Becoming a Value-Driven Lab

The Lab’s Role in Care and Cost Transformation

Karen Kaul, M.D., Ph.D.

Chair, Pathology/ Lab Medicine

NorthShore University HealthSystem

Clinical Professor of Pathology

University of Chicago Pritzker School of Medicine

DISCLOSURES:

No Relevant Financial Relationship(s)

No Promotion of Off Label Usage

CMS Goals:

• Reduce per capita cost• Improve quality of episodic care• Improve population health

©2014 MFMER | slide-4

Labs are well-positioned to influence cost and quality

New Financial Realities in Healthcare

• Lab testing: $60 billion – 4% of health care cost (1.5% of Medicare)– dictates 70% of downstream spend

• Increases of 4-5% annually• Federal government now funds > 50% of our

nation’s $3.8 trillion expenditures• Already seeing CMS cuts

– 11% reimbursement cuts since 2010– 26% reimbursement cuts expected in 2014

Lab’s role in Care Transformation• Transition from fee-for-service

– Volume-based system becomes quality and efficiency-based delivery

– Improve outcome, reduce over all cost of care

• Lab must reduce cost and increase value• Look beyond traditional models and roles

Lab’s role in Care Transformation

• Reduce waste, unneeded testing• Use of appropriate testing• Faster, more valuable results • Coordinate lab tests across spectrum of care

– Inpatient, outpatient, outreach

• Be more integrated, more available to care team

• Create IT solutions

Laboratory Outreach

• Added volume brings incremental benefits• Decreased cost per test

Optimize operations as a SystemCore tertiary-care hospital3 integrated hospitals14 Patient Service sites7 Outpatient Draw sites88,000 Courier stops

Leverage Outreach

• Outreach clients have become Medical group members – incentivize system operation– Fewer independent docs; limits new opportunities

• Novel outreach opportunities• Home Health• Nursing homes

– Infection control– Routine lab testing, phlebotomy– Radiology services

Laboratory Outreach

Future: need to operate as system– All testing in same system, same lab, same platform – Continuity of care– Coordinate inpatient/outpatient/outreach testing– Service providers to nursing homes, home health– Point of Care

Laboratory Outreach

Future: need to operate as system– All testing in same system, same lab, same platform – Continuity of care– Coordinate inpatient/outpatient/outreach testing– Service providers to nursing homes, home health– Point of Care

Interface ordering, resultingAllows application of test utilization rules

Lab utilization projects at NorthShore

• Lab Practices Committee• Oversight of send-out tests

– Move sendouts to outpatient setting– Lab formulary

• Reduce unnecessary testing • Pathologist directed disease work-ups• Transfusion guideline enforcement• Improve lab consultations

Opportunities for Lab utilization improvement

• Right test at the right time– Clinician understanding of 50-100 tests– Strongest predictor of clinician lab order patterns is

residency– Technology evolving quickly

• Tests over-ordered? under-ordered?• Who orders tests?• Nomenclature

Algorithm-driven ordering

CBC with differentialHours between reported result and next order

0 <1 <2 3 4 5 6 7 8 9 10 12 18 240

10

20

30

40

50

60

70

80

90

60%

10%

10%

20%

Ordering errorOrdered by other serviceClinical situation changedPersonal preference

Surveyed Physicians’ reasons for ordering multiple CBC with diff tests within 24 hours on inpatients

Potential financial impact, CBC/diff

Average of 505 tests per month ordered more frequently than q 24 hours on inpatients

Potential cost impact:500 x $4 = $2000 (Automated diff)100 x $10 = $1000 (Manual diff)

$3000 monthly for one test

Germline genetic tests: “Once in a Lifetime”

• Overordered Germline tests: – Hypercoagulation mutation assays– CF carrier testing– SMA carrier testing– Ashkenazi prenatal panels– Pharmacogenomics– Cancer Risk panels

Once in a Lifetime intervention

• Need unique test code• Ability to scan over all encounters• Designed BPA to present previous test results

Best practice alert used

Once in a Lifetime Alert - Stats

Deployment Date: Jun 11, 2012

Duplicate CF testing: Cost savings significant

But….why 25% still ordered?

Inpatient vs Outpatient Efforts

• Focus utilization control efforts on inpatient labs• DRGs vs CPT billing• Will need universal utilization control eventually

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Blood utilization

• Major source of

variability and expense• Significant implications

for clinical outcome

Randomly assigned ICU pts.- Restrictive (hgb <7.0, target 7-9)- Liberal (hgb <10.0, target 10-11)- 1o outcome; 30 day mortality

Younger & less-sick patients did BETTER with less blood

Hebert, NEJM, 1999

Pulmonary and cardiac outcomes drove improvement

2o Outcome Restrictive Liberal Signif.

In-hosp. mortality 22.2% 28.1% p=0.05

MI 0.7% 2.9% p=0.02

Pulmonary edema 5.3% 10.7 p<0.01

ARDS 7.7% 11.4% p=0.06

Multiorg fail (adj) 20.6% 26.0% p=0.07

Angina 1.2% 2.1% p=0.28

Cardiac Arrest 6.9% 7.9% p=0.60

Infection 10.0% 11.9% p=0.38

Hebert, NEJM, 1999

Utilization data slides

RBC's / 100 Discharges - ALL

11.416.0

13.5

19.716.1

0.05.0

10.015.020.025.0

EH GB HP SK NS total

RBC's / 100 Discharges

All Transfusions A B C D TOTAL

Discharges 22526 12684 12153 9111 49696

Patients with RBC trx 1085 969 734 796 3584

% patients with RBC trx 4.8% 7.6% 6.0% 8.7% 7.2%

# RBC Units 2557 2021 1635 1796 8009

RBC's / 100 Discharges 11.4 16.0 13.5 19.7 16.1

Units/patient 2.4 2.1 2.2 2.3 2.2

RBCs/100 DC compares favorably with other academic medical centers

SK is an outlier

16 RBCs/100 DC at SK would = 338 RBCs saved, $67,648

A B C D Total

NS Medicine patients; back-to-back RBCs

Back-to-back = 2 units within 8 hours without an intervening CBC

A B C D TOTAL

# of pts getting 2 units 494 519 426 508 1947

# B-to-B between 1 & 2 285 289 249 344 1167

% of 2 units tx back-to-Back 57.7% 55.7% 58.5% 67.7% 59.9%

% with Hgb>11 after 1-2 B-to-B 4.2% 6.2% 7.2% 9.0% 6.8%

# of pts getting 3 units 198 180 167 177 722

# B-to-B between 2 & 3 56 31 43 44 174

% B-to-B between 2 & 3 28.3% 17.2% 25.7% 24.9% 24.1%

% with Hgb>11 after 2-3 B-to-B 8.9% 12.9% 14.0% 6.8% 10.3%

Potential cost savings

• Improvement in quality of patient outcome• Reduce unreimbursed care• Reduce purchase of blood products• Extend to platelets, plasma, other products

Lab performance standards in AP

• Historical indicators:– TAT, frozen/permanent agreement rates

• Systems for data gathering evolving• New indices for efficiency and quality

– Standards for recuts, deeper sections– Use of IHC, special stains– Cost per diagnosis?

• Adherence to guidelines

Pap Smears and HPV:Adherence to guidelines

ASCCP guidelines for HPV testing:• HPV testing not indicated under age 21• HPV if ASCUS in women aged 21-29• HPV for primary screening over age 30, can

extend follow-up interval

Informatics methods for laboratory evaluation of HPV ordering patterns• Jackson and Shirts, JPI 1:26, 2010

Increasing consultation and communication

• Electronic communications prevail• Information at fingertips

The Lab Help Button

• Select the Lab Help button to select the appropriate action

• Contact the Lab allows physicians to send an InBasket Message to pathology

• Pathology Resources displays a webpage with links to pathology related information

In Basket Message

Message is prepopulated with custom SmartText to lead the user through the process of receiving help.

Notification

The on-call resident will receive a page as notification that a Lab Help Message has been sent to their In Basket.

The Message

Log into Epic and select In Basket and the Lab Help Message folder to review the message.

Searchable Test Catalog

• Searchable Test Catalog provides a link to the NorthShore Test Catalog on NorthShore Connect within Epic.

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Lab automation

Value of new technologies

• Workload efficiency• Addresses aging workforce issues• Lower cost• Flexible work schedule• Faster results

– Continual incubation– Molecular and MALDI detection– Faster diagnosis and treatment

Total Microbiology Automation

Audience response:What lab utilization tools have you

employed?

• Test formulary• Review of expensive send-out tests• Bringing send-outs in house• Limited order-ability/deemed users• BPAs/pop-ups• Algorithms/pathologist directed work-ups• Improved communications

©2014 MFMER | slide-41

New Technologies in the Lab

• Upgrade automation in Core lab, Microbiology• MALDI-ToF in microbiology: reduce LOS• Instrument interfacing and autoverification• CPOE• Bar-code sample tracking• Telepathology, digital pathology in AP• Array technology and Next Generation

Sequencing

Lab value and cost efforts

– Increase impact of testing

– Improve overall patient outcome

– Episodes of care– Increase support of

clinical colleagues– Population health

management

• Reduce waste• Reduce testing• Find efficiency

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How do we get this all done?

• Secure IT resources/influence– Lab-Based HIT representation– Lab-focussed HIT optimization staff– Demonstrate savings to administration

• Incentivize department staff• Negotiate incentives for results

– Share risk and reward