عاجرا ماظن و هکبش یکشزپ هاگشيامزآ · laboratory network. 6. Make...

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Medical Laboratories: fNetworking and Referral System

Afshin Safaie, Doc. Clin. Lab. Sci., MPHAlborz University of Medical Sciences

Siamak M Samiee Doc Clin Lab Sci PhDSiamak M Samiee, Doc. Clin. Lab. Sci., PhD Reference Health Laboratory

Ministry of Health and Medical Education

The 7th International & 12th National Congress On Quality Improvment In Clinical Laboratories ( April 17‐20 , 2014 Tehran ,

Iran )

The transition from traditional fee‐for‐service reimbursement to global budgets for medical services will strongly incentivize providers to control unnecessary utilization.

Ancillary services including Radiology and Medical Laboratory testing are frequent targets of utilization management:• generally perceived to be over‐utilized• because they can be readily quantified• Utilization management almost always works!


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Laboratory practice and Utilization Program

• Practicing to volume: performing more testsPracticing to volume: performing more testsand charging for higher test volumes

• Practicing to value: performing onlyPracticing to value: performing onlythe necessary tests has been termed

Utilization programs are a growing part of shifting the culture of laboratory medicine from practicing to volume, toof laboratory medicine from practicing to volume, to practicing to value.


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Terminology C. Snozek et al. / Clinica Chimica Acta 427 (2014) 118–122

• Overuse. Overuse occurs when a service is provided even though its risk of harmexceeds its likely benefit—that is, when it is not warranted on medical grounds.

• Underuse. At the same time that some services are overused, others do not getprovided even though they would have been medically beneficial.

• Misuse. That term includes incorrect diagnoses as well as medical errors andother sources of avoidable complications.

• Utilization management. Utilization management (UM) represents a broad arrayof techniques designed to influence the consumption of health care services,usually with the objective of promoting Cost containment

• Efficiency and effectiveness. “In the management literature, efficiency is oftenassociated with performing activities as well as possible or ‘doing things right’h ff ti i ft t d ith th l ti f th ti itiwhereas effectiveness is often equated with the proper selection of the activities

or ‘doing the right things’”The United States Congressional Budget Office


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A Toolbox for Laboratory Utilization Management TacticsA. Huck, K. Lewandrowski / Clinica Chimica Acta 427 (2014) 111–117A. Huck, K. Lewandrowski / Clinica Chimica Acta 427 (2014) 111 117

• Physician education– Practice guidelines

• Clinical pathology consultation services– Practice guidelines

– Posting test costs– Physician profiling

services• Financial motivation• Structural changes• A diting tili ation• Imposing limitations on testing

– Discontinue obsolete tests (banning)

• Auditing utilization– Benchmarking against peer

organizations

– Use of gatekeepers– Establish a laboratory formulary

• Order entryy– Decision support– Testing guidelines

Use of “pop ups”– Use of pop‐upsThe 7th International & 12th National

Congress On Quality Improvment In Clinical Laboratories ( April 17‐20 , 2014 Tehran ,

Iran )

Point Of View ` Successful utilization control Howthe cost of parallel laboratory testing

1) Testing strategies that strike a balance between parallel and serial testing in the diagnosis phase to minimize total costs,

The first step is to establish a steering team that works to identify opportunities in

the cost of serial laboratory

cost-effectiveness(Dr. Art Eggert

i i )

that is, laboratory plus length of stay costs.2) Well-structured pathways that use the laboratory to provide no more costly information than needed to assure sound treatment management.3) Automated patient models that help

team that works to identify opportunities in the form of utilization problems that need to be solved. Step two is to develop approaches to address the problems as they are identified. One type of solution will not

k f ll h bl

testing

discussion)) p p

patient care physicians and laboratorians determine what is the best way to monitor a patients progress, and4) An outsourcing strategy that eliminates providing costly services internally while

t lli th t f t t t t

work for all the problems.The third step is to develop methods to measure the effectiveness of the utilization control effort. The final step is not to view anything that has been done as the final step.

the cost of not testing

controlling the costs of tests sent to reference laboratories.

p

Overutilization of laboratory services( Interventions that improve

Patient pressure

Patient education

Physician education

Gentle guidance → → → Strong guidance• Posting of guidelines on the

requisition• Computerized reminders regarding

utilization guidelines

Incomplete understanding of the effect of low pretest probability on the diagnostic

atio

n

laboratory utilization)

Physician education

Computerized physician order entry (CPOE) Guide or restrict physician choices.Education can be made more effective by combining it with other methods that make

utilization guidelines• Utilization report cards • Changes to manual requisition or • Computerized physician order entry

( CPOE)• Utilization report cards with peer or

leadership review

probability on the diagnostic value of a test.

Failure to understand the harmful consequences of overutilization

t Util

iza g

the desired behavior more likely. leadership review

• Requirement for high level approval (e.g. Pathologist) or consultation (e.g., Medical Geneticist)

• Utilization report cards with leader-ship review and financial penalties or incentives to encourage desired Defensive testing

Tes behavior

• Forbidding tests

The best approaches to improving laboratory utilization combine multiple interventions

Focus In depth health history Test utilization management programs


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http://www.evidence.nhs.uk/qippThe 7th International & 12th National Congress On Quality Improvment In Clinical Laboratories ( April 17‐20 , 2014 Tehran ,

Iran )

Regionalization/Networking: THE SPECIFIC GOALSRegionalization/Networking: THE SPECIFIC GOALS

• No duplication of lab resources.p• Equality. labs must operate on an even playing field.• Economies of scale.

– Pooling of the technologic prowess of a community's individual labs can create economies of scale by combining testing capacities.

– Networks can also lower unit costs by increasing the test volume.

• Logistical support.• Continuity of care.• Compatible data.• Universal principles


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PRACTICAL MODELS of regional laboratory operations

• Barter arrangements– to achieve the optimum volume/cost ratio.– Not a viable long‐term solution.

• Single hospital with outreach (in competition with commercial Laboratories)

• Regional referral models (minimal consulting activity and virtually no other reciprocal service from the testing lab to the test requester)– off‐site core, – the on‐site core,– the mosaic* "integration" and "rationalization“! integration and rationalization !

• Regional cooperative models(Networks): noncompetitive cooperation within a prescribed regionA C t id t k• A Countrywide network


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Responsibilities of Core Laboratory in a NetworkResponsibilities of Core Laboratory in a Network

* Provide education for technologists* Transfer technology, both methodological as well as management• Provide expert consulting through either teleconferencing or traveling consultant

services* Offer regional data processing support and database management* Insure regulatory compliance through periodic audits of the regional labs* Supply resources, including couriers, client service, billing, as well as marketing

bili i i l l b hcapabilities to support a regional laboratory outreach program* Assist regional labs in acquiring esoteric testing, either at the core lab or from a

remote referral lab* Provide expertise to undertake joint bidding for managed care organization contracts* Provide expertise to undertake joint bidding for managed care organization contracts


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Why Implement a Laboratory Network?improve laboratories’ quality/cost/efficiency ratiop q y/ / y

Quality:• Centralized supply of quality controlled reagents• National quality assurance program• Staff receive refresher on critical issues• National data management systemCost:• Reorganization of the laboratories → optimization of all working conditions,

workload• and analytical processes → economy• Centralized supply of reagents → economy of scale• Preventive maintenance policy → increased equipment lifespanEfficiency:• Sample transportation instead of patient transportation (if any)• Improved data management• Improved links between laboratories and disease surveillance systems• Improvement of the prescription/interpretation of medical analysisThe 7th International & 12th National


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PHL: Steps to building a statewide laboratory network of public health and private‐sector microbiology laboratorieshealth and private sector microbiology laboratories

According to APHL

1. Identify a team that will lead the development of the laboratory network.2. Define the purpose, short‐term goals, long‐term vision, and potential

benefits of the network.3. Develop a broad proposal for the public health laboratory administration.p p p p y4. Plot the course.5. Identify the potential needs and resources for the development of the

laboratory networklaboratory network.6. Make contact with potential partner laboratories.7. Select and conduct laboratory network development activities.


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Risks of Laboratory NetworkingRisks of Laboratory Networking

• Reduced Competition (Managed competition)Reduced Competition (Managed competition).• Financial risks.

l i• Pre‐analytic errors.• Induced demands!


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“It is not the strongest of the species that survives, nor the most intelligent, but rather the one most adaptable to change.”

Charles Darwin(1809‐1882)


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Thank you!yThe 7th International & 12th National


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