September 2024—A “grimoire” for laboratories—that’s what J. Mark Tuthill, MD, of Henry Ford Health was asked to talk about at the Pathology Informatics Summit in May. Once he learned what the term meant, he got to work, and his book of magic for laboratories unfolded. He did not use a large language model to create his spells because “only a wizard” can teach such things, he said, which is why he consulted his 11-year-old grandson. His playbook for laboratories, as presented to summit attendees, follows. Dr. Tuthill is head of the Henry Ford Health Division of Pathology Informatics.
For more on value-based care and Clinical Lab 2.0, see CAP TODAY, July issue, https://bit.ly/CT_0724-MW.
What is a grimoire? Its etymology is unclear. It’s most commonly believed that the term originated from the Old French word grammaire, grammar, which had been used initially to refer to all books written in Latin. By the 18th century the term had gained its now common usage in France and had begun to be used to refer solely to books of magic.
What it refers to is a spell book, or even a book that contains potions and descriptions of how to create amulets. But in today’s context we’ll call this our management playbook, and we use this as a guide to help us understand what we’re going to be dealing with during the next couple of years.
First, I’ll define value-based care. The term was created in 2006 by scholars Michael Porter and Elizabeth Olm-sted Teisberg in the seminal work Redefining Health Care: Creating Value-Based Competition on Results. But this has been going on a long time. We could even say that the beginning of the Centers for Medicare and Medicaid Services was an effort to move into value-based care. Historically, we can go back to the ’20s and ’30s. The creation of Mayo Clinic and even Henry Ford Health was an attempt to create value-based care in populations of people who could be pulled together and provided with more efficient and effective health services.
But we’ll start in the modern age, 1965, with the creation of Medicare and Medicaid. Managed care organizations rose in the ’70s and ’80s and were focused on cost control and care coordination. HMOs, DRGs, CPTs, and ICD-9s came into existence between 1980 and 1990 as a way to collect data and information and to organize our patients into care groups. The 1999 Institute of Medicine (now National Academy of Medicine) “To Err Is Human” report plays into this, as does the “Crossing the Quality Chasm” report shortly thereafter, because the idea that people were getting hurt in medicine was unconscionable. This led us to think about a more detailed patient-centric approach to care.
In the early 2000s, value-based purchasing initiatives emerged. In 2010 we have the Affordable Care Act, which brought a lot of patients into health insurance and established accountable care organizations, bundled payments, and the Hospital Readmissions Reduction Program. For us, the HITECH Act of 2009 created huge expenditures in IT, EHR, and health information exchanges and other integrations.
Then there’s MACRA and the Quality Payment Program in 2015, with its Merit-based Incentive Payment System and Alternative Payment Models, and the CMS Comprehensive Primary Care Initiative in 2018–2019. And all the payment reforms we see coming at us, which come down to reduced reimbursement for services and, ultimately, collecting those services into outcome-oriented care and treatment.
For pathology and laboratory medicine, this has translated into a lot of cost-cutting, which has been challenging. So we need a different playbook; we need new spells to use in our environment. We have to expect further commoditization of laboratory services. We have to expect there to be continuing resource and financial constraints owing to the pandemic and all of the capital spent during that time. Venture capital mergers and acquisitions are happening at a rapid pace now, at the laboratory and hospital levels and even across institutions, with huge purchases.
And, of course, there’s the specter of value-based care, where fee-for-service finally goes away—maybe. So how do we get paid transactionally? How do for-profit lab testing companies get paid? That’s a challenging question.
The classic Stupefy or Expelliarmus, the disarming charm, is not going to work. Extinctor Capitalaris is not good enough. And Reductor Commoditat-ization is not going to help us.
Our spell book still rests on our academic mission—it’s the services our laboratories provide, our education, and our research missions that are of value to our organizations. We have to figure out how we’re going to provide that value in this new environment.
Where do we start? We start with effective and efficient laboratory services, and for that a spell probably isn’t good enough. We need a potion because potions can be diffused and suffused into the air. And the first and probably most important potion we need to use is Lean Olfactorum Veritas: Smell Lean everywhere and find the truth of Lean in your laboratory. Have your house in order at the deepest level. This brings us to integration, informatics, and analytics. It brings us to efficiency, to defect reduction, to knowing your cost per test, and to understanding your competition. This is Clinical Lab 1.0; some call it Lab 1.5.
But even this is not enough, and this is where spells become essential to prevent the darkness of outsourcing, being sold, or being undervalued. So it’s time for Expecto Patronum, a protector, the Patronus charm, which will ward off Dementors and other evil forces such as those who make decisions above us.
In Lab 2.0 we could also cast Accio, known as the summoning charm. This is a useful spell for retrieving out-of-reach items. What would we choose to summon? Perhaps we would summon capital. Perhaps we would summon recognition of our value to the organization. And perhaps we would summon our own engagement and our interaction with our customers. It’s about quality patient service, reducing the cost of care, and improving outcomes.
But again, the answer isn’t a simple spell but instead a potion; perhaps it’s a subtle ether that we need to turn to. And for this, we need another potion: Felix Felicitorum Lab-a-tora-forte, that which through felicity brings lab to the forefront and shows the strength of local laboratory services.
In the end, though, what we really need to do is put the patient in the center of this because when the patient demands our laboratory services, we win. So it’s public health, molecular diagnostics, precision medicine, digital pathology, impactful technology—all with direct, profound impact on patient care. So, rather than a simple patronum, we need Expecto Patronum Patiatum, where the patient comes forward into the center of our reality.
Education and research can provide value and safety, but they are not amulets. Even historically educational organizations have been part of mergers with for-profit health care. I wonder how these medical schools, these academic institutions, are going to survive when they’ve been outsourced to venture capital organizations whose primary goal is not education or research but instead making money.
If you can show that what you do with the laboratory, through clinical service, education, and research, brings patients to the forefront, leaders begin to understand what laboratory services are; the C-suite starts to pay attention to the value. They’re starting to recognize: If all their data goes out to third-party testing organizations, how do they run public health? How do they truly accomplish Clinical Lab 2.0? And what are they going to do with value-based care? How do you show value if you don’t have data? Maintaining local laboratory testing is essential to research, especially genomics. If you don’t have the data, you can’t do the research. If the data isn’t real time, you can’t change life. And what’s worse, patients get hurt.
You have to sell these ideas, and these ideas can be sold, and they need to be sold through potions and probably some simpler spells that we need to look for. The grander approach to this is something we can’t even begin to imagine, but imagine if the pandemic happened and there was no laboratory-based testing. We would not have been able to operate our hospitals. What we did locally in our laboratories is what put patients through our health systems, saving lives.
To summarize: Potion number one: Lean Olfactorum Veritas, because nothing works without Lean and without an efficient laboratory. Potion number two: Felix Felicitorum Lab-a-tora-forte, that which through felicity brings lab to the forefront of the mind of the C-suite and they never want to see you leave the organization. They want you to do more for them. Potion number three: Expecto Patronum Patiatum—put the patient in the center of this. When the patient demands your laboratory services, you will never be displaced. And patients know the difference. They know a two-week wait time versus getting their CBC result before they even get home.