Technology driving care ... and staffing: POCT expansions have potential to drive medical technologist staffing.
Issues near and dear to the medical technologist, particularly ensuring quality results, ring seemingly just as true today as when the idea of expanded home testing surfaced years ago. Questions remain, as well, concerning whether self-testing and monitoring will ultimately impact staffing levels in an already crunched laboratory field.
Interpretation Still Necessary
Robert Newberry, MT(AMT), MLT(ASCP), MT(HEW), POCS(AACC), Coordinator, Point of Care Testing and Laboratory Safety at the Yuma Regional Medical Center, Yuma, AZ, said POCT devices simply are not as accurate or precise as laboratory instrumentation.
"Even capillary glucose meters can have up to a 20 percent bias to lab plasma glucose," he explained. Further, he said, if lab tests are performed at home, "who interprets the results? Most of the home POCT tests are designed for patients to interpret the results and self treat (such as capillary glucose and adjusting insulin dose)."
However, he said, as the number and complexity of tests increase, the shift will be toward electronic transmission of these results to a centralized location where a group of healthcare professionals will electronically inform patients how to interpret the results and adjust medication.
Staffing Already Impacted
Sheila Coffman, BSMT(ASCP), Implementation Project Manager at Abbott Point of Care, Orlando, FL, asserted that POCT as a whole "will and already is impacting laboratory staffing." By example, she said there has been a transition of ACT being performed by perfusionists, cardiac markers by emergency department staff, creatinine by radiology, blood gases by respiratory, PT/INR by Coumadin Clinic staff, glucose by every healthcare professional and numerous other tests.
"The concerns of the acute setting of laboratory professionals have to do with ensuring quality of the test results and costs. Who pays for the POCT tests (lab or department?) and who receives the revenue (lab or department?)? Home testing is more likely to impact the physician office and reference labs rather than staffing in the acute setting," Coffman said.
Coffman said the concept of POCT remains controversial for a number of reasons. She provided these examples:
* Burden of Cost: Tests may be covered by CMS or insurance, but often require out-of-pocket costs that can be in excess of the cost of going to a physician or lab to have the test done. For example, Patient Self-Testing (PST) for PT/INR can cost $2,500 or more for the test device, plus $10-20 per strip/cartridge or disposable. The out-of-pocket cost might be more than $500 for the device and then only one test per week may be covered. Patients often have errors and waste strips or test more often which can be out of pocket. At $20 per strip, costs rise quickly and patients struggle at times to cover.
* Training: The patient or a caregiver taker must demonstrate ability to perform the test. The patient may often take on this responsibility and then decline in ability due to health or confidence or a caregiver is no longer present to assist or perform. Coffman said with PST PTINR, there are several pre-analytical considerations that can greatly affect the accuracy of the result. Training may be covered as a cost for the prescribing health care professional or the IDTF may provide a trainer in the home. While training is reimbursed, it is a one-time covered cost.
* Troubleshooting: Patients will seek out the freedom they feel PST will allow them so they can test more frequently or without hassles associated with office visits. The process can become stressful at times due to the fingerstick or other technical issues such as quality control with the device and disposables or even unexpected results: high or low. These issues cause high anxiety and while most independent diagnostic testing facilities or manufacturers offer technical support, this can be overwhelming at times and patients will stop testing.
* Communication: Results are required to be communicated to the physicians. This can be done in a number of ways such as telephone direct to the physician office, use of an IVR program through the IDTF or entry through an Internet program accessible by the patient and healthcare professional, sometimes even allowing for a bi-directional communication. Coffman said physician offices not set up efficiently can incur a lot of process increase for attempting to monitor remote patients. Done right though, physician offices can increase their volume of patients and thus their income while delivering high quality care. Non-compliance with communicating results can result in loss of physician support (for example, no more prescriptions). It can also result in denial of insurance reimbursement for future supplies.
* Liability: Physicians sometimes are wary of the liability of writing prescriptions for PST and non-compliance resulting in an adverse outcome for the patient.
Quality of Care Concerning
Dave Glenn, MASCP, MLS(ASCP)[CM], Lab Manager, Pathology Services, P.C., North Platte, NE, said concerns are rightfully focused around poor quality care.
"I think anyone that is college trained is concerned that CLIA Waived testing performed by non-college trained personnel may be poorly performed or interpreted leading to poor quality care. Also, when lab tests are performed by anyone without formal training, it sends a message to administration, physicians, and nurses that 'anyone can do lab work' and that harms the image of the profession.
Meanwhile, he said many tests are shifting toward POCT. "Home pregnancy tests, glucose testing, and PT/INR testing are already very popular in the home." He said many new technologies being developed will enable many tests to be developed for the home market.
"I can't guess what they would be but I suspect the companies working on these tests will be doing market research of what the public wants and then they will offer what they can along those lines ... perhaps home HIV, flu tests, drug screens, urinary tract infection screens and lipid screens will become popular for the home market," Glenn noted.
Power to the People?
Coffman said more tests should be accessible by patients. "I think that information is power and advocating for our own healthcare is already primary as we all seek out experts, second opinions and alternative therapies," she explained.
She said the challenge lies in the financial support of the payors and the technology advances that allow bidirectional communication with our healthcare professionals outside the normal of the face-to-face office visit. "I am hopeful that with apps and Internet access extending into all homes, healthcare professionals will adapt to this type of remote care," she said.
She added that medical device technology is soon to allow those tests that are currently used in a POC setting to be extended to the patient self-testing environment. "In fact, most devices can have the bells and whistles we use in the professional setting removed and the simplified device can be user friendly for the self tester," she said, noting current technology is "packable" for a home use device. Samples sizes are smaller allowing for the fingerstick samples to be used to gain information and the feedback quality codes are better directed to guide a patient through troubleshooting.
Caveats and Considerations
Coffman said laboratory professionals should embrace technology and empowerment of patients. "Disease management through self monitoring is a good thing. We need to be forward looking at technology and thinking outside of the box. Can you imagine a diabetic without a glucometer? Nope. Someday, it will be that there is a laboratory tool for other disease management. Embrace, don't race (away)," she said.
"Patients who have personal control over their health and healthcare needs, have a far better quality of life than those who are dictated to by healthcare professionals," Newberry said, noting, "I believe home POCT will ultimately have a positive impact on laboratory staffing and the field as a whole. Laboratorians will be recognized and utilized as the resident experts on lab testing and interpretation. It will be the laboratory that will be the driving force for positive patient outcomes."
Glenn cautioned, though, that if testing is performed poorly or test results are not understood properly, patients may misinterpret the need to see a physician. Laboratory interpretation of many tests continues to require skilled, educated medical technologists.
"Lab tests are valuable but they can't always replace a consultation with a physician. A patient who tries to diagnose themselves is treading a dangerous path that could prevent a quick diagnosis and proper treatment. To paraphrase William Osler's quote, 'A physician who treats himself has a fool for a patient.' POCT could lead to 'A patient who treats himself has a fool for a physician.'"
* Matthew T. Patton is a freelance writer based in Atlanta. He has covered the clinical laboratory profession for more than a decade. E-mail him at firstname.lastname@example.org or visit his website at www.matthewtpatton.com.
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|Title Annotation:||point of care testing|
|Author:||Patton, Matthew T.|
|Date:||Sep 1, 2012|
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