CEO SUMMARY: With an estimated 780,000 diagnosed and undiagnosed diabetics in their city, officials at the New York City Department of Health and Mental Hygiene decided to take proactive action. Labs will now electronically report HbA1c test results electronically to city health officials, who will use this information to proactively interact with both clinicians and patients to improve diabetes care and outcomes.
IT’S A DOUBLE-EDGED SWORD when Big Brother decides to put private laboratory test results to use for “public good.” Two recent government healthcare initiatives indicate a shift in the country’s healthcare system from a reactive to a proactive paradigm.
At the heart of this change is a government effort to use lab testing and test data to change patient outcomes. This move is significant to laboratory administrators and pathologists because it is a tangible sign that some part of the healthcare establishment recognizes that more effective use of laboratory testing has the potential to significantly improve healthcare outcomes.
Using Lab Test Data
The boldest initiative has been launched by the New York City Department of Health and Mental Hygiene (DHMH). It is taking the first steps to create a diabetes patient registry that will be used to identify and manage the treatment of diabetic patients. A key part of this effort is for laboratories to report patient lab test data to the registry.
New York considers diabetes to be its single biggest health problem. Living in the city are 530,000 diabetics. Another 250,000 people are believed to be undiagnosed diabetics. Diabetes is the fourth leading cause of death in New York City. In 2003, 1,891 people died of the disease and it is now costing $7 billion to treat diabetics in the city.
In a public health agency first, DHMH is requiring 127 laboratories in the city to electronically report HbA1c results into the Electronic Clinical Laboratory Reporting System (ECLRS), run by New York state. When a patient’s hemoglobin A1c results are 8 or higher, DHMS employees plan to alert that patient’s physician. They can also send an alert letter to the patient.
DHMS will not have patient consent to collect this data. It says that access to the data base will be under tight control. It also intends to allow patients to opt out of the project.
Several aspects of the project trouble consumer advocates and privacy experts. “This isn’t smallpox,” declared James Pyle, an attorney actively representing health privacy groups. “The state, or the city in this case, does not have a compelling interest in the health of an individual that overrides that individual’s right to privacy.”
The counter to this argument is that diabetes needs to be handled in the same fashion as public health threats. “We respond with surveillance when we believe something has reached epidemic proportions,” observed Amy Fairchild, Ph.D., a professor in the School of Public Health at Columbia University in New York City, “and this may fit the profile. Have we become a nation of obese people who are all going to get diabetes?”
Public Health Sector
Regardless of the ethical arguments for and against the NYC effort to proactively intervene in diabetic care, the reality of this program should catch the attention of pathologists and lab managers everywhere. It is an early marker of how the public health sector has a motive—and the power—to act assertively on issues it deems relevant to protecting public health.
It is also a demonstration of how laboratory test information is growing in value for health policy makers. By collecting this data across a population, policy makers recognize they have the opportunity to intervene with clinicians and patients. However, this puts the lab industry squarely in the middle of a debate over the right to privacy versus the “public good.”
As the country moves ever closer to an integrated national health information system, opportunities for government to use private healthcare data for “legitimate” public health purposes—such as in the case of the New York City proposal—will soar. And so will the opportunities for government to infringe on the individual’s right to keep that information private.
The New York City diabetes monitoring project is a significant event. It pushes the lab industry one step deeper into a new debate over the ownership of, access to, and uses for laboratory test data.
What Kind Of Response?
Individual laboratories and pathology groups can expect to see more of these types of initiatives, particularly from Medicare and Medicaid. What adds to the challenge is the fact that the laboratory industry, collectively, has yet to formulate either a policy or a response to this new dimension of healthcare. For that reason, lab managers and pathologists will need to devise their own strategy on this issue.
NYC Borrowing Strategy Now Used In New Zealand
THROUGHOUT THE WORLD, there are multiple examples of using lab test data to monitor diabetic patients.
One of the most interesting examples comes from New Zealand. In Auckland, the Counties Manukau District Health Board serves 400,000 people. This region includes a large Maori and Pacific Islander population, which has a high incidence of diabetes.
It initiated a program to electronically collect hemoglobin A1c lab test results, then track and manage diabetic patients. The system has built-in best practice rules. Based on test results and other information about a specific patient, the system, called the Integrated Care Server, will send treatment recommendations to the attending physician.
This automated system has made a big contribution to diabetes care. The Manukau Health Board reports that the number of diabetic patients with an hemoglobin A1c result of 9 or higher was reduced from 34% to 7% since implementation of the automated system.