Lab Soft News

Cleveland Clinic's Top Ten Medical Innovations for 2017; Focus on FHIR

The Cleveland Clinic lists its choices on a yearly basis for the top ten medical innovations. It recently posted its 2017 list (see: Cleveland Clinic names top 10 medical innovations 2017):

• The microbiome. The microbiome is made up of trillions of helpful bacteria that make a home inside the human gut – to prevent, treat and diagnose disease.
• Diabetes drugs that reduce heart disease and death....Novo Nordisk’s liraglutide, sold as Victoza, and Eli Lilly’s empagliflozin, sold as Jardiance, have shown promise in reducing these heart-related complications (see: Novo Slumps as Study on Victoza’s Heart Impact Disappoints).
• CAR-T therapy for leukemia and lymphoma. Using a new method called chimeric antigen receptor – T-cell therapy, doctors are now enlisting the patients own immune cells in the fight against leukemia and lymphoma....
• Liquid biopsies to find cancer. Finding a way to test for a cancer that doesn’t involve the pain and cost of a doctor a chunk of tissue from your body has long been on the wish list of oncologists.. It’s now possible to find tumor DNA circulating the blood, spinal fluid and perhaps even urine....
• Automated car safety features and driverless capabilities....Starting in 2018, the NHTSA will require back-up cameras in new cars. Collision warning systems, adaptive cruise control, lane assist, and cross-traffic alerts are some other innovations on the horizon to further reduce the more than 38,000 fatal car crashes each year.
• Fast Healthcare Interoperability Resources, or FHIR. FHIR is an interoperability specification that can act as a translator for EHRs that don’t normally play well together. It’s been tested in a number of trials. Health Level 7 is expected to release it next year....
• Ketamine for treatment-resistant depression. For one-third of people with depression, nothing helps – not therapy or medication, not even electro-convulsive or shock treatments. Ketamine, once known as a club drug, improves symptoms rapidly for the majority of these patients in initial studies, prompting the FDA to grant the treatment fast-track status for development.
• 3D visualization and augmented reality for surgery. Many eye and brain surgeons do their work in very small spaces, peering through high-powered microscopes with their heads bent and necks strained....3-D cameras are helping surgeons and their teams get a better view....
• Self administered HPV test.....The HPV test, designed for routine use in women over age 30, detects te presence of high-risk types of HPV in the cells of the cervix with a vaginal swab. It’s a simple test, but women who don’t ger to the doctor will never get it.
• Bioabsorbable stents....About 2 percent of people develop life-threatening blood dots at the stent site, according to the National Health-Lung and Blood Institute....Absorbable stents are already in use in Europe and recently approved by the FDA, do exactly that. The absorbable stents also appear to reduce chest pain after surgery compared with the wire option.

Here's some more information about FHIR, the sixth item in the list above (see: FHIR’s Impact on Population Health):

FHIR is a specification from HL7.org that outlines how to support an API for the purpose of exchanging data among HIT systems. The specification itself is still in DSTU 2 phase and, therefore, still evolving. The premise of FHIR is that HIT vendors will expose the API endpoints detailed in the specification, which can then be accessed by anyone who is properly authenticated and authorized. There are numerous API functions that FHIR supports, including both putting data into and getting data out of vendors who support the API. For example, FHIR provides endpoints for lab results, procedures, medications, and documents, among others.

So, as is often the case with IT standards, success will lie in whether the various healthcare software vendors will adopt and market the feature. Regarding this likelihood, I continue to believe that the majority of vendors and healthcare executives don't support EHR interoperability in their hearts because medical record portability can enable patient shopping across competing health systems. This same point was made in a recent article about FHIS (see: FHIR: The Last, Best Chance to Achieve Interoperability?). 

[A] worrisome....barrier to adoption [of FHIR] is the persistent doubt that most EHR systems, and most medical centers, are truly committed to reducing barriers to data sharing – carefully crafted public comments to the contrary. The question is whether in their heart of hearts (or more accurately, in the office of the CFO), hospitals and EMR systems really want to share data.

Large-Scale Programs to Reduce the Cost of Healthcare Such as Algorithmic Medicine

I have been trying to come up with a list of significant ways to reduce the cost of healthcare. I have addressed one of them, telemedicine, in a recent note (see: Ten Megatrends in Healthcare with Special Emphasis on Ambulatory Care). A second would be wellness programs, given that a large percentage of our healthcare costs are caused by lifestyle choices that can potentially be changed (see: Wellness Plans Use Carrots and Sticks; Disease Management Plans Lower Costs; Hospitals Diversify with Wellness Centers; New Facility for Population Health). Drug prices have gone through the roof and can be reduced by political and governmental pressure and new legislation (see: Pharma Money Flows into California Opposing Proposition 61). Broader use of clinical analytics and population health can be employed  to diagnose diseases faster, thus increasing the efficiency of care and reduce costs (see: Cerner Emphasizes Population Health but Pay Attention to the Details). Finally, algorithmic medicine can be used in a number of ways to increase the efficiency of care processes.

The term algorithmic medicine is cropping up more frequently to refer to the use of rules (i.e, algorithms)  to increase the efficiency and effectiveness of care processes. These include the use of algorithms in various ways ranging from the the very simple example of blocking unnecessary lab tests to more complex ones such as rapid computer diagnosis of diseases. Below is the abstract from a paper published  in 1984 by Greeo and van Gelder on algorithms in medicine (see: Algorithms in medicine). Many of the key points still seem valid to me.

The ever rising costs of health care in Western countries necessitate some form of cost control. Restrictions can be and will be imposed externally by, for instance, the government. These measures will probably lead to a decrease in quality of health care and the profession should therefore seek ways to prevent outside interference by developing an internal means of cost control. On short terms a form of internal control with preservation of the quality of care would be the introduction and widespread use of algorithms, restricting the use of useless and unnecessary tests and therapies. For long term results education must take on new tasks leading to a better understanding of costs an benefits of medical activities. The development of algorithms is hindered by the lack of common consensus of optimal care, the lack of relevant data and the inefficient way data are managed. When introduced the algorithm, especially when compulsory, will engender much resistance and unhappily, ways must be found to overcome them by sanctions. The profession must realise that if they do not do anything it will be done for them.

Regarding one aspect of algorithmic medicine, it should be relatively easy to triage ambulatory patient visits to the most appropriate provider such as a nurse, nurse practitioner, or physician. The introduction of algorithm-driven questionnaires prior to a visit would make the process more efficient. Most large health systems and practices have already automated the generation of prescription refills via patient portals. One intriguing question in this context is whether patients will tolerate completing electronic forms prior to a visit. My sense is that they will do so if and when the forms are well designed and the patients understand that the completion of the form will make their visit more efficient. What patients will not tolerate is the frequent request to provide information that they have previously supplied.

Pharma Money Flows into California Opposing Proposition 61

One of the major obstacles facing the healthcare system  today is the rocketing price of drugs. Here are more details about drug prices (see: The Challenge of High Drug Prices in the U.S.):

Americans pay higher prices and spend more per person for prescription drugs than other developed country. Unlike other countries our laws and regulations and the way they are enforced permit pharmaceutical manufacturers to set their own prices with little government oversight....The average annual growth rate in per capita spending on prescription drugs increased nearly every year between 1970 and 2010, but the sudden spike in drug costs, just as the ACA was expanding insurance coverage, has put a spotlight on the issue....Between 2010 and 2013 $84 billion in branded drugs came off patent. This situation changed suddenly in 2014 and drug price inflation returned in force. First, the portion of new patented drugs began to increase, particularly for expensive specialty drugs, such as the new hepatitis C drugs, which alone made up about one-third of the $32.4 billion in increased spending on prescription drugs in 2014.

Although there have been claims by Hillary Clinton that she will take steps to restrain drug prices if elected (see: Hillary’s Plan to Respond to Unjustified Price Hikes for Long-Available Drugs), interest is now being focused on a drug-price ballot issue in California, Proposition 61 (see: Drug companies funnel $108 million to defeat California drug-price ballot question). Below is an excerpt from the article:

Political donors have spent a record $450 million to support and oppose [the] 17 November ballot initiatives in California, beating the state's own record for the most spent on propositions appearing on statewide ballots in a single year....The fundraising has soared at least $12 million past California's previous record, when $438 million was spent on the campaigns for and against 21 measures on the ballot in 2008.....Proposition 61, a proposal to cap what the state pays for prescription drugs at the lowest price the U.S. Department of Veterans Affairs pays, has drawn the biggest spending. Pharmaceutical companies have contributed most of the $108 million that's been raised to defeat it....The AIDS Healthcare Foundation, which placed it on the ballot, has spent about $14 million backing it. Because Proposition 61 would not force drug companies to change their prices, the state legislative analyst says its fiscal effect on the $3.8 billion market is unknown.

Here's an excerpt from another article that digs deeper into the reasons why Big Pharma is opposing Prop 61 (see: Big Pharma fears Prop. 61, but not for the reasons Bernie Sanders says):

[Bernie] Sanders writes, ”It’s unacceptable that the exact drugs that we buy in our country are sold in Canada, Britain and other countries for a fraction of the price.” You might ask why U.S. pharmaceutical wholesalers don’t simply buy their drugs from Canada. The reason is that the Prescription Drug Marketing Act (PDMA), signed into law by President Reagan in 1988, prohibits the reimportation of U.S.-made drugs once they have been shipped to a foreign country. Even more outrageous, the law signed by President George W. Bush creating Medicare Part D prohibits the federal government, Big Pharma’s largest customer, from negotiating the prices it pays for drugs. The reason that Big Pharma is pouring so much money and effort into defeating Proposition 61 is that its passage may just open the door to inquiry into the PDMA and the Medicare Part D law. 

To summarize, drug wholesalers in the U.S. can't obtain product from other countries like Canada where prices are lower. Medicare Part D also prohibits the federal government, the pharmacutical industry's biggest buyer, from negotiating lower drug prices. Prop 61 in California can't force drug companies to lower their prices but it draws attention to the drug price problem. I think that we are now on the cusp of meaningful change regarding drug prices.

Ten Megatrends in Healthcare with Special Emphasis on Ambulatory Care

I recently presented a lecture at the CompuGroup Medical (CGM) User Group Conference entitled Ten Major Trends Facing the Healthcare Industry in Ambulatory Care on a Five-year Horizon. You can view a PDF of my lecture here. I made reference to this lecture in a blog note about how the future of healthcare was inextricably bound to information technology (see: Future of Healthcare Changes Inextricably Bound to Information Technology). Here is a slightly modified list of the ten megatrends that I presented in Las Vegas:

• Big Medicine continues to dominate healthcare delivery.
• Healthcare payers demand cost reductions.
• The configuration. design, and purpose of hospitals is changing (e.g., bedless hospitals).
• Telemedicine is rapidly becoming the new normal.
• The majority of physicians are becoming health system employees.
• Sicker patients are gravitating to ambulatory care and telemedicine settings.
• Consumerism is driving the decentralization of healthcare.
• Wearable devices and home mini-labs are gaining broad acceptance.
• Precision medicine is maturing as a medical discipline.
• Health networks connect providers, patients, and consumers.

I would now like to extend some of my comments about the growth of telemedicine. The cost of healthcare as a percentage of the GDP continues to grow at an unsupportable rate. For me, the best way to deliver care to an increasing number of patients at a reasonable cost is with telemedicine. Such an approach will allow a rapid expansion of the scale of healthcare without rigid investments in bricks-and-mortar facilities. I also believe that sicker patients, as noted in the list above, will gravitate to ambulatory care settings as bedless hospitals are built with more sophisticated capacity to manage virtual care visits. This is trend is analogous to the trajectory of outpatient surgery over the last decade, offering increasingly complex procedures.

The replacement of in-person ambulatory visits with virtual ones will usher in a major transformation of healthcare. I suspect that some older physicians may not feel comfortable with this change. Most younger physicians will immediately relate to virtual care because they use technology such as FaceTime on a daily basis. I am seeing almost daily advertisements from large health systems about the availability of telemedicine visits as an option. Here's a quote from a recent article on this topic (see: Telemedicine Statistics Show Big Growth Potential):

Insurers have jumped on the bandwagon and have begun to partner with telemedicine providers for a number of their health plans. According to Workforce’s January article, “Insurers Connecting to Telemedicine” Aflac added teleservices to its group critical-illness plans last November. Blue Cross Blue Shield Association partnered with provider American Well in 2014 as did Anthem Inc. to offer telemedicine services to approximately 3.5 millions of its members. It’s expected that more health plans will rollout teleservices in pilot programs or targeted geographic areas in 2016.

Future of Healthcare Changes Inextricably Bound to Information Technology

I delivered a lecture yesterday in which I listed what I thought were the ten most important trends in healthcare, particularly in ambulatory care. Needless to say, a number of them were directly or indirectly related to information technology (IT). The major trends I listed included telemedicine as a major means for ambulatory care delivery, bedless and "command center" hospitals, cloud-based personal health records for consumers, consumer-oriented genomic testing, and wearable health monitoring devices. One of the audience members approached me afterward and said that my comments had reinforced his belief that the future of healthcare changes was inextricably bound to information technology. It occurred to me that I believe that this is true but I had never heard the idea expressed exactly in this way.

As I mulled over this idea, it occurred to me that IT could potentially be a challenge for the healthcare industry in the future. It has not been particularly adroit in deploying new information technology. How else can one explain why hospitals EHRs, often costing hundreds of million of dollars, are disliked so intensely by one major group of healthcare professionals that they are designed to serve, physicians (see, for example: 9 Reasons Physicians Hate EMR - The 2013 RAND Study; 25 quotes that show just how fed up physicians are with EHRs)? Here is a list of some possible reasons why the healthcare industry might be slow to adopt new information technology:

• The industry is highly regulated so it's difficult for innovative IT solutions to succeed.
• Defensive medicine and the fear of lawsuits militate against many innovations including IT.
• Healthcare professionals are, appropriately, deeply conservative about adopting new technology because patient lives are at stake.
• The industry is partitioned off from others and adheres to its own rules that sometimes serve as impediments to innovations that are common in other industries.
• Healthcare cannot compete on the basis of salaries for the most sought after IT professionals and turns instead to less talented personnel within its own ranks.

I think that part of the solution to this problem, if you agree that it exists, is the empowerment of healthcare consumers who demand IT services similar to what they encounter outside of healthcare. Unfortunately, the trend is being countered by healthcare insurance companies that are trying to reduce consumers choice and competition by various means such as by the adoption of "narrow networks" (see: Network squeeze: Controversies continue over narrow health plans). I suspect that ultimately the boundaries around healthcare are going to become more porous. After all, healthcare expenditures are huge and continue to attract new companies. It has taken a very long time but the basic tier of health services is slowly becoming more competitive with walk-in drug store clinics and urgent care facilities (see: Rapid Growth of Urgent Care Clinics; Cost Competition for Hospital ERs). There now are more than 1,000 MinuteClinics inside CVS/pharmacy stores in 33 states and the District of Columbia (see: MinuteClinic history). 

Identifying Patients for Remote Monitoring with Predictive Analytics

One of the most interesting new areas in medical and pathology informatics is predictive analytics. It uses statistics, modeling, machine learning, and artificial intelligence to analyze clinical data to make predictions about the health of individual patients and patient populations. A recent article discussed how this technology can be used to select the best patients for remote monitoring (see: UMMC pinpoints ideal patients for remote monitoring with predictive analytics). Below is an excerpt from it:

The $1.6 billion University of Mississippi Medical Center emphasizes a value-based approach to healthcare. As part of that approach, the organization’s Center for Telehealth uses remote patient monitoring to better manage chronic diseases, including diabetes, hypertension and heart failure – diseases where education and timely interventions can improve individual healthcare and ultimately overall population health. An important part of remote patient monitoring is identifying patients who are the best candidates for the technology, patients who will respond well to the technology. But how does a healthcare organization best identify these optimal candidates for remote patient monitoring? That’s tricky, said Richard Finley, MD, professor of medicine for infectious disease, professor of emergency medicine, and director of medical analytics for the Center for Telehealth at the University of Mississippi Medical Center.....“But given our population, our health problems, and such a big rural and indigent population, we have a lot of difficulties in terms of trying to reduce hospital readmissions and doing so efficiently,” he said. “What I am working on right now is using different analytics tools to conduct pattern recognition to partition patients based on risk factors.....But Finley would like the medical center’s remote patient monitoring program and the process of identifying patients to be more aggressive than that, zeroing in on patients before hospitalization.“We have to recognize factors that we can clearly identify to make reasonable predictions and thus allow us to efficiently do interventions, whether they are simply education or in more extreme cases to use remote monitoring at home, especially for heart failure and diabetes, to try to prevent them from coming into the hospital to begin with,” Finley explained.

Remote monitoring of patients with chronic diseases by hospital personnel is beginning to receive the attention that the technology richly deserves (see: Telemedicine Transforms Intensive Care Units in Smaller Hospitals with Remote Monitoring; Keeping Tabs on Patients Post-Discharge Via Telemonitoring; Telemedicine Transforms Intensive Care Units in Smaller Hospitals with Remote Monitoring; Cost Savings Associated with Home-Based Physiologic Monitoring). Part of the reason why hospitals are paying more attention to their patient readmission rate is that they are being financially penalized by CMS when it rises too high (see: Talking to Patients Helps Reduce Hospital Readmissions; The Hospital Readmissions Reduction (HRR) Program). As noted in the excerpt above, home patient monitoring can now become an even more useful tool, particularly when coupled with predictive analytics. The latter is used to predict which of the patients being monitored at home have the highest probability for readmission to the hospital. This will cause a redoubling of efforts to intervene early and often for those patients.

Regarding the use of predictive analytics in this way, here is the bottom line lesson to be learned from a recent article on the topic (see: 4 Essential Lessons for Adopting Predictive Analytics in Healthcare):

In order to be successful, clinical event prediction and subsequent intervention should be both content driven and clinician driven.....Notably, prediction should be used in the context of when and where needed – with clinical leaders who have the willingness to act on appropriate intervention measures. The more specific term is prescriptive analytics, which includes evidence, recommendations and actions for each predicted category or outcome.  Specifically, prediction should link carefully to clinical priorities and measurable events such as cost effectiveness, clinical protocols or patient outcomes. 

So the use of predictive analytics for the subject at hand, reducing hospital readmissions in remotely monitored patients with chronic diseases, the prescriptive analytics seem clear. For patients deemed at risk, determine which clinical protocols will be the  most effective in stabilizing or improving their health status in an ambulatory care or home environment and put them into effect.

First Diagnostic Management Team Conference Scheduled for Next February

For more than a decade, Dr. Mike Laposata, pathology chairman at UTMB Health in Galveston, has been pioneering the concept of diagnostic management teams (DMTs) whereby pathologists and lab professionals, engage with their clinician colleagues to help diagnose patients, particularly those with complex medical problems. A recently announced conference on February 7-8, 2017, will provide more details about this new facet of the practice of pathology. Below are some details from an email that I received today from Dr. Laposata:

This inaugural Diagnostic Management Team Conference will have historical significance as we change the way we, as laboratory leaders and pathologists, assist healthcare providers on diagnostic test selection and results interpretation. The National Academy of Medicine report from 2015, Improving Diagnosis in Health Care, endorsed the formation of diagnostic management teams to address the major problem of diagnostic error that affects the lives of hundreds of thousands of individuals every year. Take a look at the program and meeting web site, imagine your new capabilities, and join us on February 7 and 8, 2017 in Galveston, Texas at the Galveston Island Convention Center....Now is the time to establish the true value of the laboratory and the crucial work we all do for patients. will have historical significance as we change the way we, as laboratory leaders and pathologists, assist healthcare providers on diagnostic test selection and results interpretation.

Here is an excerpt from an article about DMT's writtten by Dr Laposata (see: How Can a Diagnostic Management Team Improve Patient Care and Save Money?) :

When physicians fail to order the correct laboratory tests or incorrectly interpret the test results, even when a lethal outcome ensues, the poor outcome is rarely attributed to the doctor’s mistake involving the laboratory tests. Even as the clinical laboratory test menu has enlarged in cost and complexity, laboratory directors do not routinely provide patient-specific, expert-driven narratives of complex clinical laboratory evaluations....The ordering physicians live in a world with thousands of tests, many new and highly expensive, where we call the same test by multiple different names in different laboratories. For example, there are at least 5 different names and 5 different abbreviations for von Willebrand factor activity, and there are at least a dozen tests with the word vitamin D in the title presented to physicians who simply want to know of their patient is vitamin D deficient. The consequence is that doctors order unnecessary tests and often fail to order tests which can provide an immediate and conclusive diagnosis.

This is a conference you don't want to miss. Improving the interpretation of lab tests will go a long way toward eliminating diagnostic errors. We owe it to Dr. Laposata and also to ourselves to support all of his efforts. You can register at the conference web site.

Strata Oncology Offers Free Cancer Genomic Testing to Some Patients

The profits from chemotherapeutic drugs and, recently, immunotherapeutics have been sky high for the pharma companies that offer the successful ones (see: Pharma Firms Eye Big Profits in New Cancer Drugs). These drugs have proved to be highly effective because they exploit the genetic defects of the cancer cells being attacked. The FDA and insurance companies are requiring that patients being treated with the these new drugs have been tested to ensure that the drug used is appropriate and effective. Strata Oncology is offering free cancer genomic testing to 100,000 patients according to the Dark Daily (see: Strata Oncology, in Tandem with Thermo Fisher, Offers 100,000 Free Genetic Cancer Tests to Patients as Part of New Clinical Laboratory Business Model). Below are the details:

Strata Oncology (Strata), a precision medicine company based in Ann Arbor, Mich., plans to provide free genetic testing to advanced cancer patients beginning in 2017. The company raised $12-million dollars and teamed up with Thermo Fisher Scientific to complete the large-scale tumor sequencing project. Using tumor tissue, Strata’s gene test sequences DNA and RNA to identify patients with certain gene mutations. This information is used to determine which cancer medications would be best for each patient. Patients are then referred to the appropriate pharmaceutical company for drug therapy and, potentially, for customized clinical trials.....Strata’s business model has a unique twist, compared to existing clinical laboratories and genetic testing companies. Strata is working from the premise that companies which manufacture cancer drugs will pay for patient referrals. Strata will use the offer of free genetic testing to find those patients. This strategy could prove to be profitable to both Strata Oncology and the drug companies. For example, if a particular cancer drug costs $100,000, pharmaceutical companies would probably be willing to pay a lesser sum of money each time Strata refers a cancer patient to them for treatment, after one of Strata’s genetic tests identifies a patient with a genetic mutation that would respond well to one of their drugs....[P]atients with advanced cancer would receive free genetic tests with reasonable odds that those test results will enable them to receive a drug that might be effective at stopping or slowing their cancer. Based on their personalized information, patients also might be selected for clinical trials that involve therapies that may benefit their specific diseases.

Put simply, Strata provides DNA and RNA provide free genomic testing to some cancer patients and then provides their names, based on lab test results, to pharmaceutical companies and cancer hospitals, presumably for a fee. Here is a cut-and-paste from the Strata home page with information about the lab's participation in clinical trials:

Beginning in early 2017, the Strata Trial will provide no-cost tumor sequencing for 100,000 cancer patients, characterizing the mutations that caused their cancer. In addition, together with our pharma partners, we will offer a portfolio of precision medicine clinical trials that target a wide range of these mutations, with the goal of maximizing the chances that a patient matches to a trial. We plan to bring the Strata Trial to 100+ partner hospitals and cancer centers across the United States, helping to broaden access to tumor sequencing and precision medicine clinical trials. We will continually be looking to add new trials to the portfolio as new precision medicine hypotheses emerge, including biomarker-guided immuno-oncology trials. 

It seems to me that the primary way that patients are referred to Strata for tumor sequencing is via physicians, presumably oncologists. I can understand why pharmaceutical companies would pay Strata for patient referrals in order to learn the identity of potential recipients of their drugs. But the patients' oncologists would still have influence over how and by whom their patients are treated. What actions could the pharmaceutical companies take independently? This is where the idea of the Strata Trial program. described above, makes sense to me. Armed with the knowledge of the results of the Strata genomic testing, the pharma companies could then contact the referring oncologist and persuade him or her to enroll the patient in one of the company's clinical trials. The Strata business model may thus be more about enrolling patients in clinical trials than the discovery of patients to be treated with its drugs.

Some Additional Ideas About the Bedless Hospitals of the Future

In yesterday's note, I discussed how decentralization/disintermediation was affecting healthcare in general and the lab industry in particular (see: Direct Access Testing; One Facet of the Decentralization of Healthcare Delivery). I mentioned the bedless hospital (BH) as part of this discussion. There are many opinions floating around about what the BH will look like (see: Are 'bedless' hospitals the wave of the future?). Here are some of my thoughts about what will be major units in BHs:

• Clinical labs and radiology will certainly have a prominent place in the BH of the future. This is partly because we are now in the golden age of diagnostics when lab tests and imaging make major contributions to the diagnosis of diseases. I believe that many of the more common lab tests will soon be performed in neighborhood health centers as point-of-care tests or in consumers' homes so the test menus of the labs operating in BHs will tilt toward more esoteric tests.
• Under pressure from MACRA, some large health systems will consolidate/insource their lab operations and testing to their own central labs. With economies of scale, these centralized labs will be able to perform most esoteric testing with few remaining send-outs such as some genomic and molecular tests. Some of these large health system centralized labs will be located in bedless hospitals.
• Because I also believe that telemedicine visits will increase exponentially in the next five year, some of the space in the BHs of the future will be occupied by physicians and nurses managing the telemedicine line-of-business in offices designed specifically for this purpose. For this reason among others, BHs will have sophisticated IT capabilities.
• Health systems with a large number of smaller hospitals will have "virtual" critical care beds in their smaller facilities (see: New Virtual Critical Care Command Center Opens May 7). These beds will be supervised locally by physicians and nurses but with continuous remote monitoring by telemetry. Thus, some of the BHs will have virtual critical care centers staffed by intensivist physicians and nurses who closely monitor the patients in the virtual critical care beds and provide support and advice to the local healthcare professionals.
• Obviously and as emphasized in the link to the article about BHs above, BHs will have large outpatient surgery units. I have been following the evolution of outpatient surgery for many years and have seen the type of cases change from minor surgery to very complicated procedures. The same trajectory will occur in the use of telemedicne starting today with minor problems and growing to the more complicated physician visits that I foresee for the future. This will require sophisticated telemetry of patients' vital signs from their homes during the visit but that technology is available even today.

Direct Access Testing; One Facet of the Decentralization of Healthcare Delivery

I have come to view direct access testing (DAT) as one facet of the high-level trends of decentralization and disintermediation in healthcare. By this I mean that some portion of healthcare will migrate away from hospitals and physician offices and toward consumers. Allowing consumers to order lab tests for themselves, for example, is one chapter in this narrative. Others include the development of bedless hospitals (see: The Design of Bedless Hospitals Continue to Evolve Based on Cost and Technology), telemedicine visits with healthcare providers (see: Introduction of the Term "Webside" to Refer to Telemedicine Interactions), and the use web search engines to help consumers interpret their symptoms (see: Paging Dr. Google! We Are Waiting for a Second Opinion). In line with all of this is a recent article in the Dark Daily about DAT (see: Why Healthcare Experts Critical of Direct Access Testing Advise Clinical Laboratories to Take Precautions). Below is an excerpt from it:

DAT enables consumers to request medical lab tests from clinical laboratories without doctors’ orders. It is legal in 29 states and the District of Columbia; 13 states require a physician pre-authorization; and nine others limit the number of tests people can obtain, explained a Lab Tests Online statement....For a growing number of medical laboratories and websites offering blood testing to consumers, DAT is a popular customer service. But prior to taking orders from the consumers, some pathologists say it is important to first carefully select the menu of clinical laboratory tests that will be directly available to the public. Opponents also say DAT can lead to confusion among consumers about which tests are appropriate to order. Consumers can often find it challenging to interpret and understand the lab test results. Another source of confusion can be false positives....DAT has grown from a $15-million business in 2010 to a $131-million business in 2015....But just because you can perform a laboratory test, doesn’t mean you should offer it to consumers,” said Robert Stern, MD, Sonora Quest’s Medical Director....Stern noted that though medical laboratory tests for some diseases and conditions are popular among consumers, the test results are “complex” and “difficult to interpret....So, rather than helping to control healthcare costs, this kind of random or unselected testing can drive up costs—even though lab tests as a percentage of overall healthcare spending is relatively low,” Stern noted.

The term disintermediation has been used in relation to the effect of the migration of businesses to the web. It's defined in the following way (see: disintermediation): 

Disintermediation is giving the user or the consumer direct access to information that otherwise would require a mediator, such as a salesperson, a librarian, or a lawyer. Observers of the Internet and the World Wide Web note that these new technologies give users the power to look up medical, legal information, travel, or comparative product data directly, in some cases removing the need for the mediator (doctor, lawyer, salesperson) or at the very least changing the relationship between the user and the product or service provider.

Just think about what computer and smartphone airline apps have done to the travel industry with most consumers now booking their own reservations and avoiding travel agents. Blood drawing stations in neighborhood retail drug stores will disintermediate hospital and reference blood drawing centers. If these same retail drug store begin to deploy point-of-care analyzers and perform common lab tests, the nature of hospital and reference lab testing will be irreversibly changed. This shift will move beyond DAT testing and encompass more physician-ordered lab testing. The view that such disintermediation will drive up lab and healthcare costs does not make sense to me. The cost of DAT testing has historically been far below that charged by hospitals for such services because the latter have included hefty profit margins.