world, more labs would be capable of delivering point-of-care testing. Consider these two examples of how point-of-care lab results might improve the patient experience and the likelihood of better outcomes.

 

A1c testing during wellness visits

 

If lab results show a patient is at risk for diabetes, clinicians can provide counseling right then and there during the visit. Exhortations to modify one’s lifestyle and diet become more urgent when HCPs can point to dangerously elevated values face-to-face with patients.

 

Coumadin (warfarin) monitoring in the office

 

If an HCP could finger stick her patient and get the international normalized ratio (INR) within minutes, she could make any necessary dose adjustments on the spot. A preferable scenario to sending the test to the lab, waiting days for the results and calling the patient back later.

Point-of-care testing might also mitigate the risk of HCPs failing to retrieve results of tests they ordered in office or in the hospital. Though our lab leaders cite this as far less of a problem than patient nonadherence, it does occur.

Ultimately, point-of-care testing is an economic decision and an issue of scale. Large hospital systems often have labs on-site that provide a full complement of testing services, delivering point-of-care results within the institution. For smaller practices, however, investing in the necessary personnel, services and machines is not economically viable.

But accelerating TAT is. When labs accelerate their TAT, they increase their value to ACOs.

Michael Astion, MD, PhD, HTBE

Division Chief of Laboratory Medicine, Clinical Professor of Laboratory Medicine

Seattle Children's Hospital

Opportunity #5: Companion Diagnostics for Precision Medicine

 

We’ve come full circle back to the issue of data harmony. The emergence of precision medicine as an approach to care renders harmonization of data more important than ever before.

Chronic myeloid leukemia (CML) testing provides a prime example. The sensitive BCR-ABL test is used to detect the fusion gene responsible for CML. Oncologists use the results to determine whether or not appropriate therapeutic effect is being achieved and if a medication change is warranted.

Before a new medication can be prescribed, a companion molecular diagnostic is needed to ascertain if the patient will be resistant to the therapy. Resistance testing of this sort can be performed on multiple platforms at multiple labs. Therein lies the danger.

Results from resistance tests performed on different platforms are not equal. In some cases, patients who receive the test in one lab may improve after changing their medication while patients from another lab worsen. This suggests that the testing platform plays a significant role in the accuracy of the resistance results, with direct consequences to care.

As laboratorians, we all need to be cognizant of testing platforms and their impact on precision medicine

 

Dive into ACOs through diagnostics

 

Look for opportunities like these in your own lab. When you find them, proactively reach out and lend your expertise to ACOs. Doing so will help you play a valuable role in improving diagnostics to secure positive outcomes for patients, providers and all major players in ACOs.

Jason Bhan, MD

Chief Medical Officer

Prognos

Contributing Lab Leaders

Les Duncan

Director of Accountable Care Solutions

Highmark Health

Michael Astion, MD, PhD, HTBE

Division Chief of Laboratory Medicine, Clinical Professor of Laboratory Medicine

Seattle Children's Hospital

Patti Jones, PhD

Clinical Director, Chemistry

Children's Medical Center Dallas

Jason Bhan, MD

Chief Medical Officer

Prognos

 

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