An Interview with ARUP Labs’ Senior Consultant, Outreach Development, Joe Miles, MT(ASCP), MHS

Joe Miles, MT(ASCP), MHS

With a new health care delivery model, the introduction of accountable care organizations (ACOs), and declining reimbursements, the role of clinical labs is changing. Managing those changes and ensuring that your lab remains integral to care delivery, as well as profitable, means in many cases streamlining workflow and interacting with physicians in ways that labs have not been required to do in the past. ARUP Laboratories, Salt Lake City, recently released a white paper outlining some changes clinical labs and pathologists should make to adapt. CLP sat down with Joe Miles, MT(ASCP), MHS, senior consultant, outreach development at ARUP Laboratories, Salt Lake City, to discuss how the industry is changing and what labs can do to stay ahead of the curve.

CLP: How will the adoption of ACOs change the way clinical labs interact with physicians?

Miles: Clinical laboratories have traditionally performed testing and provided test results in response to physician requests. In the past, laboratories have had a passive role in the selection and sequencing of test orders. In a coordinated care model such as an ACO, laboratories will have the opportunity to influence test selection and timing through collaboratively developed clinical pathways. Taking this idea a step further, physicians are challenged to be current in the use and interpretation of new test technologies such as molecular diagnostics and gene sequencing. Therefore, we at ARUP have begun to provide consultative services designed specifically to support the selection and understanding of the right test at the right time for given patient situations. This program has already been enthusiastically received by our clients, saving them thousands of dollars in unnecessary testing. This is a practice that we’d like to see the rest of the lab industry adopt.

CLP: Under the new ACO model, have clinical laboratories become a more integral part of care delivery?

Miles: Clinical laboratories have always been an integral part of care delivery and play a critical role in the diagnostic cycle. These new models of health care delivery are putting a spotlight on the dynamic capabilities of the lab, giving clinical lab professionals a chance to really step up and show that there is more to lab medicine than just samples in and results out. The practice of medicine will continue to be driven in large part by clinical data. It is noteworthy that laboratory data is utilized in 70% to 80% of medical decisions. Access to test information at the time of care is critical to reaching an accurate and timely diagnosis, which in turn influences all subsequent care choices and health care spending. A basic element of highly functioning ACOs will be access to complete and longitudinal medical records and the ability to share them among a variety of providers. This is essential for ACOs to create better outcomes while reducing overall costs of care. Clinical laboratories will continue to generate and distribute a large amount of this key clinical information.

CLP: How can hospital laboratories establish their value as an integral part of the clinical process?

Miles: Currently, hospital laboratories perform testing for inpatients, emergency patients, and outpatients. By extending their services to physician’s offices and postacute care facilities, hospital laboratories can create a complete record of lab testing. The integration and communication of test information through electronic medical records creates improved safety, efficiency, and timeliness of care. In addition, in coordinated care models, hospital laboratories have the opportunity to expand their traditional role and provide services and critical decision support expertise in nonhospital settings.

CLP: How difficult is it for laboratories to integrate with a provider’s electronic medical records?

Miles: The number of EMR vendors has increased considerably since the passage of the HITECH legislation. What we see in the industry are more creative solutions being developed to support interoperability and meet meaningful use criteria. On the technical side, it can be very difficult and expensive to produce a hard interface with a provider’s electronic medical record. Laboratory connectivity vendors are experimenting with new models that will help coordinate integrations and reduce or eliminate interface expenses. On the financial side, in our practice we see many laboratory clients struggling to get the capital dollars necessary to support their outreach growth. The most successful outreach programs have made the link between providing competitive laboratory services and deploying EMR connectivity. These top programs have secured the financial and administrative support of their senior executives to build a network of communications solutions in concert with their lab services.

CLP: Can laboratories assist in the development of clinical decision support software?

Miles: Absolutely. Pathologists and laboratory professionals have a once-in-a-generation opportunity to play a critical role in the development of clinical decision-support software. Pathologists are trained physicians with an emphasis on diagnostic skills. More than any other specialists, pathologists have the academic and medical training to maximize first-dollar decisions that result in timely and accurate diagnoses. In addition, pathologists have the knowledge necessary to analyze aggregate outcome data in order to uncover improvements in treatment protocols and use the information to design early clinical pathways.

CLP: What steps can labs take to streamline their operations and eliminate waste in this new delivery model?

Miles: Two significant sources of waste in laboratory testing are duplicate testing and unnecessary testing. Duplicate testing generally occurs when a previous test result is not available electronically, and therefore, the test is reordered. Consolidated medical records eliminate fragmented records and can identify duplicate orders at the time of order. Unnecessary tests are tests that provide no beneficial clinical information or no additional clinical information. Decision-support software can detect both duplicate test orders and test orders that appear inappropriate or out of sequence. Lab professionals can also be a voice for change and a real resource to other medical professionals, helping determine how to improve medical outcomes and eliminate medical and downstream waste.

CLP: What are some other things that labs can do to improve clinical care and boost their value in the care delivery model?

Miles: The challenge for ACOs is to create a system of coordinated providers across a continuum of care. Laboratories willing to work within an ACO model will need to establish relationships with all of the care providers participating with the ACO. This may mean working with ambulatory surgery centers, retail clinics, specialty clinics, rehabilitation hospitals, skilled nursing facilities, nursing homes, long-term care facilities, and home health care providers, among others. Each relationship will have different service needs and will require laboratories to develop and deliver a full scope of services.

CLP: What concrete steps can pathologists and clinical laboratories take to play a pivotal role and demonstrate greater value in facilitating the integration of clinical information across the continuum of care?

Miles: At ARUP we believe the real opportunities for pathologists and clinical laboratories to demonstrate greater value in the integration of clinical information are in the preanalytical and postanalytical phases of lab testing. In the preanalytical phase, laboratory professionals can influence test selection and sequence through CPOE and decision-support software. In addition, we have been promoting the idea of developing institutional laboratory formulary committees. These committees can function similarly to traditional pharmaceutical and therapeutics committees, and develop and approve clinical pathways as well as policies that manage the use of reference laboratories and police access to very low-volume esoteric testing. In the postanalytical phase, laboratory professionals can demonstrate clinical expertise by analyzing aggregate clinical data for given clinical conditions. We are producing large warehouses of clinical data that contain hidden answers to improving clinical outcomes, but to date, the right people have not been engaged to mine the information. Correctly analyzed, this data can identify the clinical protocols that produce the highest-value outcomes.

CLP: What steps should labs be taking today to ensure that they flourish under the new mandates of health care reform? How do they become “strong” and “integrated,” what concrete steps must be taken to leverage outreach relationships, and how can they initiate active participation in the formative stages of ACO development? Is it through industry membership organizations or through their own efforts?

Miles: What we see in our practice at ARUP are leading laboratories engaging their laboratory medical leadership (pathologists) and proactively defining new emerging business strategies. The elements of these strategies have common themes: extension of laboratory services outside the walls of the hospital to physician offices; deployment of comprehensive electronic-connectivity solutions; development of test-utilization management tools; aggressive management of operational costs; and promotion of laboratory services to physician and payor organizations. Waiting for “the right moment” to tell the story of their value and services will ensure that the opportunity will be missed.

CLP: Under a new payment model, how can labs prepare now to cushion the impact of reimbursement changes—or redefine their value and role in the future of health care delivery?

Miles: Reimbursements from commercial payor and government sources are generally declining. Formulas for reimbursement from bundled payments received through ACOs have not yet been defined. The laboratories most able to weather the impact of ongoing reimbursement pressures are the laboratories that are focusing attention on internal efficiencies and the cost of operations. In addition, the investments in connectivity solutions made today will pay dividends as more coordinated care models are developed. Some of the bundled payment models being proposed for use in ACOs place diagnostic service lines in competition with one another for a share of a single reimbursement pool. We work with many laboratory clients that have worked hard to help their senior executives see their laboratories as real health system assets. In many cases they have linked the hospital’s growth strategies with successful laboratory outreach programs. They have seized upon a once-in-a-generation opportunity to reaffirm the central role clinical laboratories play in the coordination of clinical information and the creation of improved patient outcomes.

Chris Gaerig is associate editor of CLP.