Lab’s-eye view on ‘hospital at home,’ ethics, sustainability

Anne Paxton

June 2024—At-home acute and advanced care testing, ethical quandaries, and the lab’s ecological footprint are three of the topics that ADLM meeting-goers can sign on for next month in Chicago.

“For so long we’ve had laboratory testing at the point of care and not the point of need,” says Jared Conley, MD, PhD, MPH, emergency medicine physician at Massachusetts General Hospital and assistant professor, Harvard Medical School, who will zero in on the point of need. As co-director of the MGH Healthcare Transformation Lab, he devotes much of his time to the technologies that he and his colleagues in the transformation lab believe will transform acute and advanced care at home.

“We can now deliver care decoupled from facilities,” he said in an interview. “There’s a huge opportunity and market to allow us to deliver care at the point of need, wherever that is.”

He and co-presenter and MGH emergency medicine colleague David Whitehead, MD, are looking forward, he says, “to a very active discussion on this opportunity with our colleagues who are experts in the space of diagnostic and laboratory medicine.”

Ann M. Gronowski, PhD, of Washington University School of Medicine in St. Louis, will take attendees through laboratory-related cases that raise ethical questions, which are “always a balance between the patient’s autonomy, beneficence, and justice,” she says.

And Ilyssa Gordon, MD, PhD, of Cleveland Clinic, will talk about, among other things, plastics and the purchasing that supports sustainability.

Testing has long been coupled with facility-based care, Dr. Conley notes.

“But many patients in acute care are not at risk of needing the ICU or a serious procedure or operation that can only be done in the hospital.” Given the option, “those patients often prefer to spend their time healing in the comfort and convenience of their own homes.”

Acute-care patients need clinicians to evaluate them. “So the medical team, led by the patient’s physician, goes into the home to obtain those diagnostics and deliver the therapeutics,” Dr. Conley says. Medicare requires patients to be seen at least twice daily, “much like they are by nurses in the hospital.”

Mass General Brigham has programs for emergency care at home also, and here paramedics and emergency physicians work as a team, together with nursing colleagues. Paramedics enter the homes to obtain the vitals and the necessary blood and/or nonblood diagnostics. “They convey that data to us through a variety of channels, including our EHR, and we can evaluate the patient virtually, and if we deem it safe, we can do the whole evaluation in the patient’s home,” Dr. Conley explains. IV or oral therapeutics are provided, as often needed.

The ED stay is avoided, “and this is particularly well designed for those who carry the heaviest burden of chronic disease,” he says, often those age 80 and older for whom being seen and treated in a facility is difficult.

“Patients love it. Their caregivers love it. We definitely see this as the future of care,” Dr. Conley says.

Is this changing emergency medicine as a specialty? “Absolutely,” he says. “It used to be that we had the binary options of admit and discharge at the hospital, but now we’re able to have a more personalized approach to patient care.”

He credits Judd Hollander, MD, and Rahul Sharma, MD, MBA, with describing the change well: Emergency physicians are the “availablists,” they wrote in 2021, for life-threatening conditions and immediate care generally, and it’s possible to do so without the emergency department. Says Dr. Conley, “We have a skill set that allows us to be available and evaluate and treat anyone, whether in the battlefield, in space, in the wilderness, in any locale, not just in the emergency department.”

For laboratory testing, the complete and basic metabolic panel and hemoglobin and hematocrit are readily available for point-of-need testing, he notes. He points to the lack of a rapid, accurate high-sensitivity cardiac troponin test as one of the key limitations at the point of need. BNP, too, is “one we haven’t had access to,” he adds. “Some of this too is not that the technology doesn’t exist necessarily, but that it doesn’t yet at a price point that’s affordable and makes sense from an operational perspective.”

Dr. Conley is hopeful: “There’s a lot of great startups, academics, engineers, and others working in this space to make this point-of-need diagnostic market more mature than it is currently.”

Neither he nor his colleagues have their eyes on sophisticated laboratory tests, he says, “but there is a growing list of blood and other bodily-based diagnostics that we would like more access to and think are feasible in the near term.”

“Human ingenuity and innovation have surprised us so many times. So together we’re actively rethinking how, through the use of technology, we can do things we never thought were possible.”

The transformation lab that he co-directs got its start 10 years ago (https://healthcaretransformation.org), and Massachusetts General began to provide at-home care about eight years ago. “We were doing it with our own system capital and resources because we thought it was the right thing to trial and develop,” Dr. Conley says. Later it became one of the first five hospitals in the U.S. permitted by the Centers for Medicare and Medicaid Services to be paid for hospital-at-home care at parity with in-hospital care for Medicare fee-for-service. “Now there are over 300 hospitals in various stages of doing it across the U.S.,” he says.

“We see that only continuing to grow.”

The question is how long the CMS acute-hospital-care-at-home waiver will remain in place. “Payment has been one of the biggest barriers for over three decades,” Dr. Conley says. “Fortunately, we continue to see positive signals in Congress that there is interest in extending the payment model.” Recently, the U.S. House Committee on Ways and Means voted to approve for a floor vote a five-year extension to the waiver.

Some say at-home care puts too large a burden on caregivers. “The data in this space suggests caregivers prefer it because the clinical tasks are still done by hospital staff and there is much less disruption to their lives.”

Despite the time and capital it will take to do the research and development work needed to advance the diagnostic technologies, Dr. Conley predicts there will be more shift to the point of need in the next few years.

With that will come less need to build new hospitals as the population ages rapidly, he says. “They cost $2 million to $5 million per bed to build, so often it’s $1 to $2 billion to build a new hospital in your community, and it can take five to 10 years.” With the shift to home-based care, “the current hospital capacity crunches we’re seeing can be ameliorated, and patients, caregivers, and staff can be delighted with the patient-centric healing process.”

Ann M. Gronowski, PhD, says that her interest in ethical decision-making in the laboratory began with a real-life hospital incident—a case that her team wrote up for publication (Jalaly JB, et al. Clin Chem. 2016;​62[6]:807–809).

In that incident, “The physicians were requesting a blood test for drug screening and we generally don’t recommend blood tests,” says Dr. Gronowski, Oree Carroll and Lillian Ladenson professor of clinical chemistry, pathology, and immunology and of obstetrics and gynecology and co-chief of the Division of Laboratory and Genomic Medicine, Washington University School of Medicine in St. Louis; and medical director of core laboratory services, Barnes-Jewish Hospital. Since a urine sample is preferred, it was problematic that the patient had declined to provide a urine sample for drug testing.

“So they thought they would just conduct the test as part of his routine blood collection. And a resident said, ‘I feel funny about that’—it felt kind of sneaky when the patient had said no to a urine drug test.” The patient had an indwelling catheter and a central line and left the hospital frequently, “and they thought he was using drugs through his line during his admission.”

In parsing this ethics-related question, Dr. Gronowski says, beneficence would be to say, “‘For me to help you I need to know if you’re putting drugs into your central line.’” To preserve patient autonomy, the solution should not go against the patient’s wishes. One solution, discussed later in this case, was not to do the drug testing but to put a sitter in with the patient to prevent him from leaving to inject drugs. “That was a wonderful compromise,” she says, as well as an example of how “with ethics, there’s often not a clear right or wrong answer, but there was a solution that did not violate the patient’s autonomy but allowed the hospital to protect the patient.”