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Q&A: TriCore President Michael Crossey on Personalized Medicine, Risks and Opportunities for Labs

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NEW YORK (360Dx) – Michael Crossey has worked for TriCore Reference Laboratories, New Mexico's largest medical laboratory, since its inception 20 years ago. In March, he was named president and CEO.

The non-profit organization, which was formed through the merger of The Reference Laboratory with the hospital laboratories of University of New Mexico Health Sciences Center and Presbyterian Healthcare Services, has changed significantly in the years Crossey has worked there. It now has 1,300 employees across 73 locations in New Mexico.

Drawing from the pathology departments at its sponsor hospital systems, the organization has approximately 50 medical directors, and now performs approximately 10.5 million billable tests a year, according to Crossey.

In an interview with 360Dx, Crossey reflected on some of the challenges and opportunities facing the lab industry, as well as the changes he has seen at TriCore and in the lab industry as a whole over the past 20 years. Below is an edited transcript of the interview.

What are some of the different roles you have had within TriCore and how have your different roles prepared you for the role of CEO?

Early on I was a clinical pathologist and medical director. The early stages of TriCore involved consolidating and standardizing across all these different hospital labs that we had brought together. It took a decade and a half to get to the point where we have the same instrumentation, the same normal ranges, the same critical action values. All that takes time because you are working with different clinical staff in different places. You are not just standardizing the laboratory, you are also standardizing the people that use the laboratory. So I would say my early years were much more devoted to standardization and optimization of the laboratories. Now we are accredited by the College of American Pathologists laboratory accreditation program but also by ISO 15189, and so the labs are very standard, very high quality across the whole system.

Now I am working more on informatics and population health and where laboratory data can be used to bend the cost curve in healthcare at our different sponsor institutions. I'm looking forward to spending a little more time as a CEO in the economic community of New Mexico and the region, and representing the medical laboratory community when it comes to what's going on in the legislature, both state and national.

TriCore includes a core lab, hospital labs, as well as outreach labs in New Mexico. Do you see those areas as separate segments? How do they work together?

They are not separate. The hospital labs are fairly standard in terms of what's done in the hospital and what's sent to the core lab. Then, there is point-of-care that is done at urgent cares or draw sites that we run for our sponsors. In fact, I don't like to think of them as silos, it's a continuum. If something is run at the hospital because it's needed for the emergency room or the intensive care unit, the same tube could be sent to our core lab for something a little more esoteric. The model is that the menu for the hospital is really geared toward giving really good service to the ER and the ICU and a few specialty clinics. Basically, it's really a lean model to keep the services levels high for the intensive service lines. The core lab is taking routine work from all over. About 90 percent of microbiology is done in the core lab, and that's where we have good bench steps and we have automation in microbiology. It's not exactly like a reference lab that is doing very esoteric stuff. A lot of the stuff we do in the core lab is really routine, but we can do it all day every day, 24 hours a day, 365 days a year. It's just kind of a continuum of care from very acute to a little more esoteric.

What are some of the challenges you see facing the lab industry? You mentioned as a CEO you hope to get involved with legislators. What are some of those key issues you hope to become more involved with?

I think PAMA is a big hit. Taking a 10 percent cut from CMS right out of the gate in 2018 is not to be underestimated. Reimbursement and the laboratory being regarded as a commodity and a cost-per-test is kind of our lot in life right now and we have to get away from that. We should be viewed as clinical colleagues contributing to a continuum of care. That's a cultural thing.

In terms of staffing, I'm actually luckier than most of my medical colleagues around the country in that we have a very good [medical technologist] program at the university, and we have a very good [medical lab technician] program at the community college here. We do a lot of training for those two programs, but staffing is always a challenge. It's trying to get people to understand what a med tech does, and why you would want to be one. When you go to the biology graduating class, I don't think anybody understands what a med tech is, so we do a lot of recruiting in that way. IT and running a really good laboratory is one thing that we are all trained to do well, but what it takes to push out all those results to 200 different EMRs across the state and 17 different hospitals, the IT challenges within the laboratory industry and within healthcare in general are pretty steep.

What are some of the opportunities you see in the lab industry?

I think the biggest opportunity for the lab is to really start thinking about the data that is produced as more information than just data. How can we use data in a population health realm instead of just a transaction where a doctor ordered a test, and we did the test and gave the result back and that's the end of the story? If you can aggregate data and show clinics, health systems, or health plans trends and insights into their own data, that's where we are doing a lot of new and interesting things. It's not selling data, it's selling insight into the data we have already produced. Since we are the producer of the data, we have pretty intimate domain knowledge of how to aggregate it, how to put it together, and how to give them something actionable. I think that data and analytics is an opportunity for the lab industry.

When people think of personalized medicine, a lot of folks think it's all about molecular diagnostics and sequencing somebody's genome, but I think it's as much about a common test that changes over a period of time. I think there's an opportunity for laboratories to think of a patient's data in a longitudinal way over years, and the trends and changes in that data. How we can help physicians pick up on those changes in lab results is an opportunity to help our clinical colleagues take better care of patients. Population health and personalized medicine are two ends of a very large spectrum. Somebody's A1C has been well controlled but all of a sudden it bounces up. Things like that can get missed in big systems. We do a lot of molecular genetics and what would be currently viewed as personalized medicine in the molecular realm, but I think a lot of those other much less esoteric tests are just as personal. If I can baseline your creatinine to you personally instead of comparing your creatinine to my normal range, which is the national average, it's much more informative.

TriCore acquired clinical IT solutions company Rhodes Group a few years ago. Does Rhodes Group work with TriCore on those types of analytics?

Yes. That is our analytics group. That group initially was a front-end registration software and back-end billing, and in the middle of it all was a big data warehouse. Our data and analytics is really using that large data warehouse, and we couldn't do what we are trying to do without Rhodes and the data repository.

When you buy an IT company, its professional, electrical engineers are crazy smart. They can move data like nobody's business, but they don't necessarily have the domain knowledge and the medical knowledge to have it make sense. Picking up Rhodes, and having them really intimately involved with me and my team in diagnostic optimization has really been fun. They know how to comb through data efficiently, but sometimes they wouldn't know the right question to ask, so there's a really nice marriage of clinical medical domain knowledge and IT savvy that makes it work. You can do a query and do something in a few minutes now that would have [previously] taken me weeks. [Before Rhodes Group] I would have made a request, and when it came out it may not have been what I really wanted. So, it's really more fun to work in a group with IT and laboratory all sitting at the same table at the same time.

TriCore was instrumental in beginning Project Santa Fe, which explores lab data analytics. What is the status of that effort?

We still meet. We had a spring meeting with the Project Santa Fe group, and we are planning to continue to do a fall workshop where anyone can come and talk about different projects and different pilot experiments.

Project Santa Fe spends a lot of time on how does what we do in the lab affect outside the laboratory. For example, if we do this test, does it decrease pharmacy cost? Does it decrease length of stay? Does it speed time to diagnosis? Getting out of the lab and making sure what we do in the lab has a downstream effect, that's a big focus of Project Santa Fe. We have to get out of the laboratory sometimes to prove that the impact of the laboratory isn't in the laboratory. If you said I did this big Lean Six Sigma project and I saved 10 percent of laboratory cost, in a grand health system that's budget dust. But if you save 10 percent of the pharmacy bill, you are talking about a couple hundred million dollars. In the old days, we were in a laboratory bubble of Lean Six Sigma and tightening up our processes, which is a good endeavor to do, but when you talk about saving 10 percent of laboratory cost versus 10 percent of the hospital cost or 10 percent of the pharmacy cost, lab costs are not even on the radar.

What types of diagnostic technologies do you see as most promising?

I still have a lot of hope for point-of-care testing if manufacturers focus on connectivity. I keep trying to tell vendors, if point-of-care testing gets done in a clinic, and gets written down on the back of an envelope and that data is lost, that's a huge opportunity missed. If you are going to make a point-of-care device that is a very good, technically solid respiratory virus molecular test, but it isn't Bluetooth or WiFi-enabled to upload that data into the greater [lab information system] or [health information system] or data repository, you are missing a big opportunity. I do think a lot of the point-of-care devices that are coming out are becoming technically quite good. As long as there is good oversight of these, and if it could make a difference in the clinic, for example, not putting someone on antibiotics because they know it's a viral infection, then I'm really supportive of point-of-care testing. If the clinic just wants to know, or if it thinks it can make money off point-of-care testing, then that creates a perverse incentive that is not going to help healthcare at large and it's just going to add cost. I do think that the technologies of point-of-care have come far. They rival a core lab's accuracy and precision. They still have to get the cost down, but I do believe it's on its way.

Are there any other types of advanced testing that you see as promising for other parts of the lab, other than clinics?

In the esoteric realm, I think it's the cell-free DNA. We used to need to get a piece of tumor tissue, and you would embed it and cut it up and put it on a glass slide. Then a pathologist would call it cancer. Then we would add the immunohistochemicals or the molecular test. The molecular technologies now can pick out strands of DNA from a lung tumor in a person's blood. When you talk about liquid biopsies and things like that, that has definitely changed things.

I think digital pathology is also going to be an interesting space. It's hard to figure out how to build a return on investment on it, but I can't imagine not being way more digital five years from now in the anatomic realm. I'm not sure how it is going to play out.

Mass spectrometry technology is becoming much more refined. You don't spend all your time tuning up the mass spec, you can actually run a lot of samples. The technology of mass specs, whether they are connected to a liquid chromatography or time-of-flight, that realm is expanding pretty quickly. Now I have a mass spec in my microbiology lab. We will probably have a mass spec in the oncology lab soon.

What are the biggest factors in evaluating new diagnostic technologies (for example, cost versus effectiveness or ease of use) and how do you weigh those factors against each other when selecting diagnostic technology?

It's a given that it's going to be accurate, specific. Where I really push now is, does it add clinical utility? Does it really change the cost of diagnosis or the cost of care? If somebody wants me to look at something and says it is two decimal places more accurate than another device, my answer would be, is that needed from a clinical point of view? We become very enamored of laboratory accuracy, but sometimes we lose sight of whether it adds anything to the patient's diagnostic odyssey. If it doesn't, it's just noise and expense. I really hold to that. It can't be just a new shiny object, it has to add something to the patient's diagnostics efficiency. We really have to hold ourselves to that because if it's just another shiny object, it's just more expense and it will come back to bite you when budget time comes around.