In response to healthcare’s transformation, a pathologist and a lab CEO describe two powerful ways that medical laboratories can collaborate with physicians, patients, health systems, and health insurers to deliver more value
DATELINE: Phoenix, Arizona—It may be appropriate that, with the pace of change heating up in both healthcare and the clinical laboratory industry, it was here in the hot Sonoran Desert that more than 500 medical laboratory professionals gathered last week for the annual Sunquest User Group Conference (SUG) hosted by Sunquest Information Systems.
Opportunities for Pathologists to Help Doctors Reduce Medical Errors
The week started with a full-day workshop featuring thought leaders in laboratory medicine and healthcare. Two speakers offered contrasting perspectives on the value of medical laboratory testing services. Each focused on a different source of opportunity for pathologists to deliver more value to clinicians through improved utilization of clinical lab tests.
Offering the perspective of reducing medical errors by better utilization of laboratory tests was Michael Laposata, M.D., Ph.D., Chairman and Professor of Pathology, University of Texas Medical Branch, Galveston, Texas. The interesting counterpoint to his presentation was the perspective of how labs have the opportunity to combine lab test data with other clinical data sources to deliver more value to physicians. This speech was delivered by Khosrow Shotorbani, CEO and President of TriCore Laboratories of Albuquerque, New Mexico.
In Dr. Laposata’s view, there is a huge upside to lab medicine and healthcare for pathologists to tackle the problem of medical errors. He recommends that medical lab professionals work more closely with clinicians to identify the sources of diagnostic errors, then, help physicians reduce those errors through a more informed process of ordering the appropriate medical laboratory tests, and becoming more effective when using lab test results to select therapies and monitor the progress of patients.
Number of Medical Errors Much Larger than Perceived
In a series of slides, Laposata demonstrated how much larger the scope and scale of medical errors actually is, compared to common perceptions. During his introduction, he made the following points:
• Medical error is a more common cause of death than diabetes, complications of Alzheimer’s disease, accidents, and stroke.
• Medical error is responsible for approximately 25% of the number of deaths from cancer.
• A large part of the increased number of these events is greater recognition that the cause of death may have been a result of medical error.
• Many opinion leaders state that the number of deaths from medical error is likely to still be underestimated.
To illustrate the level of diagnostic failures that are believed to be more common than indicated by healthcare statistics, Laposata said, “In a study published in the Journal of the American Medical Association (JAMA), a collection of 53 autopsy studies revealed that 23.5% of the cases had a missed diagnosis while the patient was alive. The researchers concluded that approximately one in four deaths includes a missed diagnosis.”
Diagnostic Errors Twice as Likely to Lead to Death
As further evidence of the impact that medical errors have on patients, Laposata presented the findings for two different published studies. “The British Medical Journal published a paper in 2013 that concluded that diagnostic errors were two times more likely to lead to death or disability than other medical errors,” observed Laposata. “In another study that was published in the Archives of Internal Medicine in 2009, physicians were asked to recall diagnostic errors that involved their patients. These physicians said that 30% of diagnostic errors they could remember and for which they were responsible produced death or permanent disability.”
As many pathologists and clinical laboratory managers know, Laposata is a passionate advocate for diagnostic management teams (DMTs). These are formal, multi-disciplinary teams that include pathologists and specialist physicians. “The DMT springs into action when physicians order tests by requesting evaluation of an abnormal screening test or clinical sign or symptom,” noted Laposata. “Upon receiving that request, the expert physician and colleagues in the DMT then synthesize the clinical and laboratory data and provide a narrative interpretation based upon medical evidence. This happens not only when specifically requested by the referring physician, but also for every case handled by the DMT.” (See Dark Daily, “Pathologist Michael Laposata, M.D., Delivers the Message about Diagnostic Management Teams and Clinical Laboratory Testing to Attendees at Arizona Meeting”, July 21, 2014.)
Time is Ripe for More Collaboration Between Clinical Lab Professionals and Doctors
After Laposata’s presentation, Khosrow Shotorbani took the podium to discuss the innovative ways TriCore Reference Laboratories is combining clinical laboratory test data with other types of clinical and healthcare data. He continued the theme that the U.S. healthcare system is ripe for greater collaboration involving pathologists and clinical laboratory professionals and physicians in support of diagnosis, therapeutic decisions, and patient monitoring.
Shotorbani introduced the concept of “targeted intervention” as the next big opportunity in laboratory medicine, given the needs of healthcare for preventive care (that requires earlier, more accurate diagnoses) and personalized care (that identifies the unique circumstances of the patient to support a customized treatment plan.) He noted that clinical laboratories are ideally positioned to support these objectives in a healthcare system rapidly evolving toward population management.
“At TriCore, we are making steady progress to support what we like to call a laboratory-driven population health management model,” continued Shotorbani. “We recognized that fee-for-service payments for lab tests will continue to diminish. At the same time, health insurers, ACOs, medical homes, and similar care organizations will readily pay for clinical information services that measurably improve patient outcomes while helping reduce the overall cost of care.”
Shotorbani described three primary characteristics for TriCore’s new strategy:
• Relies on current and historical clinical laboratory data to provide real-time targeted interventions.
• Focuses on diseases with high incidences, increasing costs, and clinically-defined risks.
• Connects patients, providers, and health plans by providing data to identify gaps in care, improve utilization, reduce costs, and provide education for patients and providers.
How Labs Can Help Improve Management of Patient Populations
Several examples were presented to demonstrate how TriCore is already delivering parts of this vision. “Currently, TriCore provides about 70% of all the medical laboratory test results generated in New Mexico,” he explained. “We are already adding other clinical data to lab test data and are reaching the point where we can answer a question like, “What if we knew the prevalence of a disease across the entire state of New Mexico?
“Adult onset diabetes is a good example,” said Shotorbani. “This disease has wide incidence, well-established treatment protocols, and most healthcare organizations can deliver disease management services. What we are now capable of doing at TriCore is help providers develop care management programs tailored to the specific populations they are managing. We can slice and dice our robust data sets to show them the needs by city/zip code, by patient, by payer, and by health system.
“We are building the capability to help providers identify uncontrolled diabetics before they are typically recognized in most medical office and hospital settings,” he added. “We have dashboards that can be produced for specific populations within our service area. The clinically useful measures in these dashboards include:
• “Real time data—Patients with elevated Creatinine
• “Real time data—Patients with HbA1c in pre-diabetic range
• “Historical data—Patients with HbA1c in uncontrolled range
• “Historical data—Patients with no recent HbA1c in last six months
“Once these patients are identified, TriCore is positioned to use these robust data sets to help providers drive higher quality,” noted Shotorbani. “We can help physicians work better with patients to get A1c test results below 7%. We can help health insurers improve their HEDIS scores. And all this results in fewer complications and acute episodes, lower costs over the long term, and optimized economics for providers, payers, and TriCore.”
Opportunities for Pathologists and Medical Laboratories
One useful insight from the remarks made by Laposata and Shotorbani is that they remind all clinical laboratory professionals and pathologists of the wide range of opportunities that exist for medical laboratories to deliver great value to providers, patients, and payers. From Laposata’s perspective, the time is auspicious for pathologists to step up and engage their colleagues with diagnostic management teams and other services that can measurably reduce medical errors, with commensurate improvements in patient outcomes, patient satisfaction, and reduced cost of care.
The contrasting perspective offered by Shotorbani is that medical laboratories should move confidently forward to combine clinical laboratory test data with other types of clinical and healthcare information. Armed with the resulting knowledge, the laboratory team can leverage its competencies in diagnosing disease, recognizing appropriate therapies, and monitoring the progress of patients to be a collaborative partner with integrated deliver systems, ACOs, medical homes, and even health insurers.
These two presentations at the Sunquest User Group Conference only scratched the surface of the strategic business, clinical, and operational insights that were shared by a first-rate slate of speakers. Each presentation centered around innovative ways that clinical laboratories and anatomic pathology groups are “raising the bar” in the value of the diagnostic services they now provide to physicians.
If there was a single message that came through all of the individual presentations, it was that all clinical laboratories have the same opportunity to increase the value of the lab testing services they provide. However, in order to realize that opportunity, the pathologists and lab professionals in these labs need to think and act proactively, and that includes devoting the capital needed to add new types of lab tests and beef up the information technology capabilities needed to add value to raw lab test data.
Robert L. Michel
Editor, Dark Daily
25-Year summary of US malpractice claims for diagnostic errors 1986-2010: an analysis from the National Practitioner Data Bank: Diagnostic errors were two times more likely to lead to death or disability than other medical errors; BMJ Qual Saf 22:672-680, 2013
Diagnostic Error in Medicine: Analysis of 583 Physician-Reported Errors:
30% of diagnostic errors recalled by physicians for which they were responsible produced death or permanent disability; Arch Intern Med 169:1881-1887, 2009