Labs Need to Focus on Providing Data-Driven Value for the System, Lab Institute Experts Say

Laboratory leaders are well aware of the unprecedented number of evolutionary forces exerting pressure on the industry and are heavily focused on regulatory and reimbursement uncertainties. But, according to multiple presenters at G2 Intelligence's recent Lab Institute conference (Washington, DC; Oct. 14-16), laboratories also need to utilize their resources to demonstrate their value to the health system.

While accurate test results are obviously needed to inform care decisions, laboratories hold valuable data that can be utilized for the benefit of the entire health care system. Sharing this data for the larger good ensures the laboratory is a valued partner and plays a role in designing the evolving configuration of health care delivery. The most immediate value laboratories can add is in the inpatient setting, given the rapid adoption of bundled payments for those services; however, forward-thinking laboratories will adapt these strategies for outpatient services as payment reform will permeate that setting as well, with increasing participation in accountable care organizations and risk-sharing models. Two case studies presented at Lab Institute demonstrate laboratories' ability to help manage test utilization and improve patient care.

Strategies to Improve Test Utilization
In a bundled payment environment, managing test utilization reduces unnecessary testing and preserves the financial incentive for providing effective, yet efficient care. This is one of the greatest opportunities for laboratories to improve clients' financial performance, while enhancing patient care.

But in his presentation "Managing Test Utilization for Better Patient Care and Improved Financial Performance" Thomas Joseph, CEO of laboratory analytics company Visiun (Ann Arbor, Mich.), told attendees that improving test management is not just focused on the problem of overutilization or unnecessary testing (estimated to occur in approximately 21 percent of all testing based on meta-analysis results). In fact, laboratories need to improve underutilization of needed tests. The same 2013 meta-analysis published in PLOS One found that underutilization of testing is even more common and can occur 45 percent of the time and can have "significant" clinical implications for patient care. Visiun data, for instance, shows that HbA1c is not reordered up to 30 percent of the time and similarly, elevated creatinine results are not followed up on within 90 days at rates approaching 40 percent in the outreach testing environment.

It's not just about educating doctors to order or not order tests, it's about teaching them to order the right tests. Joseph offered some strategies laboratories can employ to affect improved test ordering.

"A combination of approaches is necessary," Joseph warns, "as no one approach will be sufficient."

• Stop offering obsolete tests, which Joseph estimates account for 9 percent of all unnecessary testing;
• Redesign test requisitions to minimize bundled testing and esoteric testing availability;
• Use computerized physician order entry to enable hard stops (like requiring a genetic counselor consult for genetic tests) and popups with guideline-driven ordering reminders; and
• Employ audits, which Joseph calls a "key element."

"We are identifying opportunities for our clients to reduce unnecessary testing from several hundred thousand to over a million dollars per year for inpatient testing alone," says Joseph. "Since this unnecessary testing is not reimbursed by DRG payments, it represents an immediate improvement to the health system's bottom line."

Visiun's Performance Insight suite of tools provides laboratory directors and managers with business intelligence and analytics to help monitor key performance surrounding operational performance, efficiency and quality, including turnaround time, productivity, quality, financial management, and utilization.

The system allows queries against a network of peer comparisons that is built upon test ordering data from 300 laboratories, including academic medical centers, community hospitals, Lean labs, and specialty labs. Visiun's graphical report cards call out heavy test users and outliers.

Lab Insights Save the System Money
Laboratory data can be used to reduce readmissions, control costs, and improve patient safety, according to Ran Whitehead, president of PeaceHealth Laboratories (Portland, Oregon). These were some of the motivations behind PeaceHealth's development of its RxAdhere medication safety panel that improves the process of prescription reconciliation.

RxAdhere can determine both non-adherence to prescribed medications and intake of uncharted medications, which are both tied to costly adverse drug events. The traditional medication reconciliation process may not detect these discrepancies because of inaccurate patient self-reporting, incomplete pharmacy records, and non-interoperable medical records. The plasma-based RxAdhere test is based on tandem mass spectrometry and it confirms the presence or absence of 184 commonly prescribed medications used to treat common, chronic conditions (anticonvulsants; eight classes of anti-hypertensives; antiarrhythmics, analgesics; benzodiazepines; NSAIDs, anticoagulants/antiplatelets; antidepressants; antipsychotics; stimulants; and oral hypoglycemics).

Medication non-adherence is a significant and common problem, Grant Beardsley, a clinical toxicologist at PeaceHealth Laboratories, told attendees. He says it is estimated that 75 percent of Americans may not take medications as directed and this contributes to nearly $200 billion in avoidable costs annually to the health care system.

By administering medications in the hospital, based on what the patient is actually taking—not what prescriptions are in the medical record—Beardsley says more appropriate dosing can occur, cutting the likelihood of a life-threatening reaction to a high-maintenance dose. Relatedly, patients can continue taking all medications that they routinely use, instead of abruptly stopping. In either case, RxAdhere can reduce inpatient adverse drug events and resulting extended hospital stays with their associated expenses.

In an inpatient validation trial of RxAdhere at the PeaceHealth Sacred Heart Medical Center (Portland, Oregon) the test had 99 percent accuracy in detecting inpatient medications in 367 patients. There were no false positives and less than one percent for false negatives. In reconciling prescription data from medical records to 310 outpatient samples (collected in the emergency room) 41 percent of patients were non-adherent for at least one prescribed medication and 31 percent used at least one medication not in the medical record (mostly due to incomplete electronic data).

PeaceHealth has soft launched the test within the hospital and is working on establishing a standardized process to ensure ordering the test becomes the standard of care. In the outpatient setting, Beardsley sees a role for RxAdhere in reducing medication nonadherence, which can improve outcomes for common chronic conditions and medication treatment decisions—for example, it can help determine if the drug or dose is not working or the patient is not taking the medication.

Takeaway: To remain competitive laboratories need to provide enhanced value to their partners throughout the health care system. Laboratory data must be utilized for the financial benefit of the health care system—whether to improve the appropriateness of test orders or prevent longer lengths of stays or adverse reactions.