Laboratory 2.0: teaming up against opioid use disorder

But from the laboratory’s standpoint, “It’s great that we have this information—it’s valuable. The number one issue for physicians is, ‘How do I interpret results like this? If I have to call the lab every time to make sense of valuable information in front of me, that is a lot of time wasted—then there’s 15 minutes with the patient and I’m having to make phone calls not only with the lab but also the insurance company.’”

To rein in this waste of time at TriCore, the Laboratory 1.0 approach has been, instead of having 10-plus screening panels, to condense them into what are called hybrid pain management compliance panels to help the physician narrow down what their question is. Currently TriCore has a statewide initiative with physicians to move from these hybrid panels to more cost-efficient and clinically effective ones. “If it’s a new patient, then we have a new patient screening panel. The other panels are for chronic pain management and substance abuse.”

TriCore’s Laboratory 1.5 step in its evolution goes further, to an enhanced result report (Fig. 1). With this, the laboratory determines at order which valid prescriptions are presented for which opioids, then goes straight to confirmatory testing. “If my patient is taking oxycodone or another opioid, why screen for it? You already know what compound you’re looking for and expecting, so let’s go straight to the confirmatory. We’re just going to eliminate the immunoassay,” Dr. Dodd said. Other panels are set up to answer a few different questions: Is the patient in treatment? Is the treatment for opioid abuse? And do they have benzodiazepines on board as well?

Some laboratories have already moved to the enhanced interpretive report that TriCore has developed, Dr. Dodd said. “They paved the path and we’re in discussions with them. There are other labs that don’t have this report yet, and we are trying to pave a path for them.”

As TriCore implements its new panels, it is working with physicians to ask what information they need. “The physician is required to enter the prescription information up front, but will the physician do so? Maybe not. If they do and the hydrocodone they’ve prescribed is not detected, well, that’s additional information up front that we didn’t have before. And we can either say the results are consistent or inconsistent with what they’ve been prescribing. Then they can walk into the patient’s room and the next process can begin.”

This is an example of the laboratory using longitudinal data on its way to Laboratory 2.0, she said. “We have the results, the consistency or inconsistency, the ICD-10 information, the laboratory screening information to see if they’re getting screened every six months or every year, and we can begin to put a picture together for the payer or the physician group.”

As the largest clinical laboratory in New Mexico, TriCore has a strength: its wide footprint, Dr. Dodd pointed out. “The patients who usually come to us are from all across the state, so we can begin to put quite a few years of data behind each of these patients and we can offer this information to the clinicians. We can now identify our high-risk patients—whether they have had an ED visit in the past, whether they have been inconsistent—and then we can help the payer or the physicians help that patient get access to care.”

TriCore’s Laboratory 2.0 effort, focusing the report on value and attributed outcomes, is still in development, Dr. Dodd said. “We are playing around with information to see what it might look like.” In the example she displayed for her audience at the Executive War College, an “Additional Drug Use” table based on the confirmatory testing (Fig. 2), the laboratory lists what the patient was prescribed down the left side, then across the top, the drugs for which the patient was found to be positive. “It shows, if they were prescribed oxycodone, how many times the patients were actually positive for morphine as well, or for benzodiazepines as well.”

“We’re a provider,” Dr. Dodd said. “If we have this information for 99.9 percent of our patients, we can expand that to say here is your list of patients who are high risk.” That is the low-hanging fruit, she said, and “For a lot of physicians, we don’t need to go beyond that.” But a pharmacist’s clinical perspective can be helpful if the laboratory wishes to pursue the data further, she noted. For the patient in Fig. 2, “We have prescription morphine. We go to heroin, which has 6-MAM as a major metabolite. Of these patients taking morphine, 16.5 percent were also positive for this heroin, but 6-MAM is not a prescribed drug. So if we were to develop an ‘illicit’ category, we would separate 6-MAM from the rest of the list. Not every heroin patient is also taking morphine, so this is where the IT and the pharmacist’s clinical expertise can come in handy in our discussions.”

The use of value-based analytical insights derived from clinical laboratory data can support risk stratification and identification of care gaps for opioid use disorder. Detecting a care gap is a major benefit of going through this process for patients treated with prescription opioids, Dr. Dodd said. “If a new patient is coming in and the physician orders a new patient screening, we can categorize that as a new patient for them. Then maybe every year after that, if that particular patient doesn’t come up in our annual drug testing, we’ll consider that there might be a care gap.”

Laboratories are positioned to provide a longitudinal history for patients who have multiple providers, and laboratories can identify high-risk patients in near real-time, Dr. Dodd said. Through a pharmacy-laboratory collaboration, clinical laboratories can enhance the value of their health data, providing insights into patients’ continuum of care and showing laboratories’ value beyond Laboratory 1.0.

“Big data is pretty intimidating. But it is a primary issue for laboratories,” she said, “and we all need to make sense of it.”

Anne Paxton is a writer and attorney in Seattle.