November 2021—Flexible scheduling to suit family life and new “lab associate” roles—two solutions in progress or in place in labs wrestling with the staffing shortage. That and precision medicine test pre-approvals and utilization were some of what Compass Group members talked about on Oct. 5 in a virtual roundtable led by CAP TODAY publisher Bob McGonnagle.
Of the flexible scheduling he envisions in his lab, Terrence Dolan, MD, said, “Young people need money, but we must develop jobs that fit their lifestyle.”
The Compass Group is an organization of not-for-profit IDN system laboratory leaders who collaborate to identify and share best practices and strategies. Here’s what they had to say last month.
I’d like to talk about staffing, precision medicine, and new technology and operational efficiencies in the lab, and I’ll begin with staffing. Joe Baker, what are you doing at Baylor, in particular about system solutions?
Joseph Baker, VP of laboratory, Baylor Scott & White Health, Dallas: We’re trying to come up with creative solutions on how to bring additional talent into our system. We’ve submitted proposals to our senior leadership to implement phlebotomy and laboratory technician training programs, in addition to expanding our current medical technology training program that we have in our Central Texas area. We’re hopeful it’ll get funded and that we can kick that off very soon.
We have about a 15 percent vacancy rate within our system, which equates to about 150 positions for laboratory.
Steve Carroll, I know you’re keen on the labor issues in Charleston. Have you seen or thought about new wrinkles that would help solve some of this labor supply problem?
Steven Carroll, MD, PhD, chair, Department of Pathology and Laboratory Medicine, Medical University of South Carolina: The long-term solution for us is to get more training in place. The issue we run into is our College of Health Professions tells us those programs will not be profitable unless we have at least 30 students in each class, and that’s a fairly big lift. It will require us to partner with other educational institutions and bring in students from multiple sites. We’re working on that with our College of Health Professions and looking at programs for training clinical laboratory scientists, histotechnologists, and so forth.
In the short term, we’re struggling. We’re trying to bring in people who can work for us temporarily, and the competition for those people is intense. We think we’ve got a long-term solution, but short term I don’t have a good answer.
Lori Gauld, executive director of pathology and laboratory medicine, Medical University of South Carolina: To help support some of our testing personnel, we recently created new lab roles within the team, and we call those roles lab associates. We have two different levels—a bachelor’s level, which meets the CLIA requirements, and a level two, which is a master’s or PhD. We’re taking some of the work that doesn’t require a high level of expertise to help create new positions in our labs. Recent posts for those have drawn 13 or 14 applicants per position, which is unheard of for clinical testing personnel. That in conjunction with the long-term solutions Dr. Carroll mentioned will help us continue to fill holes and support good clinical work.
We have to be creative and do a better job of marketing what we have internally to the university science departments.
Joe Baker, everyone is talking about doing more training but not enough people are showing up to be trained. Is that fair to say?
Joseph Baker (Baylor): Yes, and it becomes even more complicated for us because we are on the Epic Beaker journey as well. We’re trying to find backfill staff for our subject matter experts to devote as much time as possible on the workflows and build. There’s nothing out there. We’ve tapped agencies and other companies and are finding that the quality of the candidates we’re receiving isn’t up to par with our expectations.
From a staffing standpoint we’re also worried about further burnout of our team when we do create our training programs and begin the Beaker journey. We’re looking for different incentives in that area.
Terry Dolan, last month you mentioned there needed to be a deeper understanding of what professional satisfaction might look like for someone working in a clinical lab. You were making the point that money alone is not going to solve the problem. Could you expand on what you have in mind?
Terrence Dolan, MD, president, Regional Medical Laboratory, Tulsa, Okla.: I’m spending more time talking to younger people to understand what gets them interested and excited about what they’re doing.
We’ve had for several years a specialty-type program where we enter people who have a bachelor’s degree in biology, for example. They are educated in chemistry or hematology or in other areas and they can qualify to take the exam for that specialty.
That won’t help us much in the community hospitals but it does increase the pool of total technologists. It’s been useful and successful over the years, and we are pushing to get it going again.
I’ve been giving thought to understanding the challenges of young mothers today. In the phlebotomy space, for example, we had young women who were trading off taking care of the kids with their husband, and their children weren’t of school age at that particular time. The women would work in phlebotomy from 2 AM until 7 or 8 AM, and go home. Their husband leaves to work, and then they cover the kids the rest of the day.
So I’m envisioning developing flexible scheduling. It will require IT capability, but it’s doable. People will give us their desired work hours in advance and say, I want this four-, six-, or eight-hour period. Then we load it into the system, and we can track the loads. We have parameters we use to staff accordingly. In a particular unit, for example, we know the time of requested collections and the phlebotomist productivity—expected collections per hour—so we can optimize staffing.
Young people need money, but we must develop jobs that fit their lifestyle.
Matt Posinski, tell me how things look from your perspective at Ochsner.
Matthew Posinski, MHA, VP, laboratory service line, Ochsner Health, New Orleans: We’re working on long-term strategies. We’re faced with the same short-term challenges in finding adequate candidates with enough experience, and/or it’s a pay issue, along with the life-work balance component.
We’ve had conversations with local community colleges to expand their classes and we have a couple of others in the works.
One of the things I noted at the AACC meeting, from the laboratorian and vendor sides, is how many retirements are cascading through the system. There is worry we might be at a grinding halt if things don’t pick up in terms of people desiring to enter the field. The return of COVID has had a dampening effect on people’s morale. John Waugh, would you agree?
John Waugh, MS, MT(ASCP), system VP, pathology and laboratory medicine, Henry Ford Health System, Detroit: It’s knocked us all down, and we have to reengage ourselves. It’s hung on far longer than any of us expected, and this last surge with delta—we’re back at 11.1 percent today in terms of positivity, and it’s in testing larger numbers of people. It’s discouraging.
We have a complicated workforce as well. Some of our labor force wants to work where they can find the most money with the best schedule and the greatest flexibility, and they can find it in other organizations if not at ours. So we’re having to accommodate.
The concern is that this is all driving burnout. We have to give people time off so they can catch their breath. We’re also competing with the high-profile nursing staff, who can attract and attain retention bonuses to a greater degree than people in the laboratory profession.
Our second topic is precision medicine and its complications, particularly given the high costs of running tests. And now there’s a rigorous hurdle on the pre-approval for test ordering and a worry about who’s responsible for pre-approval. Is it the laboratory’s responsibility, and is there anything in the EHRs that’s helping you solve this problem? Greg Sossaman, can you speak to this?
Greg Sossaman, MD, system chairman and service line leader, pathology and laboratory medicine, Ochsner Health, New Orleans: We all have concerns as we see precision medicine, however you define that term, continue to expand. We see it expanding in anatomic pathology, with reflex testing on new tumor or new cancer diagnoses, and with our population health program, where they’re looking to screen more individuals with different tests.
We don’t have a pre-service workflow built in Epic, and there is not a good way to build it into the system right now. It will require a combination of a good, solid workflow built into the EHR plus expansion of your own in-house genetic counselors or financial counselors, to determine what’s fair for the patient to pay, what’s covered by their insurance, those kinds of things.
It will be even more complicated as we see the new regulations around surprise billing, and then insurers will require even more stringent work as far as reimbursement. Coverage doesn’t equal reimbursement. So there will be more hurdles put into place around pre-service.
We’d love to hear if others have a good handle on that.
Jim Crawford, there’s an extraordinary amount of sophisticated testing that’s part of the Northwell lab and pathology offering. How are you coping with the pre-approval dilemma in your labs?
James Crawford, MD, PhD, professor and chair, Department of Pathology and Laboratory Medicine, and senior VP of laboratory services, Northwell Health, New York: I’ll back up a step and say from the start of our journey in precision medicine in 2016, my own approach has been that as health care providers, we should at least share, and if you’re in a fully capitated risk arrangement we should carry, the burden of laboratory testing and support the total cost of care. It’s our responsibility to exercise the necessary discipline and hopefully represent that to the payers.
How does that play out for our working relationship with BioReference, which started in January of 2016, which is germline as well as somatic? We took on the revenue cycle and hence the pre-approvals, the investigation of benefits, and the effort to inform the provider and patient. It’s a huge challenge to take on the benefits investigation and notice of coverage, but for our risk population it constitutes a strategy for exercising discipline.
The second is that institutional centers of excellence for different forms of cancer, and NCCN guidelines that are enforced and audited, are a mechanism to groove the process of ordering tests when appropriate, track our compliance with those guidelines, and say no under that umbrella when appropriate. I’m not saying it’s perfect, but it gives the leadership of our center for genomic medicine as well as pathologists the clearance to move forward with reflex testing when it fits NCCN guidelines and the right to question if it does not.
The back side is tracking coverage denials, and I think we will get a bigger taste of that in 2022 when we get our next-generation sequencing lab stood up at our core lab, which is our goal.
Sterling Bennett, what is your experience with pre-approvals and precision medicine as it makes demands on your system?
Sterling Bennett, MD, MS, senior medical director, pathology and laboratory medicine, Intermountain Healthcare, Salt Lake City: Our program isn’t as well developed as Jim Crawford’s, but we have pockets within our system that work quite well. Much of the genetic testing we see comes from our pediatric population, and we have genetic counselors involved and a rigorous pre-approval process for precision medicine tests that come through the pediatric hospital. We’re working to expand that service to all of the hospitals because we see pediatric patients everywhere, not just the children’s hospital.
The other area of focus is in cancer precision medicine, and we have an active oncology group in that domain. They have a molecular tumor board, for example, and a well-developed process for evaluating the genetic tests that are likely to be contributory. They have a good process too for tying those results to therapeutics—getting patients enrolled particularly in clinical trials but also approved precision, targeted therapies.
Would anyone else like to comment on this question of precision medicine?
Dr. Dolan (Regional Medical Laboratory): Blue Cross and Blue Shield in our region is looking at a concept I call the gold card. It amounts to a specific group of physicians who have been pre-approved by Blue Cross. Their order would be all that’s required along with accompanying background information. It’s an interesting concept and has some merit.
Does anyone else have experience with selected groups of physicians that can make orders without interference? Wally Henricks, how are you dealing with this at the Cleveland Clinic?
Walter Henricks, MD, vice chair, Pathology and Laboratory Medicine Institute, and laboratory director, Cleveland Clinic: There are a couple of layers to our approach. One is a laboratory stewardship committee that we’ve recently strengthened. I co-chair it with a clinical colleague who is an ICU doc and has a leadership role in medical operations. Additions to the test menu have to be approved by our committee, especially new send-out tests. The committee set up a preauthorization process working with our Epic IT support and revenue cycle management teams. We set up a process that allowed molecular tests that require preauthorization to be directed to a group within our revenue cycle management team, which facilitates preauthorization before the order comes through to the lab. It was a long struggle to get put into place, but it’s helped.
Another area that is bubbling up—and I know because we’re getting deluged with requests—is the effect of aggressive sales tactics by lab test vendors. The boutique lab vendors with new, highly focused and often expensive tests are coming in and influencing clinicians that they have to order the seller’s new test. Sometimes physicians call the laboratory and expect us to start doing it as a send-out even if special kits and special handling are involved, let alone putting it on our bill when not covered by insurance.
Our stewardship committee has a process to corral these requests: We require the interested clinicians to present the rationale and need for esoteric send-out tests. Then we get other key clinical subject matter experts and stakeholders involved, and it might be approved, or it might not. It could be approved with restrictions on who can order it.
One reason that works is if it comes through our lab send-out area, we can stop it, or mostly stop it, because they need us to handle the specimen acquisition—blood draws—and specimen transport. We’re working on this. It’s very process-oriented, and it comes at you from all angles. There’s always the latest and greatest liquid-biopsy-test this and whole-exome-sequencing that coming in. Depending on the request, we might have genetics counselors, preauthorization, and the stewardship committee all looking at the send-out tests marketed directly to clinicians.
Stan Schofield, is this becoming an increasing problem for you at NorDx, or are you holding it at bay, the demand for specialty tests, expensive tests, and preauthorization?
Stan Schofield, president, NorDx, and senior VP, MaineHealth: We’re fighting a good fight. If it’s an outpatient, we control if it gets sent out or the preauthorizations, and that’s been pretty solid. Inpatient work, not so much.
The oncology group here is very responsible, and most of the work has to be approved or sanctioned by the pathologists. A clinician cannot order a bunch of markers or send out tests to a lab without the participation of the pathologist.
The rules are changing. Anthem is constantly moving the goalpost. More preauthorization and more denials are taking place, but preauthorization is not at the lab level; it’s at the clinician level. Or if it’s NGS that we’re doing here, then we make sure the preauthorization is done before we commence the work. That doesn’t mean we’re going to hold something for a week. We would never do that. In the outpatient arena, sometimes it’s 24 to 48 hours before the work gets done.
John Waugh (Henry Ford): We have some growing pains at Henry Ford. We’re working with our clinicians; we have an employed group practice—and that helps to some degree—but bottom line is physicians won’t do the preauthorization work. They’re busy. They don’t have time to wait on hold to talk to an insurance agent. So we have done some work assisting with prior authorization. We have developed solid organ tumors, hematopoietic tumors, inherited predisposition studies, fusion panels, and for lung tumors, which tend to be very small, we have the 170-gene TrueSight Tumor 170 panel, because it may be the only shot you get at a tumor.
We ask our physicians to buy at the company store, since we’ve developed those services in-house. And we work with our insurance plan.
Clark Day, what is your experience with these expensive tests and tests that are often under scrutiny?
Clark Day, VP of system laboratory services, Indiana University Health: We’re structured a little differently, since we’re a health system connected to a school of medicine. Our precision medicine—we call it precision genomics—is housed in and more affiliated with the school of medicine. From a laboratory operations standpoint, I haven’t been directly involved in it yet.
It’s interesting about the boutique send-out vendors calling on physicians. That has not hit my radar. But in the last two to four weeks, I’ve had multiple vendors ask about my next-gen sequencing strategy, and saying, “How can we help you? We want to partner with you.”
We haven’t developed the capability yet at IU Health in the pathology laboratory to do this testing, so our precision genomics leader sends it out. He focuses on the quality of the test and the financial assistance package offered by the provider of that test in choosing who to send it to. He also selects vendors based on whole genome sequencing versus non-whole genome sequencing, and we send to two different vendors based on that.
Matt Posinski, tell me how the lab fits into precision medicine at Ochsner.
Matthew Posinski (Ochsner): We’re exploring it at this point. I’m hearing there are good best practices out there that we need to tap into regarding how we frame this moving forward.
Dr. Sossaman (Ochsner): There is a lot we can learn from the preauthorization or pre-service work, so I was interested to hear what Dr. Henricks said about what they’re doing at Cleveland with Epic. That’s where the rubber hits the road—how to handle the order and figure out what needs to happen before it even gets to you.
Our next challenge will be figuring out how we partner with our Epic IT colleagues.
Do you think it’s inevitable that you’ll need sophisticated NGS capability in-house?
Dr. Sossaman (Ochsner): I do. I think they’re going to stand that up as an institute here and want that expertise, educating the physicians and pairing that with expanded screening and other things, not just directed diagnostics.
I don’t think we’re big enough to have the informatics pipeline. That’s something we’ll have to outsource. There will be a role for having it—if you’re a big enough size, your cancer institute will want that as part of the system offering.
Ian McHardy, tell us about your feelings on precision medicine.
Ian McHardy, PhD, D(ABMM), director, microbiology, molecular, and immunology laboratory, Scripps Health, San Diego: We’re hoping to learn from this group how to optimize precision medicine. We’re in the early stages of standing up lab stewardship. We rely on reference laboratories for most of the cancer diagnostics and so on. We’ve explored the possibility of bringing on NGS, but the expertise required, including the bioinformatic piece, is a bit beyond where we could comfortably compete with the available reference laboratories.
As far as lab stewardship, we’ve been trying to limit repeat ordering for certain tests and are looking into various strategies.
Let me turn to our final topic. Joe Baker and Peter Dysert, do you see new technologies on the horizon that could help further improve operational efficiencies in the laboratory?
Joseph Baker (Baylor): Not at this time. Our priority at BSWH is more related to stabilizing our staffing. We do have automation coming into some of our labs, but we always pose the question—is the automation worth it, for the expense, and are we actually getting the operational efficiency benefit by implementing it?
Peter Dysert, MD, Department of Pathology, Baylor Scott & White Health, Dallas: I don’t have an answer, unfortunately. The single biggest short-term opportunity is for laboratorians to be involved in the optimization of the investments in IT. It reminds me of the early days when IBM entered the business world, and nobody got fired for buying IBM. It seems like Epic, in the same way, is starting to dominate the marketplace and laboratorians are being asked to go to Beaker, for all the reasons we understand.
Our organizations that have Epic have spent a lot of money on that product, and it seems from the laboratory perspective we haven’t benefited on a proportional basis for the magnitude of the investment. With the investment we’ve all made in Epic, maybe the best use of our time and effort is if we, from a decision-making perspective as laboratorians, could get a seat at the table and work on leveraging the power of that investment to make the front end and the order-entry process and utilization work as efficient as they can be.
One example of the downstream impact that Epic has is that we have to cancel daily between 20 and 30 percent of the orders for blood products—because of the way the front end is designed in Epic. It’s becoming a drain on my staff as staffing becomes even more challenging.
It’s a complicated geopolitical setup with IT, the Epic alignment to the IT people, and that this company started as an EHR vendor and not as a laboratory support vendor. There are real challenges there.
Stan Schofield, you know the Epic story as well as anybody. What is your reaction to what Pete Dysert said?
Stan Schofield (MaineHealth): It’s true. We’ve been with one brand of LIS for years, and we’re launching the conversion to Beaker; it’s an enormous undertaking, an enormous cost. But even with deep-dive financials, we’re going to save $8 to $10 million over 10 years versus staying with the current vendor.
A seat at the table, streamlining efficiency—all important. Where is AI or IT going to come in to relieve some of the technical burden within the laboratory? Releasing results and autoverification is one element, but there are more capabilities I see.
As for what automation we need, we need blood drawing robots right now, and there aren’t any, not in Japan or elsewhere.
Maybe it was 10 years ago I got into trouble at a meeting when I said Epic is taking the money out of everybody’s pocket in the room. Ten years and hundreds of millions of dollars later, it’s still not fully operational and not completely optimized.
Epic is taking a lot of resources out of this system that haven’t been able to go back into anything with a return on the investment.
Jim Crawford, do you have a comment?
Dr. Crawford (Northwell): I come in from a different angle. New technologies and operational efficiency are solved in detail, and I would invite people to think about workstations. To harken back to our first topic, it is your ability to deploy your lab workforce that determines your survival as a laboratory.
The integrated health system—skinnying down hospital-based labs, bringing testing to an in-system reference lab, which is the Northwell story—allows you to use the automated technologies in a central location and to get standardized equipment lines across your entire health system and achieve workstation efficiency, and hence the staffing across three shifts that gives you a glimmer of survival. This is the glass half-full version, not a glass half-empty.
On the IT side, business intelligence is where I go, harmonized data anywhere you can get it. In the clinical record, you’re looking to reduce utilization and cut out 30 percent of excess lab tests. On the operational side, you’re looking for business intelligence for load-balancing in your laboratories, and in turn productivity of your workforce—all in support of your existing workforce having a reasonable workload.
There is opportunity to leverage these technologies, but you have to think about it in terms of your staff.
Janet Durham, anything you’d like to remark on?
Janet Durham, MD, medical director, Wisconsin operations, ACL Laboratories, and president, Great Lakes Pathologists, West Allis, Wis.: We’ve been using Epic EHR for close to 10 years in Wisconsin and for a couple of years in Illinois. We went live with Beaker in Wisconsin in February 2020 and in Illinois we went live December 2020. With the transition to Beaker there’s a lot of room for optimization. Large health care systems on Beaker, like those of us in the Compass Group, need to make sure we are at the table to assist with the optimization. For example, with the preauthorization issue—that’s one area in which the Epic EHR system is not helping us.
As a pathologist, I enjoy using Beaker. I like being able to quickly go to imaging or the patient’s medical record and then back into my report. There are a lot of good things with Beaker but still a lot of areas for optimization.