Views on point of care versus core and more

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February 2023—Point of care or core lab? An old question but a new conversation, this one on Jan. 12 between Stan Schofield, formerly of MaineHealth (until his retirement on Jan. 6), Werfen chief commercial officer Brian Durkin, and CAP TODAY publisher Bob McGonnagle (asking the questions). Here’s what they said about that and health care economics, autoimmune testing, tube supplies—and, of course, the labor shortage because it affects nearly everything in health care. “We know the labor shortage isn’t going to turn around,” Durkin said.

Stan, give us a brief history of your consciousness and then your deployment of the question of where we put the testing—core lab, highly efficient, low cost per test versus at the point of care, which has the advantages of the patient being close by, where it’s convenient, and the physician getting a result that can be acted on quickly. Give us a summary of where you’ve been in the past 10 years on those questions.
Stan Schofield, vice president and managing principal, the Compass Group; former president of NorDx and senior VP of MaineHealth: We’ve watched point of care evolve and grow, but running a core lab was all about economics, speed, and enhancing technology. Centralizing allowed us to lower our costs and compete in the outreach program and lower the costs of hospital operations dramatically. A standalone lab without the core lab in a network hospital without efficiencies has operating expenses that run 15 percent higher. So the core lab concept has always been solid.

Schofield

Point-of-care technology has evolved and improved in the past 10 years. It’s convenience versus cost. In hospitals, in the lab, and in health care in general, cost is a huge consideration and will continue to drive selection. Point of care has demonstrated its ability, especially with COVID. Prior to COVID, it was convenient, and a few assays made a difference, if compliance was a problem, when the patient was onsite—hemoglobin A1c, for example. But $35 for a test result versus $3 is a big differential, and insurance companies don’t pay that kind of differential. Economics drives the core lab, but COVID technology allowed people to make better cost-related decisions around isolating patients, protective personal equipment, room allocations. And without a test result around, say, COVID or the respiratory viruses, you’d spend a lot more money than what you spend on the point of care.

Werfen has a foot in both of these solutions because so many coagulation tests are done at the point of care, but it also has an automated coagulation solution. Brian, give us your view of this point-of-care versus core question.
Brian Durkin, chief commercial officer, Werfen: Rather than say central lab versus point of care, we should talk about how they coexist. That’s the philosophy of Werfen. We have three core business units: autoimmunity, acute care diagnostics, and hemostasis. Our strategy for hemostasis testing is to help our customers manage it from the central lab to the point of care. The ACL Top series systems and HemosIL reagents lead the hemostasis worldwide market for instrument and reagents, but we also have a handheld point-of-care hemostasis device, the Gem Hemochron 100 system. When I’m asked where testing should be, my answer is wherever it’s more efficient and effective.

The pandemic changed everything. But it validated that in vitro diagnostics, whether lab or point-of-care testing, is crucial to patient care. We were proud to contribute to the care of patients with our hemostasis and blood gas products. And while health economics is always a key question, our philosophy is that it’s about the total cost of ownership, not cost per test. Looking at cost per test can be shortsighted. We bring a different approach to the labor- and blood-shortage challenges—we talk about automation, cost efficiencies, and total cost of ownership.

As you deploy this strategy, is there an 80/20 adoption? In other words, do about 80 percent of customers have similar approaches to how they roll out the total coagulation solution, or do you find there’s quite a bit of individual variation depending on the systems and locations?
Brian Durkin: From my perspective, 100 percent of our customers have a central lab hemostasis solution. There is more variability at the point of care, where we see approximately 50 percent or more of our hemostasis customers testing. A good example of this is activated clotting time testing using the Gem Hemochron 100, which is performed routinely in the cardiovascular operating room.

Stan, what’s the distribution in the NorDx system?
Stan Schofield: We have ACL Top instruments in all our labs, but point-of-care coagulation is limited to our physician practices, mostly for economic reasons, and in more remote satellite locations. It’s not more than five or six percent in our 800 employed physician practice sites.

How is the immediate follow-up with patients handled? Is there a lot of bidirectional interface in which you’re getting back to those sites to say that a particular patient needs their warfarin adjusted as soon as possible?
Stan Schofield: In a nursing home, as an example, if it’s drawn at 7 AM and comes into the core lab by noon, results go back electronically by 2 or 3 PM before the nurse or physician leaves for the day, and they make the adjustments. For emergency departments, the laboratories are responsive with ACL Tops and tube systems to transport the specimens.

Our problem is having phlebotomists available at an outpatient setting for a patient to get a routine draw or maintenance. A patient who is supposed to get blood drawn once a month but forgets to make an appointment may not get seen. The staffing is critical, mostly in phlebotomy and phlebotomy outpatient arenas—it’s hard to get appointments and be seen on short notice.

There’s a lot of dependence on patient scheduling and a discipline in the system to make it all work, at least optimally, correct?
Stan Schofield: Yes. And if a specimen comes in and it’s abnormal and the INR is not therapeutic but dangerous or critical, then we contact the physician and nurse practitioner immediately, based on CAP protocols for critical value calls. It works 24 hours a day. This kind of testing is same day in a maintenance mode. If a patient is critical, then they go to the hospital or the emergency department. Plus, the core lab runs 24 hours a day, even if it’s a stat.

Brian Durkin: I agree with Stan. The labor shortage in health care, and overall, is dramatic. When we talk to leaders, they’re looking for more automation and instruments that are easier to use, that help interpret and provide straightforward results, so someone who is not as skilled can talk to a clinician and take action.

Another big trend I see in health care is the struggle to find experienced staff. We need to invest in educational tools to help our customers train their newer and younger staff members. During the pandemic we improved our digital training capabilities, including operator training and clinical educational content. Customers can watch our online training, 24/7, to learn how to perform certain activities, operate a system, and better understand a variety of disease states. When I started in this business, you were selling an instrument and a reagent. We have evolved to a more consultive approach with a total view of the lab and point-of-care setting.

Brian, you are based in Barcelona and have global commercial responsibilities. Are there similar labor and cost problems outside the United States?
Brian Durkin: Yes. Every November we look at trends in health care, and number one is labor. Health economics is always there as well, to different extents. So we’re changing the mindset of the market away from focusing just on the cost of an instrument or test and shifting it to how we can deliver the full value from the time the patient is admitted to the ED to their discharge.

Stan Schofield: As we talk about labor, there was point of care as a convenience and as an opportunity for rapid results with the patient still there. What has happened is not just in laboratories. Emergency departments and medical practices are short-staffed. In our medical practices, there are hundreds of open positions for medical assistants and in nursing. So nursing staff and medical assistants in practices are pushing back now, saying, “I don’t have time, I have to take something off my plate, and I’m going to stay with the nursing responsibilities and next to the patient. I’m not running the labs anymore.”

Does that mean specimen collection is happening increasingly at the main hospitals and clinics and centers as opposed to the offices?
Stan Schofield: Many physician offices stopped drawing blood 10 years ago. They almost always send the patient to a patient service center. Prior to COVID I had 23 patient service centers, and now I have 13 and can staff only nine.

Brian Durkin: People are using the ED as their primary care provider, and the EDs are overwhelmed. We’re trying to help health care institutions solve that problem, and the best way is through effective information management and products that are easier to use.