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
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 System
Core tertiary-care hospital
3 integrated hospitals
14 Patient Service sites
7 Outpatient Draw sites
88,000 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, resulting
Allows 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 differential
Hours between reported result and next order
90
80
70
60
50
40
30
20
10
0
0
<1
<2
3
4
5
6
7
8
9
10
12
18
24
Surveyed Physicians’ reasons for ordering multiple
CBC with diff tests within 24 hours on inpatients
20%
10%
60%
10%
Ordering error
Ordered by other service
Clinical situation changed
Personal preference
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
already been performed.
Best
practice
To locate result; click
the Alert
hyperlink alert
to Chartused
Review > Lab tab; then
search for result.
The Once in a Lifetime Alert will display for the following Genetic Labs:
 LAB1203 – Cystic Fibrosis Mutation
 LAB1056 – Factor V Leiden Mutation
 LAB1088 – Prothrombin Mutation
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
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
RBCs/100 DC compares
favorably with other
academic medical centers
RBC's / 100 Discharges - ALL
25.0
20.0
15.0
10.0
5.0
0.0
19.7
16.0
EH
GB
A
16.1
13.5
11.4
HP
B
C
SK
SK is an outlier
16 RBCs/100 DC at SK
would = 338 RBCs saved,
$67,648
NS total
D
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
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.
Lab automation
Value of new technologies
•
•
•
•
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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?
•
•
•
•
•
•
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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
New Technologies in the Lab
•
•
•
•
•
•
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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
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