Optimising clinical laboratory service delivery with electronic decision support: An analysis of market structure and impacts of regional clinical information strategy - Part 2

Click here for Part 1 of this paper.

• Building the Laboratory EDS Business Case
• Auckland Metropolitan Laboratory Work Stream Project Managed by the NDSA
• The Promise Offered by Laboratory EDS
  • How EDS Supports Demand Side Management
  • How EDS Supports Supply Side Management
• Conclusion
• The Way Forward

Building the Laboratory EDS Business Case
This paper has argued that a deficit of high quality information is a significant problem at all levels of diagnostic laboratory service provision. The Auckland RISSP^{[ 1 ]} is the Auckland metropolitan region IT strategy approved by the CEOs of the Auckland metropolitan DHBs and aims to improve health outcomes for the people of Auckland through appropriate information exchange. It is therefore essential, if uptake of EDS in the Auckland metropolitan region is to increase, that a robust, rigorously staged and transparent EDS business case with a high benefit-cost ratio be incorporated within the RISSP.

The RISSP is underpinned by the seven principles of the New Zealand Health Strategy^{[ 6 ]}(2000), the Ministry of Health (MoH) strategy document that translates the New Zealand Health and Disability Act 2000 into a framework of action for the DHBs. The foundation of any diagnostic EDS business case in the Auckland metropolitan region is, therefore, the demonstration that this business case adds value to the key projects that have been selected to implement the RISSP. The RISSP key projects that diagnostic EDS would add value to include:

• Chronic Care Management, involving the implementation and enhancement of a consistent and integrated regional chronic care management solution incorporating EDS tools and allowing people to access their own information.
• Clinical Audit, involving the implementation of support tools (such as EDS), providing access to patient records, capturing additional clinical information and reporting on clinical outcomes and the effectiveness of clinical processes.
• Clinical Data Repository, involving the development of a regional clinical data repository architecture that will allow logical integration of patient records and clinical images.
• Clinical Notes, (clinical forms and database solution) to allow clinicians to capture specific clinical data, integrated with patient management systems and the clinical data repository
• e-Prescribing, involving the implementation of an e-prescribing system that delivers the right medication to patients, reduces medication errors and the overall cost of pharmaceuticals.
• Mental Health involving the creation of a single mental health patient record accessible by all stakeholders including patients; to facilitate better coordination of care between primary health care, community organisations and secondary care providers; and incorporate clinical decision support tools and to support a mobile workforce.
• Order Entry, requiring a regional computerised physician order entry (CPOE) system, incorporating clinical decision support tools.
• Primary Health Care Information Services, that would allow easier and cheaper access to information technology for primary and community/NGO health care providers by exploring the possibility of facilitating a shared information services capability.

Having established a sound strategic case for funding EDS in the Auckland metropolitan region, identification of an EDS implementation vehicle is a logical next step. There are clear cost-efficiencies and resource savings to be made by utilising a pre-existing vehicle, hence the authors’ contention that the NDSA project-managed regional laboratory workstreams should be utilised as the vehicle for Auckland metropolitan diagnostic laboratory EDS development.

Auckland Metropolitan Laboratory Work Stream Project Managed by the NDSA
A suite of Regional Laboratory Workstreams, project managed by the NDSA and overseen by the DHB Regional Funding Forum, was established in response to an increase in the rate of laboratory testing over the last five years. The current status of some of these workstreams is summarised in table 1.

Entry of the Auckland metropolitan DHB providers into the diagnostic laboratory market in order to increase efficiency would require that two major barriers be addressed:

• DHB provider labs currently lack a means of collecting, storing and transporting specimens collected in the primary sector.
• DHB provider labs currently lack a means of providing primary care providers with real-time electronic access to laboratory test results.

The following associated demand-side workstreams will be of particular value in addressing these barriers to competition:

• The Regional Éclair Laboratory data repository, which will provide a means by which authorised users will be able to access patient-centred integrated laboratory test reports regardless of where the test was performed.
• The MoH/Health Information Standards Organisation sponsored national Logical Observation Identifier Names and Codes (LOINC) laboratory test project, which will provide a national standard for common laboratory test codes and electronic transmission formats that would be essential for the efficient operation of the planned Regional Éclair Laboratory data repository.

Table 1: Current Auckland Metropolitan Regional Laboratory Work Streams

Given the impending expiry date for the current contract between the Auckland DHBs and DML, it is essential that a range of options and recommendations to guide future community laboratory contracting be available by November 2004. Key elements of this regional strategy will comprise:

• Intersectoral regional collaboration, coordination and governance, eg, DHB provider labs/community labs, referrer/provider, specimen transport/collection.
• Test appropriateness - duplication, cost-effectiveness, schedule reform.
• Alignment of clinical responsibility and financial accountability, eg, improving clinical outcomes.
• Cost-transparency and information sharing.
• Pathologist/technologist training and retention issues.
• Quality improvement initiatives, eg, benchmarking.

The Promise Offered by Laboratory EDS
A systematic Australian-based literature review has identified a number of critical challenges to the role of diagnostic laboratory testing in the provision of high quality patient care. This review undertaken by Ken Harvey’s group concludes that a significant proportion of pathology tests ordered fail to contribute to the diagnosis and/or treatment of individual patients while some cause patients harm.^{[ 1 ]} The Harvey review therefore posited the value of a creating a sustainable mechanism to authoritatively distil the plethora of medical scientific papers, meta-analyses and consensus statements into practical, concise and consistent best practice guidelines to assist health practitioners and consumers. The literature review also showed that the increasing use of computers in clinical practice is creating a unique opportunity to provide best practice information at the point of clinical care when decisions, such as tests ordered or drugs prescribed, are being made. There is good evidence that such decision support systems can substantially reduce inappropriate and/or unnecessary ordering (and prescribing), diminish errors and improve practice.

How EDS Supports Demand Side Management
EDS can contribute to improvements in the management of the quality of test utilisation, ie, both over and under utilisation, by adding value to the clinical information. Examples include:

• The provision of real time evidence-based/best practice-based guidelines to help GPs determine the most appropriate (and cost-effective) tests to order without compromising the equity of access, quality of care and by reducing harm from unnecessary testing.
• Increasing the accurate utilisation of the patient NHI as the unique identifier for all electronic laboratory requests and referrals. The NHI can then be used to validate a patient’s demographic data to determine whether the patient is eligible for a free test or a fee should be charged for the service. This removes the gatekeeper responsibility from the test orderer.
• Facilitating accurate service utilisation and test order pattern data for quality audits, data mining and feedback information to the test orderers.
• Facilitating continuous quality improvement (CQI) initiatives such as the use of statistical process control charts (SPC).

How EDS Supports Supply Side Management
EDS has the potential to facilitate and organise the automated collection, collation, analysis and reporting of the quantitative information essential for supply side management. Accurate monitoring of market signals, for example, real-time test costs, prices and capacity, is essential for determining whether any market is operating efficiently and therefore requires no intervention by a regulatory or funding authority.

Should a market be deemed efficient, regulatory and funder monitoring remains important because markets have the potential to become inefficient, often requiring intervention to restore and/or maintain efficient operation. Real-time, cost-efficient accessing of clinical, financial and infrastructural information relevant to monitoring the market is an important contribution that can be made by EDS.

In reality, laboratory markets vary in their degree of efficiency, both on the basis of geography and of time. The mix of market and regulation is therefore critical and can only be optimised if robust and reliable information is available. In addition, because economics is not an experimental science, funders and planners require a means of establishing what effect any proposed intervention will have, what the magnitude of that intervention should be, what effect other market drivers, eg, other interventions, will have in a quantitative manner with an estimate of certainty, ie, simulation modelling. EDS has the potential to supports this modelling approach by:

• Providing accurate, robust and real-time information to construct and test an appropriate system model.
• Providing a real-time distillate of the evidence base to formulate novel model rules.
• Interfacing with knowledge discovery statistical approaches eg, data mining (drill-downs and extracting implicate rules), Bayesian approaches, neural networks and support vector machines, to formulate previously unknown model rules and provide sophisticated data extracts.
• Constructively managing the relationship of fixed/marginal costs and economies-of-scale to maximise benefits without unduly distorting the market.

Conclusion
The planning, funding and delivery of high quality, cost-effective, diagnostic laboratory services is becoming of increasing importance to the Auckland metropolitan region DHBs, due in part to the need to address DHB budget deficits and to free up scarce health care resources to address pressing health priorities (New Zealand Health Strategy 2000).^{[ 6 ]} To this end, the Auckland metropolitan DHBs have sponsored a number of both supply- and demand-side laboratory management workstreams projects that are managed by the NDSA.

The impending expiry of the national laboratory contract has highlighted the absence of a regional laboratory strategy and of robust, reliable information that would assist in the formulation, implementation and evaluation of such a strategy and its longer term outcomes. Diagnostic EDS has been identified in the international literature as a tool that has the potential to address this information deficit for both supply and demand side laboratory market management.

In addition, EDS has been identified as critical to a number of key projects included in the Auckland metropolitan RISSP.^{[ 6 ]} Advocates have advocate lobbied strongly for the increased utilisation of diagnostic EDS in the Auckland metropolitan region within the IT governance framework authorised by the Auckland metropolitan DHB CEOs. Parallel international EDS developments, particularly those sponsored by the Australian Department of Health and Ageing (DOHA) provide a serendipitous foundation upon which considerable economies of scale could be leveraged provided a robust business case with a large benefit-cost ratio could be made to the senior mangers of the Auckland metropolitan DHBs.

The Way Forward
This paper has established the considerable benefits that judiciously implemented EDS would offer to laboratory services funding, planning and delivery for the Auckland metropolitan region. It is therefore recommended that the first step towards preparing a business case for Auckland metropolitan diagnostic EDS development should be an inventory of regional diagnostic EDS resources in consultation with the stakeholders responsible for those resources.

Having established that there is a strategic basis for formulating an Auckland metropolitan regional business case for diagnostic EDS, the next step is the choice between the two fundamental approaches to building an EDS business case:

1. The top-down approach, in which a business case is constructed to fulfil the requirements of a multidisciplinary stakeholder consensus informed by a systematic and comprehensive review of the published literature. The drawbacks to this approach include the cost, difficulty of implementation, eg, only two or three large academic centres in the US have come close to going live with such a system, and the opportunity cost of not leveraging on similar international developments, particularly those of the sponsored by the Commonwealth Government of Australia.
2. The bottom-up approach, in which the starting point is a regional inventory of available EDS resources accompanied by focused stakeholder consultation and a focused literature review. Such an approach has the advantages of ensuring pre-existing EDS resources are aligned and utilised in the most efficient manner possible, and maximum advantage is made of possible trans-Tasman linkages. A workbook and templates can be used to guide the development of the Australasian regional inventory. The workbook and template created by the Healthcare Information Management Systems and Society, US, (HIMMS) are available as Internet downloads for no charge^{[ 7 ]}. HIMSS is actively encouraging user feedback and partnership as part of the ongoing development of their inventory workbook, providing an opportunity for forging Auckland metropolitan links with centres of international excellence.

It is recommended that the "bottom-up" approach be adopted, using the HIMSS workbook and templates as a first step in the development of a diagnostic EDS business case for the Auckland metropolitan region. Without a catalogue of existing resources there is a significant danger of systems duplication with the ensuing wastage of scarce resources and blunting of a strategic IT focus.

On completion of an inventory, preliminary stakeholder consultation and review of relevant literature, and with the assistance of trans-Tasman and US collaborators, a formal cost-benefit and resource impact assessment then becomes possible. The convening of a project management team with designated sponsor, manager, reporting line, deliverables, key performance indicators, risk assessment/mitigation strategy and suggested post-implementation review then becomes the logical next step.