Molecular testing has, historically, been a siloed, decentralized, and/or fragmented endeavor. However, with the rise of platform consolidation—and the economies of effort they can provide—some health systems are moving to a more centralized, core model of testing. At the same time, other areas like point-of-care (POC) testing have spurred the growth of new distributed models. As laboratories take steps to adapt to the changing healthcare landscape, they will need to evaluate which models may work for them and in what instances.
Here, lab leaders examine the advantages and challenges of centralized versus decentralized testing models, while discussing what the future may hold for organizational structure in the molecular lab Test.
While future change can appear as a great unknown, some health systems have paved a clear path forward for centralized core lab models. Three years ago, one such system, the South Carolina-based Atrium Health, consolidated seven non-contiguous lab spaces —churning out over 750,000 tests annually—into a central, 29,000 square-foot core lab. Dr. John Longshore, director of Molecular Pathology at Carolinas Pathology Group, Atrium Health, who led the transition, says that the impetus for the move—and the chief benefit of a centralized model—has been the improvement of operational efficiencies, with greater potential for expansion.
"We've seen a tremendous improvement in specimen flow, by co-locating our esoteric testing areas—that'd be HLA, flow cytometry, cybergenetics, and molecular pathology. We've had a lot of tech time savings and improved process optimization because technologists really are best at performing technical work." Dr Longshore says that, in addition, co-locating multiple areas of the lab under one roof has spurred dramatic improvements in communication and collaboration, both among laboratorians and with providers, along with a newfound ability to continually optimize processes.
While the potential benefits of centralization are obvious—process efficiencies and platform consolidation and automation—the move also comes with challenges. Dr. Longshore says that one significant difficulty lies in the paradigm shift from a traditional lab structure and, in particular, the challenge of finding a consistent management structure, along with formulating guidelines for standard processes and standard work.
Meanwhile, another pitfall for many cost-siloed labs is that, today, a centralized model is simply unfeasible. Speaking about moving high-volume tests to a core lab, Dr. Pam Ward, associate professor of Clinical Pathology and scientific director or Molecular Pathology at the Keck School of Medicine of USC, says,"It's moved from high complexity to low complexity, so that's economy of technical scale and effort. It just makes economic sense.
From my point of view, that won't happen well at my facility because we're still working on this fragmented model, where each individual area of clinical pathology is its own cost center, and each individual area has to show that it's economically viable."
While centralization could help ease the financial constraints of fragmentation, the change, for some, will be slow. Yet, Dr. Ward sees the shift to centralized models, if not inevitable, as a welcome one: "From our point of view, we're going to have to maintain that high volume viral testing. But long-term, I see that it makes perfect sense to roll it into that core lab and really bring down the cost of healthcare. Because, in the United States, each little hospital system is working as a silo. We're all working against each other."
On the other hand, many labs remain decentralized, which can have its advantages. As Dr. Ward notes, lab leaders are highly passionate, if not protective, about the high- complexity testing they have worked hard to develop. For many, the transition to a core lab could mean relinquishing some degree of control over their molecular work, especially as, with new pre-analytics solutions and expanded platform menus, some high-volume or middle-complexity testing could be rolled into a chemistry environment.
However, the expansion of decentralized testing in other areas, in particular the distributed model of POC testing, could help give labs leaders the best of both worlds: By moving higher volumes of rapid, even middle-complexity testing to or near the patient bedside, lab leaders can free labor hours to focus on higher-complexity tests— thereby improving access for patients and potentially diminishing workloads. This shift is already well underway, as the POC market is expected to grow at over 7 percent per year, through 2024, according to Global Market Insights. That said, labs will still bear the responsibility of overseeing quality and rollout in POC testing programs at large.
In this way, with both inward and outward lab pressures, a dual trend is emerging for the molecular lab. Dr Longshore observes: "I think we're going to see both consolidation of labs—there are going to be fewer healthcare systems and more consolidation into core lab environments for routine testing and high-volume testing—and we will also see the distributed model of near-patient or POC testing for more routine tests, where answers are needed in a very rapid fashion."
For many labs, the answer to the question, centralize or decentralize?, is not, either/or. In all cases, lab leaders must carefully consider where consolidation, if any, would help to improve value and drive efficiency for the lab, and where decentralized models can help them play to their expertise, while improving patient access. That said, for many labs under increasing financial pressure, some degree of change is inevitable—and with the advantages of new models on display, that change should be a welcome one.
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