Re-evaluating diagnostic testing
Hospital radiologists and pathologists are on the receiving end of orders for scans and tests. But they can’t do their work alone.
With that in mind, they are building relationships with ordering physicians and working with them to ensure that patients get the right tests at the right time in the right place and in the right manner. They are encouraging ordering physicians to be thoughtful about what tests they order while also identifying ways to make diagnostic testing more efficient and patient-focused.
“We’re coming out of our darkrooms and going to conferences and serving on committees,” says Geraldine McGinty, M.D., a radiologist with Weill Cornell Medicine in New York City and vice chair of the American College of Radiology board of chancellors. “It’s important because you don’t get to just impose these kinds of changes on a large organization without building relationships.”
Weill Cornell: Decision support for imaging scans
Beginning in January 2019, Medicare is expected to require physicians to consult evidence-based, appropriate-use criteria via qualified clinical decision-support tools when ordering advanced diagnostic imaging services such as CT scans, MRIs and positron emission tomography scans. At this time, the requirement only applies to certain conditions in outpatient settings.
To prepare ordering physicians for these requirements, which were passed as part of the Protecting Access to Medicare Act of 2014, Weill Cornell is starting to implement appropriateness criteria and decision support for some advanced scans, such as whole-body PETs.
The hospital’s decision-support tool mines the electronic health record for data that show the physician’s imaging order complies with appropriateness criteria. If the data exist, the order for the scan goes through automatically. If not, the ordering physicians get a pop-up message letting them know that the test doesn’t meet appropriateness criteria.
The decision-support system doesn’t have any hard stops built in. Ordering physicians can talk with a radiologist to explain why they believe a scan is needed. “We’re not trying to second-guess our colleagues,” McGinty says.
The American College of Radiology also offers a program to help radiologists educate ordering physicians about appropriate scans and decision support, McGinty notes. The Radiology Support, Communications and Alignment Network, or R-SCAN, is based on imaging topics included in Choosing Wisely, which is an initiative sponsored by the American Board of Internal Medicine Foundation to help physicians and patients choose appropriate tests and treatments.
In R-SCAN, referring clinicians and radiologists form a team, pick the imaging topics they want to focus on and review cases for appropriateness using a free American College of Radiology decision-support tool. After identifying areas for improvement, the radiologists offer education to ordering physicians and staff to guide image ordering. The review is repeated to determine whether ordering patterns have improved.
“It’s very low-key and is not punitive,” McGinty says. “It’s an opportunity to begin the conversation with your colleagues.”
In 2018, the American College of Radiology plans to roll out Radiology Teaches, an online portal that uses case studies to teach participants, including medical students, about appropriate imaging utilization and encourages them to choose the best imaging modality for the clinical scenario. The program, initially piloted at Baylor College of Medicine in Houston, simulates the process of requesting imaging studies and gives participants evidence-based feedback at the virtual point of order entry. “It really supports physicians throughout their education and training,” McGinty says.
Cleveland Clinic: Bedside clinicians help to lead the charge
For years, the Cleveland Clinic has fostered appropriate use of laboratory tests through its Test Utilization Committee. That panel, which comprised primarily pathologists and lab medicine professionals, got a makeover earlier this year and was renamed the Enterprise Laboratory Stewardship Committee. Now, half of its members are medical practitioners, including specialists, nurses and physician assistants.
“We felt it was important to incorporate clinicians as a part of this process to get their insights from the bedside and learn how they care for patients,” says Anita Reddy, M.D., the committee’s co-chair and a pulmonary and critical care medicine physician.
In August, the committee launched an initiative that focuses on high-volume daily labs, such as blood counts, chemistries and coagulation factors. “When patients are admitted to the hospital, labs often are ordered the day they’re admitted and continue every day until they’re discharged, and not much thought goes into whether patients need those labs every day,” Reddy says. “We want to encourage more clinical decision-making around lab usage. ‘Does your patient need that lab? Is it worth waking up your patients in the early morning hours when they’re not feeling well to draw the labs?’”
The initiative encourages clinicians to weigh the downsides of daily blood draws against the clinical insights the labs provide. In addition to being unpleasant for patients, frequent blood draws may lead to hospital-acquired anemia from blood loss. Daily labs also consume hospital resources and contribute to high health care costs. When tests come back slightly abnormal, that can trigger other labs or studies that aren’t clinically relevant to the hospitalization and could be better addressed in the outpatient setting after discharge, Reddy adds.
To prompt physicians to consider the usefulness of daily labs, Cleveland Clinic’s EHR now asks doctors to select one of three default options when ordering labs: Perform the test once during the patient’s stay, daily for three days or every other day. When physicians feel that their patients need daily labs for more than three days, they can change the order, but they receive an alert that asks them to confirm that the labs are clinically needed, Reddy says. In addition, exceptions are built in for certain types of patients who need daily labs, such as chemotherapy and transplant patients.
The Cleveland Clinic committee is working on a number of other projects, including a process in which an expert reviews orders for lab tests that cost more than $500. The goal is to determine whether the test is clinically relevant for that patient, whether a less expensive test would provide the same information and whether the test needs to be done in the inpatient setting or can wait for an outpatient appointment.
Also in the works is a process to evaluate whether new tests should be added to the lab formulary, Reddy says. Questions would include whether the test is clinically useful, whether it is supported by guidelines, whether it would replace another test, its cost, and how the cost would be covered (i.e., by the patient, insurance or the institution).
Cleveland Clinic: Keys to success for appropriate test utilization
• Leadership support.
• A multidisciplinary group, with individuals representing many areas of the organization.
• An open, transparent and collaborative process.
• Team members focused on optimal patient care, improving the patient experience, decreasing phlebotomy and reducing costs.
• Collaborative meetings with mutual respect, acceptance, and healthy and collegial debate and innovation.
• Rational, evidence-based initiatives.
• Good project management with regular reporting of results.
• Top-down support with bottom-up team building.
• Inclusion of high-level partners from information technology.
• The ability of information technology to respond rapidly to change requests.
• ‘Pre-selling’ initiatives with the opportunity for feedback.
• Anyone affected by a decision should be involved in the decision.
• A willingness to learn and change.
• Recognizing you don’t have to win every battle to win the war.
The committee’s work builds on successful past initiatives. For example, Cleveland Clinic has a hard stop in its electronic ordering system on same-day duplicate tests for more than 1,000 tests that should not be conducted more than once a day. The system also limits ordering complex molecular genetic tests to clinicians who are experts in the disease for which they’re ordered. A lab-based genetics counselor makes sure the proper test is ordered.
The committee’s interventions stopped 24,753 inappropriate tests in 2016 for a cost savings of $775,860. Since 2011, the initiatives have prevented 78,555 tests, which has saved $4.2 million, according to the committee’s 2016 annual report.
University of Oklahoma: Building bonds outside the lab
Yaolin Zhou, M.D., entered her position as director of molecular pathology at the University of Oklahoma (OU) Health Sciences Center in July 2016 with an overarching goal: She wanted to improve testing efficiency and bring ordering patterns more uniformly in line with published clinical guidelines and recommendations.
But before Zhou could begin, she had to get to know the hematologists and oncologists at OU’s Stephenson Cancer Center who place many of the molecular pathology orders. “My task is to understand their needs and what it is about the ordering process that is complicated or difficult, what would fix the problem, and then make it a reality,” Zhou says.
After getting the nod from the chief of hematology/oncology section, Zhou met one-on-one with every physician in the department. At each meeting, she asked the same question: “What can we do to make your life easier?”
The effort already has netted results in the form of a new, simplified procedure for testing patients suspected of having chronic myeloid leukemia. It starts with a test that shows whether a genetic change has occurred and the specific type of gene rearrangement. If the patient tests positive for the more common rearrangement, the lab automatically performs a second test that helps to guide treatment choices.
Before the new process, physicians had several testing options, some of which had similar names, which caused confusion. Some doctors would order all potentially relevant tests to cover all their bases, while others ordered the test with which they were most familiar. The danger was if they ordered the wrong test and missed the chance to identify the specific type of genetic change, which would be needed for long-term monitoring, Zhou says. “You can’t know how to follow your patients if you don’t know what they have from the get-go.”
Zhou has also worked to improve care for patients with other tumor types. By understanding the perspectives of her oncology colleagues and collaborating with them, she is able to develop workflows that expedite molecular testing for major cancer groups, such as melanoma, brain, lung, endometrial and colon cancer.
A meeting Zhou had with a hematologist/oncologist who specializes in melanoma treatment led to a change this spring in testing for patients who are found to have metastatic melanoma in their brains.
The hematologist/oncologist was frustrated because these patients did not automatically receive a follow-up test in the hospital to see whether the melanoma cells had a BRAF mutation. Therapies exist that target the BRAF protein directly and can help to prolong patients’ lives.
Out of respect, the pathologists thought they should wait for the oncologist to order the BRAF test. But waiting for the order ended up delaying the start of life-extending treatment.
Now that pathologists understand this perspective, they order a BRAF test when metastatic melanoma is discovered. “Soon after this meeting, we had several cases of metastatic melanoma, we performed BRAF testing, and we were able to provide those results to the physician. It really helped to decrease the turnaround time,” Zhou says.
Beyond her efforts in molecular pathology, Zhou gives presentations to physicians from various specialties on the concept of health care value and how to increase it by choosing lab tests and imaging scans more wisely. She goes over specific Choosing Wisely recommendations and presents data that are relevant to that particular specialty. Zhou, who was recently selected as an American Society for Clinical Pathology 2017 Choosing Wisely champion, has given more than a dozen such talks, with audiences ranging from cardiologists to pediatricians.
“I decided to talk about this from different angles with different individuals, and maybe I’ll slowly but surely be able to make some type of impact,” Zhou says.
Geri Aston is a contributing writer to Trustee.
Trustee takeaways
The shift toward value-based care requires innovative planning strategies for radiology and pathology, says Jeff Gruen, M.D., a managing director and chief clinical innovation officer in health care at Huron Consulting. Here are some of his insights:
- To successfully take on risk under value-based reimbursement arrangements, hospital systems need to be able to track utilization of all services — including radiology and pathology tests — on an episode basis by physician and even by patient. Utilization data can shape physician decisions, while achieving savings and creating a high-reliability environment.
- In pathology, the growth of specialty pharmaceuticals could drive up utilization of some tests in order to lower overall health care costs. Appropriate prescribing is increasingly contingent on conducting the right genomic or other targeted diagnostic test to ensure that only patients who could benefit from some expensive medications receive them.