decentralized testing: the new world order...• as accountable care organizations and integrated...
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Decentralized Testing: The New World Order
Greg Lyons & Nancy Stoker Orchard Software Corporation
June 21, 2018
1. Define decentralized testing.
2. Clarify decentralized testing workflow.
3. Discuss workflow management considerations.
4. Examine various testing modalities.
5. Evaluate new and emerging technologies.
6. Review testing economics.
7. Coordinate patient data using software.
Learning Objectives
Topics • Terminology • Defining Workflows • Management • Differing Modalities • Laboratory Trends • Testing Economics • Coordinating Patient Data Using Software
Former Laboratory Managers:
• Nancy was a microbiology manager and multi-specialty group lab manager
• Greg was a hematology/oncology laboratory manager
HOW DID WE GET HERE?
A Bit of Disclosure
Terminology • Solicited vs. Unsolicited • Near-patient Testing vs. Bedside Testing
What are we doing?
http://www.heftone.com/recordings/down_home_rag_uke.mp3
Decentralized Testing Key drivers of decentralized lab testing: • Managing chronic diseases
– Diabetes
– Cardiac
Decentralized Testing • The increasing virulence
of infectious diseases
• The need for better drug monitoring for diseases such as cancer • The advances in technology
making laboratory testing more portable and “dummy proof”
• Solicited Orders – Orders are placed and sent from
host system (EMR) – Straightforward – Core lab very comfortable with workflow
• Unsolicited Orders
– No host orders exist, anywhere – More common in hospitals – Dependent upon HIS/EMR
ability to accept unsolicited results – Handheld devices that move from
patient to patient
Orders: Solicited vs. Unsolicited
• Near-patient Testing – Usually outpatient sites, such as
clinics and physician office labs – Testing site consolidation – Could be inpatient STAT lab
or hospital ER lab
• Bedside Testing
– Usually hospital inpatients – Could be outpatient but
performed “at the patient side”
Near-patient vs. Bedside
Defining Workflows • Solicited Orders to Near-patient Testing Location • Unsolicited Orders Performed at Patient Bedside
Solicited Near-patient Testing
Example: Automated CBC in Oncology Clinic
• Order for CBC placed via EMR • RN or MA runs CBC on analyzer • Results transmit to EMR • Decision made on therapy
Solicited Near-patient Testing
Management Considerations:
• Someone monitors QC
• Someone manages operator certifications or competencies
• Where does that “someone” live?
• It’s all about the NOUNS: Who, What, Where
Solicited Near-patient Testing
Common near-patient testing: • Urine strip readers • Urine pregnancy • Rapid flu • Hgb A1c • Basic chemistries • Cholesterol and lipids • Hemoglobin • CBC
Solicited Near-patient Testing
Unsolicited Bedside Testing
Glucose Monitoring of Hospital Inpatients • Glucose monitored 4x per day but no host order is
sent to the laboratory information system
• Patient’s finger stuck and glucose performed
• Decision made on therapy
• Results make it to EMR “magically”
Unsolicited Bedside Testing
Management Considerations:
• Non-laboratorians running the test
• Initial, 6-month, annual certification cycles
• Expired certification status sent to device
• If a certification is expired, the device can lock out the operator!
• It’s all about the NOUNS: Who, What, Where
Unsolicited Bedside Testing
Common bedside testing: • Glucose • Creatinine • Lactate • Electrolytes • Cardiac markers • Pregnancy • Coagulation • Blood gases
Unsolicited Bedside Testing
Management • Who? • Where? • What?
• Laboratory
• Respiratory Therapy
• Nursing
• Pharmacy
WHO
• Tests
• Instruments
• Kits
• Strips
WHAT
• Bedside
• Ancillary Departments
• Clinics
• Physician Offices
• Pharmacy
WHERE
• Industry consolidation means more remote testing sites – What is considered remote?
– Is the testing taking place across the hall or in another state?
• As devices become more advanced, their use in the
outpatient arena is increasing
WHERE, continued
Differing Modalities • Consumer-based Modalities • Impact of Technology
• At-home Testing – Traditional: glucose, urine, pregnancy, prothrombin time
– Newer: hemoglobin, hemoglobin A1C, drug screening, colon
cancer screening, cholesterol, and more
Lab Testing Modalities
• At-home Sample Collection
– Kits for mail-out testing
– STDs, allergies, cholesterol, lipids, DNA, paternity, hormones, vitamins, and more
Lab Testing Modalities
• Retail Pharmacy Clinics
– Pharmacist testing
– Increased consumer demand for walk-in clinic services
Lab Testing Modalities
Advances in Technology • Processing and analyzing
• Testing made simpler and smaller
– Microfluidics for CTC
• Patient self-education
Decentralized Molecular “As personalized medicine continues to advance, bringing molecular diagnostic testing to the point of care in the physician’s office will continue to be in demand.”
*GenomeWeb. “Decentralized MDx Testing Gaining Steam but Obstacles Remain, Industry Execs Say.” December 2008. Retrieved from: www.genomeweb.com/decentralized-mdx-testing-gaining-steam-obstacles-remain-industry-execs-say.
• The range of disciplines and use cases for which POC testing is a suitable option has expanded dramatically over the past decade, driven by advances in detection technologies and electronics
Expanded Capabilities
Quote and image source: Kate McLaughlin, PhD, and Donna Hochberg, PhD, “Horizons in Point-of-Care Testing,” November 30, 2017, Retrieved from: http://www.clpmag.com/2017/11/horizons-point-care-testing/?ref=fr-title on June 1, 2016.
– More recently developed POC platforms apply on a smaller scale the same principles as high-throughput core lab instruments
– Many are capable of executing complex protocols that include centrifugation, washing, and multiple reagent incubations in a self-contained disposable format
Advanced Functions
Quote and image source: Kate McLaughlin, PhD and Donna Hochberg, PhD, “Horizons in Point-of-Care Testing,” November 30, 2017. Retrieved from: http://www.clpmag.com/2017/11/horizons-point-care-testing/?ref=fr-title on June 1, 2016.
On the Horizon
Image source: Kate McLaughlin, PhD and Donna Hochberg, PhD, “Horizons in Point-of-Care Testing,” November 30, 2017. Retrieved from: http://www.clpmag.com/2017/11/horizons-point-care-testing/?ref=fr-title on June 1, 2016.
Portable & Smaller
• Testing Meters
• Smart Phones
• Smart Watches
Wearable • Continuous Glucose Monitoring
– Patch or smart watch
– Can be used in conjunction
with insulin pump to make automatic adjustments
– Data can be shared with healthcare provider
Image Source: The Diabetes Council. 2018. Retrieved From: https://www.thediabetescouncil.com/continuous-glucose-monitoring-everything-you-need-to-know/
• Other modalities in development
– Glucose monitoring contact lenses
– Bio-sensitive tattoo inks
– Implanted bio-sensors
– Who knows what is next!
Micro-wearable
Now Back to Reality…
Laboratory Trends • Patient Care • Quality • Billing
• As healthcare becomes more consumer-focused, the need for convenient diagnosis, monitoring, and screening tests is expanding
• Focus on improved patient outcomes and OVERALL cost of healthcare is considered, not traditional laboratory cost-per-test model
Laboratory Trends
• Test Quality – Are your remote testing sites
manually entering results to the EMR?
– Have you discovered errors?
– Is QC being performed?
Laboratory Trends
WHAT ARE THE RESOURCE COSTS OF MANUALLY MANAGING THESE ACTIVITIES?
• People Quality: Certifications
• Documentation that all personnel are qualified to perform testing
Laboratory Trends
• Billing – How are you billing for these tests?
– ARE you billing for these tests?
– If you are dependent upon manual
entry to the EMR….
Laboratory Trends
ARE YOU SURE YOU’RE CAPTURING ALL CHARGES?
Why is this important?
• Electronically capturing quality measures (QC and certification are just a start)
• Capturing charges for ALL testing events ensures your payors will have the quantity metrics along with the quality metrics
Laboratory Trends
Testing Economics • Point-of-Care Value Proposition
=
Point-of-Care Value Equation
VALUE CLINICAL OUTCOME
COST
Clinical validity, utility, and improved patient experience
• Improve chronic disease monitoring
• Decrease admissions/readmissions
• Face-to-face interaction with provider for more personalized approach
Clinical Outcomes
• Better monitoring = improved outcomes
• Improved outcomes = better reimbursements
• Improved outcomes with shared risk contracts = more dollars back to your organization
Value
Go back to the NOUNS:
• WHO is doing the testing?
• WHERE are they doing the testing?
• WHAT are they testing?
Cost Factors in Value Proposition
• Core laboratory is used to measuring cost per test
• Cost per test often higher in POCT testing
• In the Point-of-Care Value Proposition, it is one element, not the sole element
Cost
• Are your contracted insurance carriers requiring more data from you? – CPT: Category II codes
– Date-time: Operator stamps for
non-laboratory tests?
– Proof of training and certification
• These items will be the foundation for insurance carriers managing outcomes-based medicine and accompanying claims
Shared Risk Contracts
• Use CPT code rules to assign CPT-II
Comprehensive Diabetes Care
• Are you thinking outside the traditional lab testing box?
• Can you leverage your powerful LIS to manage data not typically associated with lab?
• Will managing this data help your organization bottom line?
Closing Care Gap: Can Lab Help?
• Diabetic Eye Exam
Let’s Think Outside the Box
If device has the capability…
• INTERFACE!
Acceptance is KEY
• The data contained within your laboratory information system is the currency that drives your organization
Data is the New Currency
• How do insurance companies look at your data?
• CPT-II codes to close care gap – HEDIS and Star Ratings
• Better (more complete) data = higher reimbursement
• POCT and core laboratory results
• Testing data that mirrors laboratory data but performed outside
the laboratory
Evaluating Data
CPT-II in Harvest: Conditions
CPT-II in Harvest: Actions
• On roadmap for Q1 2019
CPT-II in Trellis or Copia
Coordinating Patient Data Using Software • Population Health Management • Laboratory Analytics
Population Health Management
Lab's Opportunities in PHM
Development of PHM analytics and
algorithms that include lab results
Decisions regarding POCT
implementation to improve patient
engagement
As clinical consultants on a
PHM team, designing EHR rules and other alerts to trigger care
interventions
Supporting providers in QPP quality
measure reporting
• Labs can help providers meet quality measures, improving quality of care for patients
• HOW? – Live Dashboard Quality Management
– Data Mining
– Automated Reporting
Quality Measures
Dashboard Quality Management
• As accountable care organizations and integrated delivery networks (IDNs) continue to develop, more testing will be performed outside of the core lab, in ambulatory settings and decentralized locations
• Shared data can reduce duplicate testing, readmissions, and more
• If all data, including decentralized lab and self-testing results, are included in the data, all the better
Information Exchange
Data Mining
• Still thinking outside the box?
• Can you leverage your LIS to include non-traditional laboratory data?
Negotiate Insurance Contracts
• Identify your highest-risk patient populations
• Monitor frequency and timeliness of tests needed for chronic disease – Comprehensive diabetes care
– Low-density lipoprotein cholesterol
– Prenatal care
Use Data to Improve Outcomes
• Patient engagement is vital to an effective PHM program – Where can decentralized testing best serve the patient
population, and how are those results are integrated into analytics for PHM risk stratification?
– Decentralized lab and patient testing have been shown to increase patient engagement
Patient Engagement
• Home meter clinics
• Compare home results to POCT or core lab results
• Face-to-face interaction
Patient Engagement
• Hospital consolidation to create larger systems
• Industry standardization
• Big data, cloud-based storage, hosted systems, and other emerging technologies make interoperability easier than ever
Interoperability
1. Defined decentralized testing.
2. Clarified decentralized testing workflow.
3. Discussed workflow management considerations.
4. Examined various testing modalities.
5. Evaluated new and emerging technologies.
6. Reviewed testing economics.
7. Coordinated patient data using software.
Learning Objectives Review
• Patti Hines (University Hospitals)
• Judy Thompson (Washington Hospital)
• Tim Townsend (Brookwood Baptist Health)
Next: POCT Panel Discussion
Thank you!
System Administrator Advanced User Microbiology Module
System Administrator
To sign up for a training class, contact your Orchard Account Executive, call (800) 856-1948, or visit orchardsoft.com/training.
System Administrator Advanced User Integration – Levels 1 & 2
System Administrator
2018 Upcoming Training Courses
• Website: orchardsoft.com • Orchard Resource Center (ORC): orc.orchardsoft.com • Newsletter online: orchardsoft.com/newsletters • White papers: orchardsoft.com/whitepapers
Orchard Resources
Updated Presentation Materials: orchardsoft.com/symposium-sessions After July 1, we will post updated presentations from this event with links to the expanded ORC. Check out our white papers on population
health management, laboratory stewardship, point-of-care testing, laboratory leadership, and more.
Website & ORC Updates on July 1 orc.orchardsoft.com
Be sure to sign in to the ORC before July for
instructions on updating your account for the expanded ORC.
orchardsoft.com Our new website is coming, with new company and product logos.
• Visit the P.A.C.E.® table to complete the sign-in form, once per day, to receive full credit.
• Be sure to enter your email address; a P.A.C.E.® certificate will be emailed to each user after the symposium.
• Complete the feedback form for the event and for P.A.C.E.® feedback (online at: www.orchardsoft.com/symposiums).
P.A.C.E.® Credit & Feedback
• P.A.C.E.® Provider Number: 526
• Program Number: 526-902-18
• Program Title: Day 2 Orchard Symposium 2018
• Speakers: Beth Eder, Chris Lamb, Clair Smith, Greg Lyons, Gwenn Brode, John Miller, Judy Thompson, Karen Abara, Kim Futrell, Leigh Boje, Nancy Stoker, Nicole Carter, Patti Hines, Ryan Howard, Tim Townsend, Yuri Dozier
• Contact Hours: 5
Day 2 P.A.C.E.® Program Information
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