Lab Soft News

The Use of Tablet Computers by Physicians for Data Entry into EHRs

There have been various conversations over the years about the use of tablet computers for data entry into EHRs by MDs (see, for example: Why Tablets Are The Future Of Electronic Medical Records; Tablet-Based Patient Registration Deployed at Longone Medical Center). This would seem to be a logical EHR capability given that one of the criticisms of these systems is that physicians spend too much time at the keyboard and not making eye-contact with patients (Doctors Need to Maintain Patient Eye Contact While Using EHRs). With a tablet, the physician can face the patient while entering data. The use of tablet data entry seems to be commonplace for some EHR vendors. For example, here is a list of physician functions that can be accomplished with a tablet using the cloud-based Practice Fusion (see: Practice Fusion Blog):

• View your daily schedule and see every provider’s schedule.
• Chart patient visits with touch-based templating, new vital sign options, and clinical decision support notifications in the new encounter.
• Access all your patients and add new patients.
• Manage your EHR users and connect with labs, imaging centers, and ePrescribing from your new EHR dashboard.

Although some tablet computers have keyboards, or can be equipped with them, most are used  with the touch screen for data entry. Here are some salient points for consideration about this topic:

• The use of EHR scribes who accompany physicians when a interacting with patients is now common (see: Four Considerations When Hiring an EHR Scribe). They perform all keyboard entries into the EHR so the physician can interact directly with the patient. This increases personnel expenses but also increases physician efficiency.
• During some ambulatory patient visits, patients are often first seen by a nurse practitioner or some other type of physician extender (e.g., ophthalmic assistant or technician). In these cases, these other personnel perform the major share of the keyboard data entry.
• It's possible to simplify tablet data entry for physicians with automatic data entry (i.e., using macros). Keyboard macros allow short sequences of keystrokes and mouse actions to be transformed into other, usually more time-consuming, sequences of keystrokes and mouse actions. In this way, frequently used or repetitive sequences of keystrokes and mouse movements can be automated.

The problem with automatic data entry as opposed to, say, the use of drop-down lists or drop-down menus, is that the macros themselves need to be memorized. Hence, they will probably need to be reserved to call a relatively small number of, say, documents that the physician uses frequently. I would be interested in hearing any reader comments about this topic.

Hypertension Management Program with Health System and Retail Pharmacists

As I have discussed for about a decade, the role of pharmacists in direct patient care continues to expand (see: More than 30,000 Pharmacists Now Administering Flu Shots in Neighborhood Drug Stores; Pharmacist-Staffed Coagulation Clinics in a Large Health System). This trend is accelerating now because of the rapid expansion of walk-in clinics in retail drug stores such as CVS's MinuteClinics that now number more than 1,000 in 33 states (see: MinuteClinic History). A report about the expanding healthcare role of pharmacists lists four major areas of pharmacist engagement (see; Exploring Pharmacists’ Role in a Changing Healthcare Environment);

• Medication management.
• Medication reconciliation.
• Preventive care services.
• Educational and behavioral counseling.

A recent article addressed a new program for hypertension management at the University of Michigan Health System in collaboration with pharmacists in the Meijer chain (see: U-M Health System announces partnership with Meijer pharmacies). Below is an excerpt from the article:

The University of Michigan Health System has established a new partnership with Meijer pharmacies to provide hypertension management services for adult patients. U-M patients will be able to visit participating Meijer pharmacy locations to receive a blood pressure check and assessment. If the patient’s blood pressure is elevated, the clinically trained Meijer pharmacist will communicate directly with the patient’s U-M Health System provider. The patient will also receive appropriate follow-up and education about disease, clinical goals, medications and lifestyle. In addition, documentation of the patient’s visit to their Meijer pharmacy will be recorded in their electronic medical record so the patient can easily discuss the reading and assessment with their U-M Health System provider at their next medical visit.....Each participating Meijer location has purchased an automatic blood pressure monitor to provide more accurate readings to patients. The device takes six consecutive blood pressure readings and provides an average of the readings....U-M Health System patients with elevated blood pressure will be identified at clinic visits and given the option to visit the Meijer pharmacy for their follow-up care.

It's interesting that the automated blood pressure devices used in this program acquire six consecutive readings and then provide an average of these readings. It would be interesting to study whether blood pressure recordings taken by a pharmacist with automated devices are subject to the so-called "white coat syndrome" in which readings are falsely elevated during a clinic visit because of patient nervousness (see: Beyond 'White Coat Syndrome'). If patients don't have too high blood pressures when interacting with a pharmacist, the name of the syndrome may need to be changed since many pharmacists wear white coats. 

Cerner Embeds Telehealth Capabilities into its EHR

Readers of this blog will know that I have been very enthusiastic about telemedicine. I believe that we are now in the active adoption phase of this technology that will be mission critical for delivering ambulatory care services at lower cost. Both the Cleveland Clinic and Intermountain Healthcare are using the American Well telehealth software platform (see: Cleveland Clinic Launches Web Site to Offer Physician Visits to Ohio Residents;Intermountain Healthcare Launches Telemedicine Program with Connect Care). In a recent press release, Cerner announced that it now was embedding the American Well telehealth software into its EHR (see: Cerner and American Well to Embed Telehealth Capabilities into Cerner). Below is an excerpt from it:

Cerner...[has] announced a telehealth agreement with American Well....Together, the companies will deliver a virtual health care experience that will integrate the American Well platform with Cerner’s electronic health record (EHR).The integration will enable providers to manage the health and care of patients beyond the walls of the health system....The integrated EHR-telehealth solution will be available to current and future Cerner and American Well clients. Patients will interact with the solution through Cerner’s HealtheLifeSM patient engagement portal, which is designed to provide access to health information, provider messaging and broad interaction with care teams.

Here are more details about Cerner's HealtheLifeSM that was referenced in the press release copied from the Cerner web site (see: HealtheLIfe):

• Secure messaging for specific requests such as medication refills.
• Direct-book appointment scheduling.
• Clinical information that can be viewed in the Cerner Millennium electronic medical record (EMR).
• Capability to view and download Continuity of Care Documents.
• Online bill pay.
• eVisit consultations between providers and patients.

I can only speculate why Cerner chose to collaborate with American Well rather than develop its own software. From the description of HealtheLIfe above, notably the reference to eVisit consultations, it might be assumed that Cerner's original intention was to use this software suite as as its telehealth platform. In the end though, Cerner may have concluded that the American Well software was better and also had an adoption advantage in the market. Regardless of these considerations, I believe that the broad integration of telehealth into the EHR is now inevitable. I don't know anything about the strategic direction of Epic toward telehealth but I suspect that this Cerner initiative cannot go unanswered. 

Major Impending Transformation Predicted for Clinical Lab Business Model

The clinical lab industry is on the cusp of a major transformation of the normally accepted business model as a result of the emergence of telemedicine as a common means for delivering ambulatory care. I have been blogging about the advantages of telemedicine for years (see, for example: Insurance Companies Can Use Telemedicine to Enlarge Their Provider Networks). In a recent note addressing megatrends in healthcare, I suggested that telemedicine was one of them and will soon be part of the "new normal" in healthcare delivery (see: Ten Megatrends in Healthcare with Special Emphasis on Ambulatory Care). My prediction was reinforced by a recent futuring article about Kaiser Permanente (see: Taking Bids on the Hospital of the Future). Here is a quote from it pertaining to the growth of telehealth:

Kaiser physicians now handle more patients via telehealth (59 million a year) than they do in person (50 million). Jennifer Liebermann, who runs the [hospital of the future] test facility, says patient feedback guided development of the TV remote system rolling out to a handful of hospitals and helped fine-tune it over the course of two years to make sure it was easy to use. Kaiser rejected at least one system interface, she says, after elderly patients deemed it too confusing.

In three to five years, I think that the majority of ambulatory care patients will commonly engage with their healthcare providers via telemedicine and thus will not be readily available for venipuncture (or finger prick) for specimen acquisition and lab tests. Instead, I think that such patients will be more inclined to visit a patient service center (PSC) or, perhaps even more commonly, a blood collection center in a neighborhood retail drug store. For this reason alone, health systems need to establish remote blood drawing centers in retail drug stores.

Hospitals have been accustomed to relatively high profit margins on their lab testing. This was feasible because outpatients have been a "captive" audience at the time of outpatient visits. It was convenient for them to just walk to the blood drawing center in the ambulatory care building. However, these high margins for even lab testing have been a challenge for patients not covered by health insurance. This is increasingly the case for consumers with high-deductible plans who may seek low-priced direct-access-testing (DAT) which will also be available in retail drug stores.  Although Theranos made many mistakes, one of the positive things achieved by the company was broad publicity about the low cost of DAT.

One more relevant point. Look for more on-site, point-of-care (POC) lab testing in the drug stores in association with blood drawing services. Think of the Quest/LabCorp business model as sophisticated logistics plus large-scale lab testing with the former involving specimen pickup at physician offices plus transportation to large central labs. Perhaps with more efficient, multiplexed POC analyzers in retail drug stores, lab testing in these sites may become more competitive cost-wise with large reference labs. Certainly, test results in an hour or less would result in much higher patient satisfaction with lab testing. The IVD industry needs to deliver POC analyzers with a much lower cost-per-test to satisfy the impending, growing demand for them in retail drug stores.

Safeway Saves Money by Introducing Reference Lab Pricing for Employees

It is a well known fact that the prices for labs tests can vary widely within one region or state. One study showed that list price for a lipid panel in California varied by a thousand-fold in 2014 (see: Variation in charges for 10 common blood tests in California hospitals: a cross-sectional analysis). Hospital and commercial reference labs can set their test price schedule at whatever level the traffic will bear. However, some employers are combatting this problem through the simple practice of price transparency (see: Using the Reference Pricing Strategy, Safeway and its Employees Reduce Spending on Clinical Laboratory Tests by 32% in Only 24 Months by Selecting Lab with Lowest Prices; Association of Reference Pricing for Diagnostic Laboratory Testing With Changes in Patient Choices, Prices, and Total Spending for Diagnostic Tests). Here is a quote from this first article:

It took just 24 months for Safeway and its employees [in collaboration with Anthem Health Insurance] to pay 32% less for clinical laboratory tests using a new health benefits strategy called “reference pricing.” This strategy targets the large variation in prices that different medical laboratories charge for the same tests and incentivizes employees in a consumer-friendly way to select medical laboratories with lower prices over labs with higher prices....This trend would put those medical labs with the highest lab test prices under significant financial pressure if other employers and health insurers were to incorporate a reference pricing arrangement in their health benefit plans....The study found combined employee and employer savings of $2.57 million over three years. Patients saved $1.05 million in out-of-pocket costs, while their employer, Safeway, saved $1.70 million. Savings were not associated with less testing. Actually, each employee had an average of five to six tests per year over the three years. It was the reference pricing, researchers stated, that led to new choices by employees in where they had lab tests performed.

And here is a quote from this second article about how the lab reference pricing was implemented:

The grocery firm [Safeway] established a maximum payment limit at the 60th percentile of the distribution of prices for each laboratory test in each region. Employees were provided with data on prices at all laboratories through a mobile digital platform. Patients selecting a laboratory that charged more than the payment limit were required to pay the full difference themselves.

For me, one of the most revealing parts of this story was the fact that Safeway and Anthem used a "mobile digital platform" to provide its employees/insurance holders the lab test data prices by lab and the amount of money they would need to be responsible for if a particular lab price was over the 60th percentile ceiling. This is a prime example about how to put essential health insurance price information at the finger-tips of the holders of insurance.

The Role of the Clinical Lab in Immunogenicity Testing for anti-TNF

The use of anti-TNF biologicals in the treatment of rheumatoid arthritis has been a major therapeutic advance. A recent article about testing for drug immunogenicity in these patients by a national reference lab, ARUP, was intriguing (see: Dancing Through the Pain: Advancements in Immunogenicity Testing Deliver Relief to Patients with Autoimmune Diseases). Below is an excerpt from it:

To manage the overproduction of TNF seen in rheumatoid arthritis, patients are prescribed TNF blockers, medications that suppress the response to TNF and decrease inflammation. What happens is the body starts seeing the medication as a foreign element, triggering the immune system to create antibodies to eliminate it. This is called immunogenicity. This happens in about half of the patients.....TNF blocking drugs don’t always work because the body may see them as foreign invaders, producing antibodies against them that make the drugs ineffective. Testing for drug levels of biologicals help clinicians figure out if the drug is still working for the patient and if it is being administered at the right dose..... [W]hen a patient has been responding to a drug, then stops all of sudden, the physician wants to know why. If the patient has developed antibodies against the drug, the physician may switch them over to another type of TNF blocking drug. There are five of them available in the United States, with one biosimilar recently approved. When the patient develops antibodies against the TNF blocker, it is important to switch to another drug, as the patient could end up with an immune-complex disease that threatens the organs.....Immunogenicity testing may also reveal that there are no drug antibodies present, indicating that the patient may require a higher dosage....[T]he most commonly used tests measure the presence of any antibody that can bind to the drug molecule, regardless of whether or not they interfere with drug activity. The ARUP test only detects the presence of those antibodies that inhibit the function of the drug, which makes it more specific for identifying the cause as to why the drug treatment is not working.

Immunogenicity can be divided into wanted and unwanted (see: Immunogenicity). The latter is defined in the following way: 

Unwanted immunogenicity is an immune response by an organism against a therapeutic antigen (ex. recombinant protein, or monoclonal antibody). This reaction leads to production of anti-drug-antibodies (ADAs) inactivating the therapeutic effects of the treatment and, in rare cases, inducing adverse effects. The prediction of the immunogenic potential of novel protein therapeutics is thus a challenge in biotherapy.

Here's more information from the ARUP web site about Adalimumab (Humira) activity and the neutralizing antibody to it:

This test is used to evaluate secondary response failures to adalimumab therapy. Secondary response failure is defined as loss of clinical response after initial improvement of clinical signs and symptoms. Therapeutic decision should rest on both the clinical response and the knowledge of the fate of the drug including the emergence of immunogenicity in individual patients. Circulating adalimumab levels have been shown to vary considerably between patients. These differences relate to route and frequency of administration and patient-related features such as age, gender, weight, drug metabolism, and concomitant medications such as methotrexate and other immunosuppressants.

Smoking Linked to One-Fourth of All US Cancer Deaths

For me personally, the noxious habit of smoking does not seem to exist any more. At home and when traveling to large cities in the U.S., I rarely see anyone smoking. And yet, here's an article that indicates that smoking is linked to one-fourth of all U.S. cancer deaths (see: One-fourth of US cancer deaths linked with 1 thing: smoking). Below is an excerpt from it:

Cigarettes contribute to more than 1 in 4 cancer deaths in the U.S. The rate is highest among men in Southern states where smoking is more common and the rules against it are not as strict. The American Cancer Society study found the highest rate among men in Arkansas, where 40 percent of cancer deaths were linked to cigarette smoking. Kentucky had the highest rate among women - 29 percent.The lowest rates were in Utah, where 22 percent of cancer deaths in men and 11 percent in women were linked with smoking....Lung, throat, stomach, liver, colon, pancreas and kidney cancers were among those included, along with leukemia. The researchers estimated how many cancer deaths were likely attributable to smoking, and compared that with deaths from all cancers. While U.S. smoking rates have been falling, 40 million U.S. adults are cigarette smokers and smoking is the top cause of preventable deaths, according to the [CDC]. The study found that at least 167,000 cancer deaths in 2014 - about 29 percent of all U.S. cancer deaths - were attributable to smoking. A government estimate based on different methods says 1 in 3 U.S. cancer deaths are linked with smoking, and the study authors acknowledge they may have underestimated the true burden posed by cigarettes. Most of the 10 states with the highest rates of smoking-attributable cancer deaths were in the South, while most of the 10 states with the lowest rates were in the North or West....The average cigarette excise tax in major tobacco states, mostly in the South, is 49 cents, compared with $1.80 elsewhere. The tobacco industry heavily influences these policies and most of the U.S. tobacco crop is grown in the South....

Note that cigarette smoking is associated with many cancers in addition to the lungs: throat, stomach, liver, colon, pancreas and kidney. For example and on average, smokers have a 50% increase in risk of kidney cancer. Smokers also have up to three times the risk of developing cancer of the renal pelvis compared to non smokers (see: Risks and causes of kidney cancer). There are some 70 known carcinogens in tobacco smoke and some of them are undoubtedly concentrated in the urine as the cause of these cancers (see: Carcinogens in Tobacco ProductsTobacco smoke).

Clearly, smoking is an essential component of the economy of the southern U.S. states and also an important part of the culture. States, not just people, can become addicted to tobacco. "Tobacco production is an important industry in Kentucky, which along with North Carolina generates two-thirds of the nation's tobacco harvest....People aren't necessarily more likely to smoke if they live in a tobacco-growing state, but Kentuckians are certainly doing their part to help the local economy. The state has the nation's second-highest adult smoking rate, as well the highest rate of smoking-related deaths. Most alarming of all, Kentucky is encouraging more smokers: The smoking rate among high schoolers is the highest in the U.S." (see: The 10 States Most Addicted to Smoking). So unless and until the South is able to wean itself off tobacco production as well as increase the taxes it imposed on cigarettes, I suspect that the cancer rate and health costs associated with this addiction will continue at high levels compared to the rest of the country.

Why a Doctor Shortage is Unlikely in the Near Future in the U.S.

With some regularity, articles are published that predict an impending shortage of physicians in the U.S., often based on the number of them being trained. However, a recent piece in the NYT questioned this logic with a look at how our healthcare system will be staffed in the years to come (see: A Doctor Shortage? Let’s Take a Closer Look). Below is an excerpt from it:

In 2014, the Institute of Medicine released a thorough analysis on graduate medical education that argued there was no doctor shortage, and that we didn’t really need to invest more in new physicians.The system isn’t undermanned, it said: It’s inefficient. We rely too heavily on physicians and not enough on midlevel practitioners, like physician assistants and nurse practitioners, especially because evidence supports they are just as effective in primary care settings. We don’t account for advances in technology, like telehealth and new drugs and devices that lessen the burden on physician visits to maintain health. And we fail to recognize that what we really have is a distribution problem. Parts of this country have lots of doctors, perhaps too many....[M]any rural areas, and less popular cities, experience more of a doctor shortage than others.The other distribution issue is in specialization....When you compare the percentage of physicians who are generalists with those who are specialists, the United States beats only Greece among developed economies. Here, financial drivers play a role. Doctors who choose to specialize can make much more money, millions more dollars over a career, than primary care physicians. Money isn’t the only reason that medical graduates choose to specialize.... A specialty that might offer you a lot more money is enticing. None of this should be taken as a cry for sympathy for the financial plight of doctors in general. They are more likely to be in the top 1 percent of earners than any other profession. 

Here's a partial list of the reasons why I think we will not be facing a physician shortage despite the fact that demand for services will surely be increasing:

• Increased use of physician extenders such as nurse practitioners to help manage the increasing patient load (see: Healthcare providers grow physician extender staffs to meet demand).
• Increased use of telemedicine for visits that should allow physicians and nurses to increase their operating efficiency (see: Introduction of the Term "Webside" to Refer to Telemedicine Interactions; Firm Offering "White Label" Service to Enable Virtual Hospital Physician Office Visits).
• More efficient use of physician time using other digital medicine technologies such as e-prescriptions (see: E-Prescriptions Linked to Higher Utilization by Patients But Why?).
• Increased use of smartphone apps and health monitoring with "wearables" to assist patients with chronic diseases and support wellness (see: Physicians Will Soon Be Prescribing Apps to Improve Their Patients' Health). 
• New drugs and the pursuit of healthier lifestyles to avoid, reduce, or eliminate some health risks (see: The impact of a healthy lifestyle on Disability-Adjusted Life Years: a prospective cohort study).

Although I discuss physician extenders above, it's likely that this term is going out of style (see: Healthcare providers grow physician extender staffs to meet demand). 

[W]hen a healthcare provider refers to physician extenders they have two primary job roles in mind – nurse practitioners and physician assistants. Nurse practitioners may actually take offense at the term,...since they may have broad authority in some states and be able to make care decisions without the need of physician sign-off. That is not the case for physician assistants, who must work with a physician in all cases. Certainly not everyone with the title of physician assistant or nurse practitioner is a physician extender, either.

Here is a quote from an article about the primary care workforce that puts some numbers behind some my staffing predictions (see: Rethinking the Primary Care Workforce — An Expanded Role for Nurses):

...[T]he number of NPs entering the workforce each year has mushroomed from 6600 in 2003 to 18,000 in 2014. The number of primary care NPs is projected to increase by 84% between 2010 and 2025....If these trends continue, the proportion of primary care practitioners who are physicians will drop from 71% in 2010 to 60% in 2025 and will continue to decline thereafter. The proportion of practitioners who are NPs will jump from 19% to 29% during those years and will continue to rise. In rural communities, this trend is even more pronounced, since NPs are considerably more likely than physicians to settle in rural America. 

Physicians Will Soon Be Prescribing Apps to Improve Their Patients' Health

One of the major changes we will soon see to improve healthcare delivery is physicians prescribing apps for their patients. Particularly for patients with chronic conditions like diabetes and obesity, it's imperative that patient education be improved. Unfortunately, physicians and nurses can't stand beside patients continuously to help with their disease management. Here's where smart phone apps will come into play. Mount Sinai Health System working with the Icahn School of Medicine has developed RxUniverse, an enterprise-wide platform of curated apps that allows physicians to prescribe them directly for their patients (see: Mount Sinai launches RxUniverse, a system-wide platform to prescribe medical apps). Below is an excerpt from this article:

The platform... aims to address the lack of standardized methodology for physicians to both ascertain which apps would best benefit their patients, and subsequently share with them directly....RxUniverse allows physicians and other healthcare providers to seamlessly and confidently integrate evidence-based digital health tools into their practice. RxUniverse integrates as a feature to the patient’s EHR, and once clinicians open the patient’s electronic file, they can click on the RxUniverse function to digitally prescribe an app through a link that is sent to the patient’s smartphone. The platform also features specifically tailored educational content, patient satisfaction surveys and other digitally-prescribed tools. As the pace of innovation in digital medicine accelerates, there will be increasing demand for the ability to quickly integrate new apps into our health care system....The RxUniverse platform was piloted this summer at five clinical areas at Mount Sinai with the goal of prescribing 100 apps. Since then, participating clinicians have prescribed more than 2,000 apps.

There is a history of similar endeavors in the commercial sector. One such company was Happtique (see: The Rise and Fall of Happtique, mHealth’s First App Prescribing Platform) that was recently acquired by SocialWealth (see: Digital Health Enablement Company SocialWellth Acquires Happtique). Here are more details:

Las Vegas-based digital health enabler SocialWellth today announced the acquisition of Happtique, creators of the first provider-led app prescribing software. Happtique was founded and wholly owned by GNYHA Ventures, the business arm of the Greater New York Hospital Association. The acquisition complements SocialWellth’s existing digital health offerings for healthcare sponsors by enabling them to be connected not only to their members, but also to providers, encompassing the total continuum of care....“We believe that the digital health market must shift from passive digital health to prescriptive digital health curation if we are to achieve the great potential which lies ahead with Connected Patients,”...[a spokesperson] added.

Regarding the health data generated by "wearables" and home mini-labs (i.e., labs-on-a-chip), I had always assumed it would be uploaded to the cloud or web sites and then monitored by physicians and nurses (see: 10 Healthcare Wearables, Devices Dominating CES). Although I expect this to still take place, I now understand that most of the monitoring will be via health apps running on the patients' own smart phones. Moreover and as emphasized in the excerpt at the top of this note, prescribed apps will also be synchronized with "tailored educational content" such as training videos. For example, if a patient with diabetes has questions about diet, he or she can directed to relevant videos on his or her cell phone.

SonoraQuest Expands Its Presence in Arizona Safeway Stores

One of the more positive aspects of the Theranos "adventure" in Arizona has been that it has paved the way for Sonora Quest Laboratories to expand its direct access testing (DAT) and PSC services in the state (see: Sonora Quest Laboratories and Safeway Expand Highest-Quality Diagnostic Testing to Greater Arizona). Below is an excerpt from an article with more details:

Sonora Quest Laboratories and Safeway ...[is opening] six new Sonora Quest Laboratories Patient Service Centers (PSCs) ...[in] Safeway stores.... throughout Arizona. The new locations in Arizona are in addition to the two PSCs opened in November 2015....The full-service retail locations offer an exceptional patient experience with convenient lab testing services, access to the most accurate and up-to-date diagnostic capabilities and a guest paging system which allows clinic visitors to shop while waiting for their time-slot or appointment. Sonora Quest Laboratories also provides time-saving services such as patient ordered lab tests through My Lab ReQuest and online (plus mobile) appointment scheduling. With quick access to all laboratory test results though the Patient Results Portal at SonoraQuest.com, patients can proactively manage their health and make educated decisions with a health care provider....Whether customers schedule an appointment for a traditional physician ordered test or walk in for a self-ordered testing through My Lab ReQuest, the retail convenience offers an excellent care experience with friendly staff, highly-skilled phlebotomists and accurate testing. 

The best way to understand this development is to state that SonoraQuest has expanded its patient services centers (PSCs) in multiple Safeway stores in Phoenix and beyond. These PSCs are located in proximity to the in-store Safeway pharmacies so that phlebotomists can take advantage of the space used by the pharmacists for administration of IV medications and flu shots. Moreover, a pre-existing Sonora Quest program called My LabReQuest allows consumers to order blood tests for themselves on the web without a physician order and then drop in to a local Safeway for the blood draw. The Sonora Quest/Safeway PSCs thus provide blood drawing services to patients holding a physician lab test order as well as those ordering lab tests for themselves.

The October 17, 2016, issue of the Dark Report (subscription only) makes the following interesting observation in an article entitled PSCs in Safeway Stores Popular with Consumers concerning the localization of high DAT activity in the state of Arizona:

DAT has been available in Arizona for more than two decades. LabXpress was founded in Phoenix in 1989 to provide low-cost lab tests and has a legitimate claim to be the first direct-to-patient low cost lab company. AnyLabTestNow currently operates six franchise locations in Arizona of which four are in the Phoenix Metro.

Perhaps now forgotten is the fact that Quest had entered the DAT business in 2001 and exited in 2006 with a service called QuestDirect and later QuesTest (see: QuesTest Bails Out of the DAT Market). It was obviously not successful at that time but but was a forerunner of events to come. Here is a quote from that note:

Beginning in 2002, QuesTest launched a new strategy for its DAT operations, using retail drug chains and grocery store chains to sell plastic cards representing various types of test panels (e.g., men's health panel). Following the purchase in a retail outlet, the customer would report to a Quest patient service center for venipuncture. Test results were mailed to the customer and could also be obtained on the web site. 

Walgreens was badly burned by its bad experience with Theranos (see: Walgreens Terminates Relationship with Theranos; Will Be Closing Operations at All 40 Theranos Wellness Centers in Arizona). It remains to be seen whether the major Quest competitor, LabCorp, will choose to compete with Sonora Quest in Arizona with its own PSCs with one of the national retail drug store chains (see: LabCorp to Offer Direct Access Lab Testing (DAT) to Consumers).