CEO SUMMARY: Here’s an integrated healthcare system that’s pushing its clinical laboratory across traditional barriers between physician’s office and clinical lab. At PennState Geisinger Healthcare, a fast-growing health system located in rural Pennsylvania, point-of-care testing is now an essential feature of the regional clinics and physician offices. The laboratory embraced this development and is now the “information manager,” gathering laboratory data and converting it into useful clinical information.
IN RECENT YEARS THERE HAS BEEN an ongoing and vociferous debate between the merits of the core laboratory versus point-of-care testing.
For laboratorians wedded to the traditional model of a centralized laboratory safely under the control of clinical pathologists, Ph.D.s, and medical technologists, discussion about pushing lab tests into the point-of-care and near patient settings is disturbing.
Yet it is a firm conviction of THE DARK REPORT that laboratory regionalization will go hand-in-hand with increased testing at the point-of-care. Both trends must be viewed as complementary and necessary.
Although this may seem a futuristic concept, a limited number of laboratory organizations are already moving towards exactly this type of business model.
PennState Geisinger Health System of Danville, Pennsylvania is a leader in this area of clinical laboratory evolution. Because Penn State Geisinger is an integrated delivery system, its laboratory division is organized specifically to serve the needs of an organization which provides the entire continuum of care, from cradle to grave.
“Our laboratory now looks at point-of-care testing as an opportunity, not a threat,” said Jay Jones, Ph.D., “What better way for the laboratory to know more about our customers at the point of care than to take responsibility for point-of-care testing?”
Dr. Jones is Director of Health Group Laboratories within PennState Geisinger’s laboratory division. He made these remarks at the Executive War College in New Orleans last May.
“PennState Geisinger is the largest rural health maintenance organization in the United States,” noted Dr. Jones. “Our insurance plan provides care to more than 250,000 people. We operate three hospitals, have 83 physician office labs in 40 counties, and we own rehabilitation facilities.”
To service this far-flung network of healthcare sites, a unified laboratory organization called PennState Geisinger Medical Laboratories (PSGML) was created. “Because of our multi-level menu of services, I use the term ‘distributed laboratory’ to differentiate us from traditional laboratory models,” observed Dr. Jones.
Today’s PSGML is the result of 15 years of continual change to the laboratory infrastructure serving the PennState Geisinger Health System. “I like to say that our laboratory organization has undergone a migratory process,” observed Dr. Jones. “This process generated widespread changes to how our laboratory is organized. Point-of-care is only one segment of these changes.
“From a broader perspective, we had to break the hospital mentality and the factory mentality to operating laboratories before we could embed our laboratory services into the integrated health system,” he continued. “This required us to move testing outside of centralized laboratory nodes to where clinicians really need us. We’ve identified that place where clinicians need us to be at the point of care.”
“During this evolutionary process, our distributed laboratory experienced a fascinating transition,” recalled Dr. Jones. “New technology and automated processes are regularly introduced into our core laboratory sites. As this occurs, medical techs ‘displaced’ by such automation migrate outward into physician office sites operated by our integrated healthcare system. As a result, we keep the experience and talents of our med tech staff, but they make their contributions away from a core lab setting, nearer to the physician.
“The concept of the distributed laboratory means that PSGML is made up of a core lab for the system, on-site labs at the hospitals, and POLs in the outreach market,” Dr. Jones noted. “Our laboratory network is expanding beyond a traditional mix of core labs, rapid response labs, and POLs. We are beginning to interact in a variety of clinical settings, exactly the types of places where laboratorians have not historically been found.
“These settings include the classical concept of hospital bedside point-of- care testing, but they expand beyond this, going into outpatient clinics, nursing homes, and home healthcare visits,” he added. “For example, as respiratory therapists administer home oxygen, we are exploring how to get state licensure for them to perform in-home blood gas testing with devices like I-Stats.
“Given the variety of clinical activities for which PSGML performs testing, the common glue binding together our laboratory system is information,” said Dr. Jones. “We developed data links so that all sites generating laboratory test results can feed those results into our LIS. We continue to refine the capabilities of those data links. At the same time, lab test data is available to authorized individuals anywhere in the PennState Geisinger Health System.”
Capturing Lab Test Results
Jay Jones describes a capability not found at many integrated laboratories. The ability to feed lab test results into the master LIS, regardless of whether the test was performed in the central laboratory or with a point-of-care instrument.
“For example, we selectively placed I-Stats in the operating room,” commented Dr. Jones. “This has been successful. It is our experience that this creates a paperless flow of information. The test is performed in the OR and the results are later batch-uploaded. Surgeons really like this arrangement and they’ve given the laboratory a lot of support and encouragement in rolling out this program.
“Although it has been difficult to measure and quantify outcomes,” noted Dr. Jones, “there have been comments by pediatric surgeons that this testing, done in the OR, has saved several lives during the last few years.
“As mentioned, PSGML is doing a lot of the standard hospital point-of-care testing about which so much has been written,” he continued. “What I call ‘new’ point-of-care testing happens outside the hospital in a very different clinical environment.”
Most Rapidly Expanding
“Such POC testing occurs in our health group laboratories, located in the primary care and specialty care clinics throughout our system,” added Dr. Jones. “These are the most rapidly expanding and challenging aspects to the integration of laboratory services with clinical providers.”
Compared to hospitals, clinics provide a different variety of issues for the laboratory. “First, we made a conscious effort to centralize complex testing. What remains at the clinic sites are waived tests, also known as Level One tests in Pennsylvania,” explained Dr. Jones. “As a result, 75% of our practice sites operate as waived sites.
“Next, we debunked the myth that if you advertise that you will do POC testing, then everybody demands it; vendors drop boxes off at numerous locations; and costs skyrocket,” observed Dr. Jones. “We had the totally opposite experience. For one thing, nurses are too busy to entertain the notion of doing another task.
“The reality is that most clinics have such a workload that their motive is now to gain the benefits of POC testing without having to take responsibility or control over the process,” Dr. Jones continued. “For that reason, our laboratorians have the full support of clinical staff in providing the necessary lab services.”
According to Dr. Jones, lab professionals maintain all testing done at the waived sites. This includes quality control, proficiency testing, and ongoing administration of laboratory testing performed at each site.
“Our laboratorians who work at these sites become involved in more than just laboratory testing,” Dr. Jones stated. “For example, some multiphasic med techs are doing radiology in addition to laboratory. As they interact with clinic staff, they get involved in things like OSHA compliance.
“It ends up that they help out in systems analysis, occasionally doing home phlebotomy and supporting home testing as that technology develops within our organization,” he continued. “Most importantly, our laboratorians have become a personal communications link with each practice site. We’ve started to call them the ‘fingertips’ of the laboratory, touching our customers at the point of care.”
Information capture is probably the most important part of making the Health Group Laboratories’ POC network successful. “Every laboratory has the problem of collecting the data necessary to process the test request,” Dr. Jones said. “Our laboratory is no different than others. We are learning that, as testing moves farther into the point-of-care environment, 90% of what we do is gathering necessary data and 10% of what we do is actual testing.
“Point-of-care is a data-rich environment,” he added. “By collecting the right types of data, we can take raw laboratory test results and develop some very useful clinical information.”
Blood Gas Testing
Dr. Jones offered the example of having I-Stat units in the physicians’ offices for blood gas testing. “An out-of-system laboratory typically charges $85 and some accessory costs to do blood gases. So even if only used twice a week, an I-Stat saves a lot of money where out-of- system cost avoidance is an issue.
“Also, take a situation where the physician sees a child with a headache in the clinic,” said Dr. Jones. “If the physician thinks the child is dehydrated and sends him to a local emergency room, by the time the child’s electrolytes are done and you add up the IV therapy, room charge, and professional charges, that simple encounter may easily run $300 to $500 dollars. Once again, having an I-Stat in the physician’s office can save a good chunk of money, not to mention improving the care provided to a patient.”
Another area that will expand the lab’s ability to provide useful information is the system-wide computer network which is constantly being upgraded.
“Currently PennState Geisinger is installing provider network PCs in examining rooms and physicians’ offices. It is an ambulatory care practice system called Epicare. This will take five years and $20 million to accomplish,” he observed. “It is more of a word processing tool and lacks the robustness to easily handle laboratory tables for assays, test results, reference ranges, etc.”
Seamless Flow Of Lab Data
“For that reason, our laboratory organization is stretching to create a seamless flow of lab data and information back and forth between our LIS and the Epicare system,” stated Dr. Jones. “This is important, because we understand that good data in the data base is like money in the bank.”
“Over time, this data will be turned into information. That information, in turn, will be used to develop a knowledge base,” he predicted. “This is where the laboratory gains an essential role in the integrated clinical environment. This knowledge base supports evidence-based medicine.”
Dr. Jones’comments about the PennState Geisinger Laboratory Group should be evaluated against several facts about the PennState Geisinger Health System.
Cost To The System
First, as an integrated delivery system providing total care to 250,000 people, the health system considers every expenditure of money to be a cost to the system. That old fee-for-service mentality of making money every time there is an office visit or a laboratory test has been replaced by a system-wide awareness by all employees that every clinical service is a cost to the healthcare system.
This has a big benefit to the laboratory. When laboratory administrators make a rational case that delivering lab testing through point-of-care solutions can be cost-effective while improving the quality of care, they have a receptive audience among both system physicians and administrators.
Lab Changes Were Mandated
Second, the administration at Penn State Geisinger has been very progressive during the 1990s. It has mandated change to the laboratory, such as consolidation of labs between the hospitals (1993), common LIS capability (1990), and standardization of instruments, assays, and procedures (1986).
Leadership by the administration has pushed the laboratory to restructure itself. It has incorporated new methods of solving system challenges on a much faster time line than other hospital systems around the country.
Third, the common information system platform that the health system has been steadily developing has actually made possible the laboratory’s campaign to push testing into various point-of-care settings. It means that test data, once input into the system, flows back to the laboratory where laboratorians convert it into value-added information for the clinicians.
Fourth, it should be noted that point-of-care testing is not used in isolated settings. Quite the contrary, HGL made it a deliberate strategy to imbed point-of-care testing into the clinical continuum.
Measuring POCT Costs
For that reason, the cost of a POC test is not measured against the cost of the same test performed in the core lab. It is measured as part of the entire clinical pathway, thus allowing the benefits of earlier detection or more rapid discharge decisions to be included in the cost-benefit analysis.
It should be no surprise that internal studies at PSG validate the conclusion that point-of-care testing frequently offers huge savings in the overall cost of patient care.
Fifth, HGL’s experience demonstrates that the arrival of POC testing does not automatically result in increased utilization. As Dr. Jones observed, POC testing has actually brought the laboratory into closer communication with clinicians and added to their value-added role within the healthcare system.
Clients of THE DARK REPORT know our longstanding conviction that laboratory regionalization is the inevitable end game to healthcare’s ongoing consolidation and integration. Regionalizing core laboratory services is a rational economic response to existing laboratory capacity.
In tandem with regionalization is the need for laboratories to participate in both clinical and operational integra- tion of healthcare services. This will require laboratories to move an increasing number of tests outside of core laboratories and nearer to the patient. Consequently, there will be an
increase both in the types of point-of-care testing assays available and the number of POC tests performed.
One factor not discussed by Dr. Jones is the ongoing arrival of smaller and more sophisticated POC instruments into the marketplace. Miniaturization of circuitry and the ability to perform a bioassay using smaller quantities of specimens and reagents will give each succeeding generation of POC devices improved clinical and economic benefits.
These are the reasons why THE DARK REPORT believes that the laboratory organization at PennState Geisinger Health System offers an early look at how laboratories within an integrated system will regionalize their services around a combination of centralized labs and point-of-care testing.
THE DARK REPORT further predicts that, during the next 24 months, point-of- care testing will carve out a new role for itself in the clinical continuum. Smart laboratories will put themselves in the forefront of this development.
Many Clinical Areas Use Point-Of-Care
PennState Geisinger uses point-of-care testing in a wide variety of clinical settings. The laboratory is expanding these boundaries where testing needs are identified, often without predefined authority. Here’s a partial list:
- Bedside glucose meters
- Intensive care (neonate, cardiac, etc.)
- I-Stats in intensive care areas
- Trauma service
- Outpatient clinics
- Nursing Homes
- Home Visiting Nurses
- Health Fairs
MORE INFORMATION AVAILABLE
This briefing was prepared from interviews with Jay Jones, Ph.D. as well as his presentation at the Executive War College in New Orleans on May 11-12, 1999.
Dr. Jones’s presentation provided a comprehensive overview of POC activities at PennState Geisinger Health System. An audio cassette and set of handouts can be ordered by calling Vicky Leslie at 503-699-0616. No charge to existing clients of THE DARK REPORT Intelligence Service. For non-clients the cost is $29.95 plus shipping and handling.