Labs entering risky payment game in the new year

This year will bring a host of regulatory, coding, billing, and payment changes that are going to challenge pathologists and laboratory administrators to move quickly or else face declining revenue and the grim specter of Medicare recovery audits. That was the somber consensus of three experts gathered for a December webinar hosted by The Dark Report.

“It will be a high-stakes game in 2015 because both government and private payers are stacking the deck against clinical labs and pathology groups,” Dark Report editor-in-chief Robert L. Michel said in a statement publicizing the webinar. “Across the nation, Medicare carriers and private health insurers are implementing myriad changes in coverage guidelines and reimbursement for both clinical lab tests and anatomic pathology services, in an effort to reduce their costs.”

The lede to my latest feature article in CAP TODAY. Read the whole shebang.

Digitized slides spur patient engagement, ‘allow for democratized medicine’

Regulatory and reimbursement hurdles are key factors blocking broader adoption of digital pathology. But the technology is already having an impact, enabling patients to grasp a firmer hold of the wheel in directing their care, said Keith J. Kaplan, MD, a pathologist and laboratory medical director in Charlotte, NC.

“This may be a little uncomfortable for some, but the idea is that digitized slides allow for democratized medicine and for patient and consumer access to their slides in an open and transparent fashion,” Dr. Kaplan said in a CAP TODAY webinar presented last month in collaboration with Ventana Medical Systems …

Lead item for CAP TODAY’s “Put It on the Board” section. The whole shebang.

Traveling with Lee Sandlin

Lee Sandlin died earlier this month. What a tremendous loss. He was a fantastic writer, and I was lucky to make his acquaintance. Here’s an obit by Michael Miner in the Chicago Reader, the longtime home for his singular brand of narrative nonfiction.

A celebration of his life and work was held recently at Chicago’s Sulzer Library and his wife, Nina (@nsandlin) — a good friend of mine from our days together at the late, great American Medical News —  asked me to contribute some thoughts. Here they are below. I post them here principally for the opportunity to share a bit of Lee’s writerly genius, and to encourage you all to read as much of his work as you can, as soon as possible.


To read is to place your trust in the hands of another, typically a stranger. When you read, the general rule is that most of what you know, what you believe about a subject, what you feel and hear and see in the mind’s eye, is shaped by your guide, the author. There was no better guide than Lee Sandlin.

The road he led you down may have been full of pit stops and detours, but every one was worth all the while. In a world where the written word is defiled by inattentiveness and, worse yet, artlessness, he kept a great faith with himself and with his readers. And, boy, did his prose show you how to go. In “Wicked River,” he wrote:

There were no beacons or lighthouses or channel buoys on the river then; there were no official markers of any kind. Here and there someone would occasionally paint a warning or an arrow on a prominent rock to alert voyageurs to danger — but these were often the work of pirates, to trick boats into going around. Nor were there any reliable maps. In that era, mapmaking, even at its best, was a mixture of supposition, obsolete or garbled information, and pure fantasy; the first rule of travel in the American interior was that only a fool trusted a commercial map.

But the voyageurs didn’t care. What did they need a map for? The land was so wild it was essentially impassable; anyone who didn’t go by the river didn’t go at all. In effect, the river served as its own map. A voyageur who needed consult it had only to climb the nearest hill. There the route unfolded, in all its blue-misted splendor: the great dragon tail of the river uncoiling the rough forested valleys and across the tallgrass prairies and into the vast shrouded swamps, glittering with ten thousand sunflecks, blurred by drifts of drizzle, blazing with reflected herds of brilliant cumulus, on and on toward the horizon. As far as the eye could see, the river was the only road.

I would give a pinky finger to write sentences so pure, so authoritative, so precise, so true. I feel lucky to have read them, and doubly fortunate to have had the opportunity to share with Lee how much they meant to me, thanks to my friendship with his lovely wife, Nina.

One could call writing like Lee’s majestic, or lyrical, those book-review workhorse words. Posh! I say. When we see nonfiction writing like this again (as will surely be rare), I suggest we call it Sandlinesque. That will be a true compliment. Thank you, Lee, for letting us travel with you. On and on, toward the horizon!

Massive transfusion: a question of timing, detail, a golden ratio

Here it was, the kind of massive postpartum hemorrhage case for which the team at Duke University Medical Center had spent months preparing. The multidisciplinary group had agreed on which laboratory tests would be done in such a case, determined which blood products would be delivered, and decided which members of the OB team would be sent racing to retrieve the potentially life-saving package.

For the two labor-and-delivery nurses designated as runners, the quickest way to get down to the blood bank was the elevator. The elevator was working, but the nurses’ badges did not allow them access to it.

“They had to run all the way down the hall, then all the way down the stairs. It took much longer,” says Evelyn Lockhart, MD, a pathologist who specializes in transfusion medicine and led the Duke team in implementing a massive transfusion protocol for postpartum hemorrhage.

“It was a surprise to us all,” Dr. Lockhart says. Fortunately, the only harm associated with the inaccessible elevator was a couple of winded nurses. That is because the elevator flap came as part of a simulation, and no woman’s life was in danger. It turned out that access to the elevator was restricted to emergency department personnel. That changed soon enough, before any real-life obstetric massive transfusion protocols, or MTPs, were initiated.

The story illustrates an essential truth in the world of massive transfusion, experts tell CAP TODAY. While a randomized clinical trial likely to be published could help answer persistent questions about which blood component ratio can best reduce the mortality rate in massive transfusion cases, experts say that fine-tuning the timely communication, processing, and delivery elements of the MTP are just as essential as determining what “golden ratio” of blood products to prepare.

My cover story from the December issue of CAP TODAY. Read the whole shebang.

How LIS tweaks can enhance efficiency, patient safety

So, you have a great idea that will improve laboratory workflow and reduce errors? Chances are the change will depend on automation of some sort, and will involve the LIS. But upgrades to laboratory information systems may not come fast enough, and the middleware may not be available to accomplish what you need. Then the question becomes how to customize the LIS to achieve your aims.

That is what the six-member pathology informatics team at the University of Pittsburgh Medical Center Health System has had to do—work on their own, with middleware providers, and with their LIS vendor to meet the demands of their laboratory colleagues.

“That’s the philosophy we have. Our users ask, and we aim to deliver,” Liron Pantanowitz, MD, tells CAP TODAY. An associate professor of pathology at the University of Pittsburgh School of Medicine, Dr. Pantanowitz also directs cytopathology at UPMC Shadyside, heads UPMC’s pathology informatics fellowship program, and is associate director of Pitt’s Pathology Informatics Division.

Dr. Pantanowitz and his colleague Anil V. Parwani, MD, PhD, detailed several innovative UPMC projects in a CAP ’14 session, “Customizing the Laboratory Information System to Improve Patient Safety and Workflow in the Pathology Laboratory.” These include using the LIS to drive improvements in anatomic pathology quality control, synoptic reporting, and specimen tracking, while exploring the promises—and challenges—of digital pathology and next-generation sequencing.

My latest feature article. Read the whole shebang.

For Ebola cases, weighing broader, faster diagnostics

Amid initial confusion over Ebola-related safety protocols for health professionals providing direct patient care, laboratory professionals report hearing a consistent message from the CDC on proper specimen handling. The pressing question for laboratories is how best to approach testing with potential Ebola patients given the dual imperatives of preventing exposure and offering faster diagnostic answers.

My latest in the Put It on the Board section. Read the whole shebang.

FDA’s LDT proposal means ‘whole new ballgame’ for labs

The Food and Drug Administration’s plan to subject many laboratory-developed tests to a new layer of regulatory requirements over the course of the next decade is drawing sharply contrasting reactions from stakeholders who view it as either an essential step to improve patient safety or a hindrance that will stifle diagnostic innovation and test improvement.

Despite that fundamental disagreement on the policy’s substance, there does seem to be consensus among informed observers that the FDA is determined to take action, that legislative intervention to block the agency faces long odds, and that the agency’s final guidance will create a regulatory challenge for labs unrivaled by anything out of Washington since CLIA ’88.

My feature article in the October edition of CAP TODAY. Read the whole shebang.

Twitter touted as tool to sway minds

Leading pathologists and the CAP are encouraging laboratory professionals to use the social media website Twitter as a way to amplify lab medicine’s voice among clinicians, policymakers, news organizations, patients, and the public. It is advice that at least one prominent social media expert and nonpathology physician says lab professionals ought to heed.

“Pathologists have a problem being recognized by society because we don’t see patients directly. This is an opportunity for us to get out there in society and to contribute value in that regard,” says Timothy Craig Allen, MD, JD, a newly elected member of the CAP’s Board of Governors and director of anatomic pathology at the University of Texas Medical Branch, Galveston.

My latest in CAP TODAY’s Put It on the Board section. Read the whole shebang.

New push for standard approach on critical values

Newly reported survey data that show widely varying international practices on managing critical values may demonstrate the need for a new guideline—already in development—to help laboratories formulate evidence-based policies.

The new data from European labs were presented during a session at the American Association for Clinical Chemistry’s Annual Meeting and Clinical Expo in Chicago (“Critical Result Management Practices: Global Perspectives and Recommendations for Best Practices”). The session also provided a preview of a forthcoming draft guideline from the Clinical and Laboratory Standards Institute that represents the organization’s first formal attempt to advise laboratories around the world on critical values reporting.

My feature article in the September issue of CAP TODAY. Read the whole shebang.

We drive

With Labor Day upon us, it seems appropriate to share another playlist. This one is called “Automobile.” The driving theme seems appropriate because so many people take advantage of this three-day weekend to take driving trips. Unfortunately, the song that inspired the title — John’s Prine’s “Automobile” — is not available on Spotify. Here’s Prine playing it live in a 1980 televised concert. Song starts about 1 minute, 40 seconds in.

Anyhow, here’s the rest of the playlist. I had to make a couple of substitutions, again due to Spotify: a Bluegrass version of “Cut Every Corner” from The Simpsons, and John Hartford doing “Turn Your Radio On” instead of Grandpa Jones.