Thursday, July 18, 2019

by IRWIN Z. ROTHENBERG, MBA, MS, CLS(ASCP) 

The convergence of two powerful forces are changing the practice of laboratory medicine in ways never imagined a generation ago.  These twin forces are the movement to value-based healthcare from the fee-for-service model and the rapid development of mobile technology allowing for continuous healthcare monitoring of patients beyond the clinical setting.

The central focus of value-based medicine is increasing the value of medical services provided for patients based on the health outcomes achieved per dollar spent. The goal is to achieve good outcomes efficiently. This is the most effective way to truly contain health care costs.  Achieving and maintaining good health is inherently less costly than dealing with poor health; reminiscent of the old adage “an ounce of prevention….”

Laboratories can impact the value proposition by increasing the speed and accuracy of correct diagnoses, monitoring patient health to prevent disease, providing rapid turnaround times that allow reduction in length of hospital stays, and promoting the most appropriate test selection options with applicable interpretations in order to help avoid adverse events and point to the most appropriate treatment protocol. Translating concept into practice, however, can be challenging. Generally, the biggest hurdle is obtaining the necessary data, which must be in the right format and of sufficient quality for decision-makers to gain the medical information they need.

This is why Point of Care testing (POCT) has become the fastest-growing area of laboratory medicine; bringing laboratory testing conveniently and immediately to the patient. The new technology is the merger of molecular biology, information technology, and biomedical engineering. POCT increases the likelihood that the patient, physician, and care team will receive the results sooner, which allows for immediate clinical management decisions to be made. With fast turnaround times and portability to a variety of settings, POCT offers many advantages for disease management. It enables migration of testing from core hospital labs to specialty-care units, doctors' offices, retail settings, and homes to provide access to healthcare services, thus improving patient compliance, reducing hospital stays, and lowering overall healthcare costs.

It is this need for immediacy in data collection and dissemination that is further driving mobile technology past POCT to wearable devices that monitor everything from glucose levels to cardiac function. This cuts costs, as well as increases connectivity and provides the platform for shared medical data in real-time.

This system allows patients to be constantly followed, alerting them and their providers when health issues are amiss. We are moving rapidly from POCT in the context of portable bedside devices run by medical personnel, to portable devices run by the patient, and now, wearable devices worn by the patient for continuous monitoring. These are fed back to healthcare providers, information is tracked on a continuous basis, allowing assessments of the effectiveness of medication and treatment.

Wearable Digital Technology:  Coming to a Joint near you

This new mobile technology is based on the same mobile platforms for smartphones and tablets. It is expected that mobile technology will enable virtually universal quality, cost-effective, preventable healthcare even in lesser developed countries, in much the same way that mobile phone technology has allowed countries to leapfrog beyond land-line phones to the cell phone era and all its possibilities.

It is now clear that the technology industry sees medicine as the next frontier for exponential growth. Companies such as Apple, Google, Microsoft and Samsung and hundreds of start-ups also see the market potential — and have big plans. This is happening because several technologies such as computers, sensors, robotics, and artificial intelligence are advancing at exponential rates. Their power and performance are increasing dramatically as their prices fall and their dimensions shrink.

We will soon have sensors that monitor almost every aspect of our body’s functions, inside and out. They will be packaged as wearables, as watches, adhesive bandages, clothing, and contact lenses. They will be in our toothbrushes, toilets, and showers. They will also be embedded in smart pills that we swallow. The data from these will be uploaded into cloud-based platforms

Artificial intelligence-based apps will constantly monitor our health data, predict disease and warn us when we are about to get sick. They will advise us on what medications we should take and how we should improve our lifestyle and habits.

All this will translate to improved patient care through patient-centered preventive medicine at reduced cost, and to the more efficient treatment of both acute and chronic illnesses; the very definition of quality care.

A report by PricewaterhouseCoopers’ Health Research Initiative (HRI) evaluated the benefits of wearable digital technology and devices. These include:

1. Moving diagnostic testing of basic conditions into the hands of patients: Close to 42% of physicians are comfortable relying on at-home test results to prescribe medication.

2. Increasing patient-clinician interaction: Half of physicians said that e-visits could replace more than 10% of in-office patient visits, and nearly as many consumers indicated they would communicate with caregivers online.

3. Promoting self-management of chronic disease using health apps: 28% of consumers said they have a healthcare, wellness, or medical app on their mobile device, up from 16% last year.  Nearly 66% of physicians would prescribe an app to help patients manage chronic diseases such as diabetes.

4. Helping caregivers work more as a team: 79% of physicians and close to 50% of consumers believe using mobile devices can help physicians better coordinate care.

It’s clear from HRI’s report that major stakeholders in the healthcare industry including hospitals, insurers and the pharmaceutical industry all believe that major changes will occur in how healthcare is delivered.

However, there are several potential barriers that may inhibit or delay the implementation of this new paradigm of healthcare. These include issues of security, privacy, consumer consent, data-sharing, fragmented workflows, and digital buy-in.

The Impact of Mobile Technology on the Laboratory

These trends portend a future of value-based medicine involving widespread use of remote monitoring of almost everyone, throughout their lives: preventive medicine to spot health issues before they arise (for example, based on genomic studies showing potential for disease occurrence), as well as for ongoing monitoring of chronic medical conditions.

One of the key areas of laboratory to physician communication is that of reporting critical values. Since critical values are defined as abnormal test results that are potentially life-threatening and require a rapid response from caregivers, any steps taken to improve this process impacts the quality of patient care.   This not only refers to the timeliness of reporting test results but ensuring that these results reach the intended physicians no matter where they are; and that the information sent and received is secure.

Thanks to the rapid spread of mobile technology, including mobile phones, pagers, pads, and computers linked to electronic health records, new more secure messaging systems to report critical values are available.  These systems offer security that normal cellphone text messaging lacks, and their two-way capabilities automate the kind of closed-loop system that patient safety experts have advocated. These mobile-friendly applications can keep critical results from falling through the cracks. They create an audit trail of message sending, delivery, and receipt, and labs can configure software that escalates an alert when the initial caregiver does not respond in a timely manner.  The application of mobile technology to real-time patient monitoring using wearables synced to mobile phones, enables the immediate transmission of any detected critical values to the laboratory’s electronic health records system (EHR.), and the physician notified immediately.

As wearable technology and devices proliferate, clinical laboratorians must be prepared to process the data received from these varied sources, including new types of information, such as real-time patient locations and environmental factors during data collection.  This data must be organized, stored and transmitted to the attending physicians and /or patients directly in as timely a manner as possible.   

As a result, laboratories will not only remain centers of actual testing but become huge database handlers as well.  Direct access to patient test results by the patients themselves opens up another huge highway of interaction with the public; another huge challenge to meet the demand for data.

Artificial intelligence-based apps will constantly monitor our health data, predict disease and warn us when we are about to get sick. They will advise us on what medications we should take and how we should improve our lifestyle and habits.

The appellation “data central” may not adequately describe the level of importance that laboratory medicine will have, where data handling may well win the competition for space with diagnostic instrumentation.

As value-based healthcare becomes the prevailing model for healthcare delivery, laboratory testing will be focused on prevention, diagnosis, and the management of chronic diseases. In this scenario, the cost of the test versus reimbursement will not be the deciding factor on whether to perform the test. Instead, the focus will be on what it can save the patient and the entire organization by enabling early detection.  The increased application of digital mobile technology advances this goal.

The paradigm shift in healthcare from episodic care to chronic-care management; from reactive to preventive care, represents a once-in-a-generation opportunity for proactive laboratories to redefine their value in a new, much larger role as integrators of critical clinical information and decision support.

References:

¹ Medical Laboratory Observer (MLO) January 2011. POCT key to widespread access to healthcare. Glorikian, H. Rajan, A. and Xie.K.

²Health Care Revolution, Starting with your Wrist.  Wadhwa.V.,  March 24, 2015.

http://amestrib.com/opinion/ vivek-wadhwa-health-care-revolution-works-starting-your-wrist/

³ Ibid.

⁴ PricewaterhouseCooper (PWC)  Health Research Institute. The Wearable Life 2.0 Connected living in a wearable world. Consumer Intelligence Series. https://www.pwc.com/ee/et/publications/pub/pwc-cis-wearables.pdf

⁵ B. Malone. The Dilemma Surrounding Critical Value Reporting.  Dec. 1 2012.  AACC. Clinical Laboratory News.   https://www.aacc.org/publications/cln/articles/2012/december/critical-value-reporting.aspx

⁶ Disembodied Devices.  AACC Clinical Laboratory News. Miller, J. May 1, 2019

⁷ K. Futrell.  Orchard Software Whitepaper: The Value of the Laboratory in the New Healthcare Model.  Diagnostic Information: The New Currency in the Future of Healthcare. July 2013.   http://www.orchardsoft.com/files/white_paper_value_lab.pdf

IRWIN Z. ROTHENBERG, MBA, MS, CLS(ASCP) 

Irwin Z. Rothenberg is a Technical Writer/Quality Advisor for COLA’s Educational subsidiary, COLA Resources, Inc. (CRI), a leader in online continuing education for physicians, laboratory personnel, and allied health professionals.  CRI offers continuing education through online courses, informational products in both electronic and hard copy form, webinars on cutting-edge technology and regulatory issues, and CRI on-site Symposia for Clinical Laboratories, providing live educational sessions and interactive workshops with leading industry organizations. For more information, visit their website at www.criedu.org or call 1-800-981-9883.