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
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