Cameron Martin - Pathology Queensland

The financial and professional hurdles

confronting PoCT

Cameron Martin

State Wide Coordinator PoCT, Pathology Qld

Financial and professional hurdles facing PoCT NPF Dec 2016

What barriers confront PoCT in Australia?

• Two broad categories

• The Technical Issues ( Easier - have defined solutions, but cost money)

• The Conceptual Issues ( Harder, involve a paradigm shift - less defined

solutions)

2

The technical issues

• Establishing a need

• Selecting an analyser

• Evaluations

• Quality control & Assurance

• Treatment of results

• IT and monitoring

• Training

• On going support

• Keeping it all together!


The conceptual issues

• Why is PoCT even needed?

• Why would they (clinicians) want to do it?

• How will it be controlled without a lab?

• Are clinicians capable of performing tests?

• What is wrong with the laboratory?

• It is too expensive

• It represents a doubling up of service

• It is inaccurate, doesn't work properly, tests not as good as the laboratory

• We don't have the staff, time, resources, IT, etc to support

• We don't want to do it! (We don't want you to do it)


The solutions

• The technical issues – have technical solutions, albeit, solutions do cost money

• The conceptual issues are mostly about why we should spend this money!


Some technical solutions

• Establishing a need This also conceptual – discuss later

• Selecting an analyser AACB, AIMS, CLSI, NPAAC

• Evaluations As above

• Quality control & assurance Can be fixed in a block

• Treatment of results

• IT and monitoring

• Training Can be fixed in another block

• On going support

• Keeping it all together!


Managing patient and QC / QA results

• Results, patient or QC - need to be managed - unmanaged is uncontrolled

• Patient results need to go to a patient file where they can be retrieved as needed

• I refer to PoCT analysers as a testing system rather than an “analyser”

• The “analysers” themselves need to be managed

• QC & QA need to go to cumulative files so the testing system can be controlled

• The only way to do this effectively in a state wide PoCT unit, is to automate it through a middleware system

• Pathology Qld currently uses two middleware systems (Conworx, Aqure)

• This enables a wide variety of cartridge based analysers to be managed remotely and report & review their patient and QC results centrally


Training systems

• Testing operators also need to be managed

• On-line training training with FTF backup is best for point of care

• The burden on the lab is decreased, operator compliance is increased

• Most PoCT analysers have simplified procedures, are easy to break down into

on-line training units

• Online material can be available 24/7 or even from home

• Without on-line training it is difficult to have an operator lockout in place

• Entire system can be automated


Support

• A defined, dedicated central support team / system / network is needed

• The lab staff are there to help at the ground level, not organise from the top

• These are people who will interact with clinicians, and keep the service together

• Find people who are interested, and give them a free reign to run things

• Point of care is a specialty in its own right, it is not specifically owned by one

discipline, ownership causes division, confusion, and dilution of services

• The support is for the the benefit of the USERS, to help the patients

Using resources that are available

Telemedicine project has been incredibly helpful to us – Teletraining

with Normanton hospital staff.

Advanced skills - Communication & Education

Improvements % errors (all )

• 2007 2008 2009 2010

• Miles 29.16 20.6 15.4 15.0

• Chinchilla 29.1 21.7 19.8 23.0

• Toowoomba 18.4 16.2 10.3 8.7

• >90% of participants thought content useful

Finding sources of trouble


• Why is PoCT even needed?

• Why would they want to do it?

The central lab model is now more than a century old - did only we think it

would never change?

Most people only resort to doing jobs outside their skills & comfort zone

when they feel they have an unmet need

The advent of clinical pathways and the trend to outpatient treatment has

made TAT an important issue on even previously "routine" tests

The central lab model has a finite wall in terms of TAT

This is particularly true in HITH and rural and remote medicine


Where is time saved?

• There is always a collection to transport lag at patient end (pre analytical)

• N/A or reduced for PoCT (simplified collection)

• There is always a transport time lag (pre-analytical)

• N/A for PoCT

• There is always a reception to testing (CSR) lag at lab end (pre analytical)

• N/A for PoCT

• Test dwell time on a lab analyser is usually longer (analytical)

• Also occurs with PoCT but analysis times are usually shorter for PoC tests

• Validation and result release / notification, can take time (post analytical)

• N/A for PoCT, the result is immediately available

• If there is no laboratory on-site then the transport time becomes much larger


• How will it be controlled without a lab?

• Are clinicians capable of performing tests?

• What is wrong with the laboratory?

• Should be controlled / managed by the laboratory, but run by clinicians

• With proper training clinicians are perfectly capable of performing tests

• There is nothing wrong with the laboratory service model - but the time has

come to extend this model in response to 21st century needs



• It is too expensive

• Expense is relative, unfortunately, we tend to only look at it as absolute

• What seems expensive to us, may save money elsewhere in the system,

• Costing needs to go past just one small part of the care chain

• Our whole budget and pricing structure was designed around the

labotatory model, this is why PoCT often does not compare well

• The problem is the way medicine is being delivered, is changing


Hospital in the home

• This unit saved millions of dollars in ambulatory admissions in the 8 years since

opening by using point of care testing

Are we effective?

I finally feel that the IT technology that QH has introduced over recent years is NOW making a REAL change in patient care…

All in all a fantastic result delivered locally to the benefit of all concerned. The staff found it also very satisfying…

Thanks for a great service

Bruce

Dr Alan Bruce ChaterRural Medical PractitionerVice-PresidentAustralian College of Rural and Remote Medicine


• It represents a doubling up of service

• It is inaccurate, doesn't work properly

• Poorly structured, implemented, or maintained support programs, and poor

instrument and test choices, lend "factual support" to these beliefs

• Used and scoped correctly, most instruments are capable of delivering

acceptable results

• Pre analytical error is the killer

• Where pre-analytical error is reduced, test confidence increases, test

quality increases, and total test cost decreases


Improved Indigenous Health TAT

Benefits of PoCT (1) Cape York

Patient 1

0

1

2

3

4

5

6

1 3 5 7 9 11 13 15 17 19 21 23 25 27 29 31 33

Episodes of testing

INR

Pre i-STAT

2011

Post i-STAT


• We don't have the staff, time, resources, IT, etc to support

• We don't want to do it! (We don't want you to do it)

• The issues technical & conceptual can be fixed, if we want to fix them

• Someone else will do it if we don't

• A good PoCT program is an extension of the lab, and acknowledged as

such by clinicians


Summary

• As scientists most of us accept the concept of evolution

• But not always with regards to our own profession

• Many developing countries will never have a poles and wire telephone system

• Affordable airfares changed buses and trains from long distance people movers

to short distance commuters, and tourist operators

• The internet killed snail mail, but provided E-Bay, that boosted parcel post

• We should be looking at these disruptive changes to see where our service can

also evolve in response to a changing enviroment

Health & Medicine

Cameron Martin - Pathology Queensland