At the Southern Arizona VA Health Care System in Tucson, the clinical laboratory made an unusual proposition to the medical staff: let us take over your hepatitis C virus (HCV) screening program. The laboratory would search its patient registry for individuals born between 1945 and 1965 who had not been tested and directly contact them through an automated letter, sent on behalf of their doctors, encouraging them to get screened. The letter could be taken to any local VA phlebotomy center and used as a requisition.
The medical staff agreed to try it, and the program was a success. The laboratory sent thousands of letters. So far, more than 50% of recipients have responded, said Ron B. Schifman, MD, chief of pathology and laboratory medicine at the Southern Arizona VA Health Care System and professor of pathology at the University of Arizona College of Medicine. Tucson has since remotely replicated the screening program for seven other facilities, including those in Los Angeles, Albuquerque, and Denver. The program has identified more than 100 cases of occult chronic HCV infection so far.
Schifman will discuss this program and other ways laboratories can partner with providers at a session at the 70th AACC Annual Scientific Meeting that takes place July 29 through August 2 in Chicago. His session is one of several at this year’s meeting about how laboratories of the future will be able to demonstrate value in healthcare systems and use emerging technology to reduce pre- and postanalytical errors.
Jonathan R. Genzen, MD, PhD, laboratory section chief for chemistry and medical director of the automated core laboratory at ARUP Laboratories in Salt Lake City, will participate in a session about solving diagnostic challenges with technology, automation, and innovation.
He will discuss the work of his colleagues at ARUP to reduce pre-analytic errors—both through simple solutions, such as putting ridges on the ends of processors’ tables so tubes won’t roll off—and by automating pre-analytic quality checks.
Specifically, the lab is developing optical character recognition systems to identify potentially mislabeled tubes and creating automated ways of checking specimen volume. ARUP also is using infrared cameras to measure specimen temperature to prevent instrument damage if someone accidentally puts a frozen specimen on the automation track.
“Our goal is to integrate as many of these technologies as possible into our automated solutions going forward so that the types of checks we’re talking about are done on every specimen as it goes through the lab,” Genzen said.
Expanding Quality of Care Through Partnerships
A team from TriCore Reference Laboratories in Albuquerque, New Mexico will lead a session on how labs can use technology to support value-based care in healthcare systems. They will discuss, for example, a program TriCore created that alerts insurers about pregnancies and births so that the insurers can steer patients into timely prenatal and postnatal care. Laboratory data identifies up to 80% of pregnancies in the first trimester, whereas claims data had tagged only about 70%, said Michael Crossey, MD, PhD, TriCore’s president and CEO.
This new role for TriCore helps managed care organizations meet their Healthcare Effectiveness Data and Information Set (HEDIS) quality standards and improve health at a population level. “When we talk to health providers or insurance companies, they’re not really sure what to do with us when we start asking them about how we can help their HEDIS measures or how can we help their gaps in care,” Crossey said. “It’s not the normal, usual conversation.”
Yet labs can and should expand their role in the healthcare system, Crossey emphasized. Laboratorians can help clinicians order the right tests, interpret results, and even drive or guide interventions and therapies, he said. By helping insurers and clinicians do their jobs better, laboratorians essentially reduce healthcare costs.
“If we just stay in the laboratory and save money it’s not going to fix anything for a health system,” Crossey said. “We have to get out of the laboratory and affect the downstream issues.”
Kathleen Swanson, MS, RPh, TriCore’s director of clinical solutions, said TriCore chose to initiate a pregnancy data program after discovering that premature births are one of the costliest health issues in New Mexico. Chronic kidney disease is another area in which laboratory-initiated data analysis could cut costs and improve patient care, Swanson said.
“If you can look at a large number of patients and drive those costs down or improve that care even slightly, it can register as hundreds of thousands and even millions of dollars for organizations and for health plans that take care of these patients and help pay the bills,” she said.
Having developed these tools, TriCore is now working to make a business case and find potential customers for this new laboratory service. “Laboratories can be the catalyst for better healthcare,” said Richard VanNess, MS, director of product management at TriCore. “With the insights we provide, we believe we’re not an ancillary-type provider. We can be at the forefront of healthcare, especially in terms of value-based care.”
Proving That Labs Know Best
Back at the Southern Arizona VA Health Care System, Schifman is doing similar work in forming closer partnerships between the laboratory and healthcare providers.
“I think clinical pharmacists have come farther than we have in terms of having this interaction with clinicians, to the point where clinicians rely heavily on clinical pharmacists to make decisions about the best treatment,” he said. “In an analogous way, we laboratorians really haven’t positioned ourselves well to do the same thing. The assumption in the past has been, well, clinicians know the best tests to order and know what the problems are with interpreting those tests. I’ll present data at the session that shows that’s probably not the case.”
Schifman’s session will focus on laboratory utilization and how laboratories can help clinicians avoid inappropriate tests, while also making sure testing that would benefit patients is not overlooked, such as the HCV screening test. One step in this direction is integrating clinical information with laboratory data, Schifman said. For example, if a laboratory had a way to recognize whether a patient is on oral anticoagulant therapy, it would prevent misdiagnosis of protein C deficiency from false-positive results. He’ll offer other examples of similar strategies to help clinicians avoid diagnostic errors and discuss how this improves patient care and saves health system resources.
“The value comes from making sure that the right test is ordered and only tests are reported that have a high reliability of being interpreted properly,” Schifman said.
In addition to population health screening for HCV, Schifman has found that patient registries also provide value in the laboratory for other applications. One example he’ll discuss is stewardship of genetic and phenotypic testing. “We find that about nine percent of those tests are reordered, and of course your genes don’t change,” he said. If a doctor orders a genetic test for a patient who is in the national genetic registry, the lab can avoid retesting and return a result immediately. The VA program automatically notifies about 65 participating laboratories about duplicate genetic test orders, regardless of where in the VA system the previous test was performed.
Such programs are just the tip of the iceberg, according to Schifman. “With partnerships among clinicians and laboratories, other registries can be used to assist with handling testing of patients who are on high-risk medications, like coumadin, or those with diabetes who need regular hemoglobin A1c monitoring,” he commented. “As they work closely with clinicians, laboratories can add tremendous value by helping manage the appropriate patient testing, which after all, is what we’re good at.”
Julie Kirkwood is a freelance journalist who lives in Rochester, New York. Email: [email protected]