CEO SUMMARY: As health networks and hospitals consider outsourcing their lab outreach programs, the lab team at Dartmouth-Hitchcock Medical Center (D-H) offers lessons about the value of retaining outreach. D-H is now in the eighth year of a sustained expansion of its laboratory outreach business. It has combined its lab outreach strategy with a proven plan of implementation. This combination is proving attractive to office-based physicians and community hospitals in New Hampshire and some surrounding states.
HOSPITALS AND HEALTH NETWORKS often fail to integrate clinical lab testing from their affiliated, office-based physicians, especially if those referrals are going out of doctors’ offices that are located near the main campus.
Ten years ago, when the Dartmouth Hitchcock Medical Center (D-H) in Hanover, N.H., noticed this problem, it implemented a strategy to integrate that testing into its core lab testing volume. The first phase started with physicians’ offices in Southern New Hampshire. The process of integrating lab testing from doctors’ offices then was replicated in other regions of the state and into neighboring Vermont. D-H’s strategy to build the lab outreach program has paid dividends in standardization of testing platforms, increased test volume, and lower costs per test.
In 2010, Dartmouth developed and implemented a system to ensure that physicians in the out-of-area clinics owned by the health system would send their routine clinical pathology specimens to the main D-H lab in Lebanon, N.H. Previously, these physicians sent their routine clinical pathology lab tests to commercial lab companies.
“The first step in our planned integration process involved putting infrastructure in place in Lebanon,” said Ellen J. Dijkman Dulkes, MS, MT(ASCP), Outreach Services Manager in D-H’s Department of Pathology and Laboratory Medicine. “We needed a million-dollar capital plan to accommodate the increased test volume.
“Therefore, we invested in technology, including high throughput analyzers and improved connectivity to manage the increased test volume,” she added. “The lab invested in hematology and chemistry automation and upgraded its laboratory information technology with the connectivity solutions needed for such a project.”
At the same time, the lab team also made plans to replace the commercial laboratory that was then operating phlebotomy and stat laboratories in buildings owned by D-H in Manchester and Nashua. D-H also had phlebotomy draw sites in other D-H clinic locations such as in Bedford, Milford, and Merrimack, she said.
In 2010, the D-H Lebanon lab assumed operation of these locations in Southern New Hampshire and since then has continued to expand its clinical laboratory outreach business based on this early model.
“Since then, our health system has used that same process to bring in lab tests from other hospitals in New Hampshire and Vermont,” Dulkes said. “In other words, the process that worked so well in 2010 to encourage physicians to use their health system lab is the same model we use today to corral lab test referrals from hospitals and physicians’ offices in other areas.”
Integrating outreach testing from affiliated practices began more than eight years ago when D-H identified several reasons for making the changeover: better patient care because the test results would be available in the D-H patients’ records and lower costs per test due to increased volume.
Integration of Lab Testing
Previously, a national lab company was run- ning the tests for physicians associated with D-H in those Manchester and Nashua clinics. Routine lab testing from Concord was integrated later when D-H assumed operation of the Concord clinic laboratory.
“Our original scope of the work called for shifting lab tests that were going out of our community group practices in Manchester and Nashua,” Dulkes said. Those tests were going from D-H clinics to a large national lab company that Dulkes did not wish to identify.
“While these three physician groups were Dartmouth-Hitchcock owned clinics, they weren’t affiliated formally with our main campus,” she noted. “Instead, in these early years, these physician groups were sort of a separate entity, and because of that, they were not fully a part of the Dartmouth-Hitchcock health system.
“Of course, the lab knew these clinics were not sending their tests to the main lab in Lebanon, N.H.,” she added. “The commercial lab leased space in the D-H clinics, its staff wore its company-branded lab coats, and it operated its own courier transportation system to move our D-H specimens to their central commercial hub for testing.
“As well, the commercial lab company had its own lab set up in our D-H clinics,” recalled Dulkes. “At those sites, the commercial lab was well integrated into our D-H clinics, using leased space and its own staff and couriers.
Bring Tests In-House
“But then a few years before 2010, our lab team started talking about all the reasons it would be best to do those lab tests in-house,” she said. “The first and most important reason was to improve patient care. Having those tests done in-house allows us to collect the data on those patients’ test results and include that data in each patient’s chart and electronic health record. We couldn’t do that when those tests were going to another lab company.
“The second reason is that—as is the case with all outreach programs—running those tests in our own lab lowers our unit-cost per test while providing us with the additional specimen volume needed to bring more tests in house,” she said.
“As a first step, we recognized the need to make certain infrastructure improvements in our Lebanon lab,” she noted. “Once we did that, then having outreach specimens performed anywhere else made no sense.
“Next, we needed a plan to make the change in a way that would minimize the disruption to the physicians’ practices, to patients, and to the commercial lab that was running those tests,” Dulkes said. “We had no ill will toward that lab company and it turned out that they had no ill feelings toward us either.
“The commercial laboratory worked well with us on a smooth transition plan for the patients and the employees,” she stated. “Everyone knew that we were making this shift strictly on the basis of improving patient care and bolstering the finances of our own lab and parent organization.
“Nevertheless, we didn’t disclose our plans to bring those lab tests in-house until about 150 days before the go-live date,” recalled Dulkes. “That go-live date came in 2010, when all locations went live on the same day, at the same time.
“Prior to 2010, we laid the foundation to support this expanded lab outreach effort by putting a plan in place to bring those tests to our lab in Lebanon, N.H.,” she added. “That was actually the first step in what became a multi-year effort to shift all tests that were going elsewhere into our own lab.
“Because we did this planning covertly, we named the project ‘Operation Rosebud’ and decided not to tell the commercial lab until there were 150 days to go,” she said. “In addition, we told everyone not to discuss the project with anyone outside of the D-H lab unless absolutely necessary.
Bring in New Lab Staff
“We wanted to do as much of the work behind the scenes as possible,” she commented. “That meant we needed to figure out how to bring in new lab workers through human resources, we had to determine a salary structure for each new staff member, and we had to assign new courier routes so that we could move specimens four times a day.
“We knew that the commercial lab company had stat labs in Manchester and Nashua, so we wanted to mimic those services as much as possible,” Dulkes explained. “In an important step, we met with the medical staffs in Manchester and Nashua to ask what they wanted on-site and what we could do to meet or exceed the services they had with the commercial lab.
How to Be a Better Lab
“At this time, we knew that the commercial lab was CLIA-certified, we knew its hours of operation, its test menu, stat lab services, turn-around times, courier routes, staffing levels, its lab-results reporting system, and we knew how its lab staff interacted with our physicians,” Dulkes said. “We wanted to be better in each of these areas, which meant our lab would be CLIA- and CAP-certified, we would have longer hours of operation, better test menus, faster TAT, and more.
“We also recognized the importance of partnering with regional hospitals in those areas, such as Catholic Medical Center and Elliot Hospital, both of which are in Manchester,” she added. “We needed regional partners for testing some time-sensitive specimens because it wouldn’t be sustainable to send them all to Lebanon. We needed these partners to provide services that we couldn’t provide on-site. And, again, we developed all of this covertly.
“We used the state inspection at each site as a milestone, following which we had what we called a Thanksgiving dinner at each site,” she commented. “The dinner allowed everyone to meet each other and it helped everyone feel like they were a member of the same team.
“By end of winter in 2010, we had a go-live date for Manchester and Nashua of March 15,” said Dulkes. “That was a Monday and the commercial lab vacated the premises in the phlebotomy draw sites on the Friday before. The commercial lab did not vacate the stat labs, however, until Sunday, on the night before we went live. Their staff left at about 8 pm or 9 pm that night and we cleaned the labs and moved in our equipment that same night. We did all that work with lab staff from the Lebanon campus who volunteered their time. It was a huge undertaking.
“Several years later, we followed the same process in Concord,” she added.
“For the entire outreach project, we hired about 30 or so full-time equivalent staff, including a new supervisor, team leaders, clinical laboratory scientists, and phlebotomists, and many of them came from the commercial lab,” she said. “We also arranged a van to drive the new phlebotomy staff from the south up to Lebanon for training prior to go-live.
“Our goal was to have the new staff become familiar with how our lab operated and we wanted those same processes in place in the physicians’ offices and in the new D-H stat labs as well,” Dulkes continued. “Also, we required our new staff to get their ASCP certifications, which they didn’t need when working for the commercial lab.
“As a result of all our preparation and planning, as each project went live, there were only a few problems,” she said. “Most of the problems involved phlebotomy. We did not anticipate the need for more phlebotomists and quickly contracted with a temp agency who filled the gap until we could train and hire permanent staff.
Lab Projected 48-Month Return on Investment
WHEN DRAFTING THE PLAN to integrate clinical lab services from three physician groups in Southern New Hampshire, the clinical lab staff at Dartmouth-Hitchcock (D-H) estimated it would take four years to get a return on the investment.
“When this project started, we knew that D-H was paying the commercial lab to run our own tests,” said Ellen J. Dijkman Dulkes MS, MT(ASCP), D-H’s Outreach Services Manager.
“At the time, capital costs for this project were estimated to total about $2.4 million, including $84,000 for new furniture, $1.75 million for new medical equipment, $50,000 to prepare the building, and $550,000 for new information technology systems,” she said. “In addition to our capital costs of about $2.4 million, we would need to spend more than $707,000 to hire 27.5 FTEs for a total estimated investment of $3.1 million.
“Once we had those numbers, we estimated that the increased testing volume would generate a margin of almost $800,000 annually,” she said. “At that rate, it would take us about 48 months to earn back this investment. Our actual numbers showed that we were just about on target for our return on that investment.”
“The technical staff performed quite well,” stated Dulkes. “That was because we mimicked the equipment that the Lebanon-based laboratory was using. By using similar testing platforms, reference ranges were now standardized across the health system, and we had the technical staff trained in Lebanon prior to go-live. Therefore, the new lab staff members were already familiar with our equipment.
“Although the problems were few, we did have one clinical practice difference that we needed to address,” she said. “Under the previous commercial lab’s procedures, physicians could order any test they wanted. But at D-H, we require physicians to order tests that comply with best practices.
“For example, in Manchester and Nashua, the physicians would often order a test for ova and parasites, in part because they have a high refugee population,” she explained. “At D-H, we order different assays. Instead of running tests for ova and parasites, we run a test for cryptosporidium and giardia. We don’t do a true ova and parasite test unless a patient has a significant travel history, meaning they’ve been to an area where such parasites are endemic.
“To address this issue, we sent our subspecialty pathologist down to do in-service training and education with their medical staff and to smooth out these kinds of bumps as they arose,” she concluded. “Outside of that, the problems we faced during this transition were minimal.”
Lab Developed Detailed Plan to Expand Outreach Program
BEFORE 2010, THE CLINICAL LABORATORY at Dartmouth–Hitchcock had medical directors in four of the hospitals in the surrounding area and these hospitals were sending anatomic pathology specimens to the D-H lab. But most of the clinical lab testing from those facilities was not coming to the health system’s core lab in Lebanon, N.H.
Under a plan the lab and health system staff developed, the lab prepared to integrate clinical lab specimens from many of the hospitals in the state, and from some physicians’ offices as well, said Ellen J. Dijkman Dulkes MS, MT(ASCP), D-H’s Outreach Services Director.
“In 2010, we took outreach testing back from three physicians’ offices in Southern New Hampshire and that was the first step in a project that continues even today,” Dulkes said. “In 2014, we put in medical directors for clinical pathology and anatomic pathology in four hospitals in the Lebanon region.
“Those four facilities are Alice Peck Day Hospital (in Lebanon, N.H.), New London Hospital (in New London, N.H.), Mount Ascutney Hospital (in Windsor, Vt.), and Valley Regional Hospital (in Claremont, N.H.). Later that same year, those four hospitals began sending more of their tests to Lebanon,” she said.
“Last year, Cheshire Medical Center (in Keene, N.H.) became an affiliate and we are working more closely now with Brattleboro Memorial Hospital (in Brattleboro, Vt.),” she added.
Contact Ellen Dulkes at 603-650-7487.