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Guidelines for POL instrument selection.

Guidelines for POL instrument selection

Believe it or not, purchasing equipment for a physicians' office laboratory can be more of a headache than for most large hospital labs. POL purchasing is more subjective. In most large hospitals, financial justification is often the only major consideration.

Equipment purchasing for a POL is usually done by one or more of the following persons - all of whom have different opinions about what the lab needs:

* The physician. Doctors look for speed, accuracy, ease of operation, and low cost.

* The office nurse. Fast turn-around time with push-button operation is often the nurse's main concern.

* Untrained personnel. Staff members want ease of operation and low maintenance.

* The consulting technologist. A technologist tries to match the equipment to the laboratory staff members who will be using it. Many times the technologist finds the goal is to flag abnormals rather than to turn out accurate results. This approach falls short of the physicians' needs and leads to unnecessary duplication of test orders for send-out confirmation - thus forcing patient costs to rise.

The ideal equipment purchase is often a combination of these requirements. The new instrument should be accurate. Tests should be no more difficult to run than the staff can perform correctly. In-house turnaround time should be shorter than the time needed to use a reference lab. The ideal system generates results while the patient is still in the office. * From the beginning. The first step toward selecting an instrument - whether a replacement or a new addition - is to get an estimate of the number of tests that will be run on it. If you are just updating an existing methodology, this is easily done.

For brand-new equipment, a workload study is in order. Relying on someone's memory as to how many tests of each kind are currently sent out can be misleading. Usually a log sheet, billing list, computer records, or some other means will help yield a fairly accurate count. With many commonly ordered tests, you can expect the volume almost to double when the work is done in-house, since the physicians will find the quicker turnaround time more helpful and will therefore order the test more often.

Obvious exceptions include very specific tests, such as amylase, CK and LD isoenzymes, and monitoring therapeutic drug levels. Armed with these figures, study the prospective equipment's practically.

Since physicians' offices vary in size - from very small solo practices to huge multi-discipline clinics - the needs of their labs also differ. When looking for an instrument, the first decision to make is to determine what tests you plan to perform on it. * Assess your space. Note how much maximum floor or counter space is available. Next, inspect the wiring - or lack of it. When you're ready to go shopping, be sure your wiring is adequate; if not, know exactly how much the necessary electrical update will cost. Consider the available plumbing as well.

Ventilation is another major concern. Windows are not necessarily an asset, because they bring in heat, cold, and direct sunlight. Where are the air-conditioning venst? Many instruments cannot adapt well to being in front of the varying hot or cold air of a heating or air-conditioning system.

Don't overlook the lab's refrigerator. If you only have a small under-the-counter model, try to find space for a full-size one. Size is a particular consideration if the reagents to be used with the new instruments will require refrigeration. If space is a problem, focus on instruments that do not need refrigerated storage space. The new equipment will already be stretching the laboratory's space capabilities. * Who will push the buttons? Think about who will operate the equipment. Will the same person be responsible for maintenance? In many physician offices, at least one technologist on staff could be put in charge of both.

Any potential operator who does not have adequate laboratory training must be willing to learn. Many physicians favor "cute little lab machines" that they expect to be run in someone's spare time. The trouble is that no one wants the job. The staff worries that the results will be inaccurate or the machine simply won't work. An overworked staff member who is squeamish at the sight of blood is not likely to make a major commitment to the equipment. Once selected, the principal operator should be included in the process of evaluating all instruments under consideration. * How much is enough? One of the greatest purchasing errors is to buy too little or too much instrument for the job. To avoid this, start by considering the lab's projected workload. If the POL has a large percentage of Medicare patients, as ours does, reimbursement per test is a good guideline to follow. To determine the projected gross revenue, multiply the Medicare reimbursement figure per test by the total number of tests per month.

Remember that Medicare groups tests. If you're considering a multichannel analyzer, use the grouped reimbursement rate as the estimate for test revenue. * Enter the sales force. You are finally ready to see sales reps. Almost anyone entering a physician's office with a briefcase, it seems, claims to have just what every POL needs. To be fair, many have fine products to offer. Manufacturers have their own vendors, who are often knowledgeable and helpful. Tap into their expertise.

Unfortunately, many vendors know little more about laboratory equipment than its cost. Carefully sift through claims and promises. Asking certain questions will help you weed out instruments that deserve serve no further consideration. * Key information. The first thing I ask a vendor is whether the instrument surpasses qualifications and regulations in our state. Because Florida licenses larger POLs, my question too often elicits this revealing response: "You don't need to worry about that because you have only four doctors." True; but since we are voluntarily licensed by the state, we have to exceed the minimum requirements. I'm reluctant to deal with any vendor who appears to know so little about the product and the market.

If the vendor gives an acceptable answer to my first question, I follow up with several others:

1. Can the instrument do all the tests we need? Promises that tests will be added in the near future are only that: promises. I feel much safer with an instrument for which all of the bugs have been worked out.

2. Can the instrument turn out the volume we need? Buying an instrument that does 200 tests per hour for a lab that typically runs 200 tests per month will probably create the need for more maintenance time than it merits. Likewise, an instrument that requires lengthy specimen preparation or incubation time may be too slow for your purposes.

3. How long does it take to obtain a result? Turnaround time is specific to the needs of the particular practice and should be a major consideration. If the doctor want the blood drawn and a result available within a specified don't consider an instrument that cannot deliver - unless the physician is willing to change his or her expectations.

4. What disposables are needed, and how much will they cost? If the vendor says that all disposables will be supplied, press for numbers. Vendors frequently send what they think you'll use. If you actually need more, you may end up paying the difference. To prevent this from happening, do a little arithemetic to include the cost of disposables when calculating cost per reportable result.

5. Can various brands of reagent be used? Sometimes the only reagents and controls that work in a given piece of equipment are those supplied by the manufacturer. Vendors can then set whatever price they want, and you must pay it.

6. Does the vendor offer a QC program? If so, how much does it cost? If the manufacturer of the instrument, its reagents, or controls can't supply satisfactory answers, steer clear of the instrument. Otherwise, you may not be able to meet upcoming Federal regulations regarding QC and proficiency testing. If your lab is small, such QC data can be a big help in keeping quality on track. Comparing your mean value and your coefficient of variation with those of other participating labs provides important insight.

7. Who will train the principal operator? A vendor who sells an instrument that's easy to run may bring it in, set it down, plug it in, and do a 10-minute demonstration. This procedure does not constitute training. The operator must understand how to maintain and operate the instrument properly. If an established training program is not available in your laboratory or elsewhere, look for one.

Any vendor who insists an instrument is "push-button easy" and maintenance free is not telling the whole truth. Even in the simplest instruments, duest accumulates, lamps weaken, and batteries run low. Regular troubleshooting for such conditions is part of a good equipment maintenance program.

8. Will you show us how it works? Most manufacturers send their own representatives to demonstrate their instruments. These reps are usually well informed; take advantage of the opportunity when it is offered.

9. What are the bottom-line costs and cost per reportable test? You'll need to know the actual cost of the instrument and reagents, controls, and disposables. Outright purchases, leases, and rental agreements are all good ways to deal with these costs, depending on circumtances. One form of acquisition may be test in one situation but not in another. Ask the vendor to put the alternatives in writing; then read the document carefully. Like other sales reps, vendors talk long and fast as they try to convince customers that one acquisition method is better than another. Only you can decide what would be best for your laboratory.

Find out the cost per reportable test to determine whether you can afford to buy the instrument. Because controls, blanks, and calibrators all cost money, you must figure out much of each you will need and add these figures to your actual test numbers. The simplest way is with the following formula. Add the total number of reported patient tests (X) and the total number of non-reimbursable tests (Y); then divide by X: X+Y/X=F Multiply the quotient, F - a number between 1 and 2 - by the cost per test to find the cost per reportable test.

Some people consider this method overly simplistic for selecting instrumentation. Actually, a simple, subjective approach works well for small POLs. For larger office laboratories, the approach must be more finely tuned. POLs rarely have M.B.A.s or purchasing agents on staff or get quantity discounts. They must therefore approach purchasing differently from larger labs.

Another consideration is time available versus staffing requirements. In the POL with one fulltime time medical technologist and a small workload, it is more cost-effective to be semi-automated than to be fully automated. If testing is to be done by a clerical person with many other duties, a small, worry-free random access analyzer is the answer. Even on such POL-specific wonder machines, each test can cost $2 to $6. A semi-automated labor-intensive batch analyzer, on the other hand, delivers test results for a few cents each. Anticipated volume, doctor's profilling needs, and available staffing are additional factors to consider.

I cannot overemphasize the fact that the least expensive instrument is not always the best buy. Quality (or lack of it), reagent and disposable costs, down time, and the operator's stress level are as important to consider as the instrument's important to consider as the instrument's base price.

I have used the approach outlined here for instrument acquisition with great success. Many tests previously sent out are now done accurately, quickly, and cost-effectively right here in our POL.

The Federal regulations likely to affect all physicians' office labs in the near future make it more important than ever to approach instrument selection intelligently. Good planning and good luck!
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Title Annotation:physicians' office laboratories
Author:Ferron, Doris
Publication:Medical Laboratory Observer
Date:Jan 1, 1990
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