Clinician-friendly tactics slash unwarranted testing

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The CPOE system also established test-ordering frequency rules under guidance from the laboratory formulary committee. For example, doctors are now prompted to order comprehensive metabolic panels only every other day, rather than daily.

At a more granular level, lab leaders worked with ordering physicians to set up favorites for common orders so they could get the tests they wanted while skipping others that were unnecessary.

As part of this CPOE project, guidelines for blood product infusion were included in the order sets. The need for the transfusion has to be specified and documented before a blood product order can be placed, while making the appropriate one-click exceptions for emergency cases. Red blood cell and platelet waste reductions alone account for nearly half of the Broward lab initiative’s savings.

Meanwhile, that resident who wanted to order those costly genetic tests for the uninsured family was not unique. In the patient safety world, there is a well-documented “July effect” in which a higher rate of adverse events is seen when new residents start practicing. Broward has seen its own July effect in the form of summertime spikes in pricey genetic and molecular testing ordered by physician trainees.

To tackle the problem, the system developed a policy on esoteric testing that was approved by the medical lab directors at each Broward site and by each site’s medical executive council. Under the new approach, any nonstandard, esoteric assays costing $1,000 or more have to be approved by the medical lab director or that director’s designee.

Insurance prequalification also is required for such testing. And if the need for testing is not acute, it is delayed so it can be done on an outpatient basis where reimbursement is better and community health grants are available to help defray the high costs. This move alone saved $220,000 on inpatient testing costs and brought in another $68,000 in pay when tests were done in the office setting. About two-thirds of the tests were fully reimbursed when ordered that way. Broward has 16 outpatient sites and three urgent care centers.

“Now when we get one of these unusual orders, it’s usually preceded by a phone call and preorder documentation,” Serrano says. “The doctors still do what they want to do and what they need to do for the patients, but now they help us to get paid for it.”

Another $74,000 in savings came from reducing send-out testing. For example, it may cost Broward $12 to do certain panel testing in-house. But many of the system’s doctors—about half are employed and about half are in independent practice—were sending them to outside labs for about $700, Serrano says. Those outside labs were doing results interpretation, so in-house pathology interpretation was added.

When it came time to develop the Broward system’s laboratory formulary, a teamwork approach again yielded great benefits. The lab formulary committee’s voting members all were practicing physicians.

“The lab formulary is going to have very little impact unless there is active engagement with the clinical practitioners by the laboratory,” Serrano says. “The lab can’t do the formulary for the doctors. The doctors have to do their own formulary.”

The committee “became the poster child of how we’re going to control runaway ordering,” Serrano adds.

All members of the committee are practicing physicians nominated by the various hospital chiefs of staff. That move “created a little bit of an issue in the administration because they suggested some nonpracticing physicians,” Serrano says. “But we needed to have people who are actually practicing make these decisions.” The administration agreed and the committee was formed.

The committee, which meets monthly, has physician representatives from community health, emergency medicine, pediatrics, surgery, obstetrics and gynecology, family medicine, internal medicine, infectious diseases, nephrology, pulmonary and critical care medicine, and pathology. The pathologists are nonvoting members to avoid any perception of impropriety.

This bottom-up strategy stands in polar opposition to the way that formularies are frequently devised, Dr. Giffler says.

“It’s a striking contrast to what often happens in the outpatient world at some of the managed care companies in cooperation with some of the larger commercial labs, where they are coming up with their own utilization formularies from the top down and without input from the ordering physicians involved,” he adds.

The committee sorted tests into three tiers. In tier one were the tests—including most routine tests—that any prescriber could order but that may have frequency controls or alerts. The second tier of tests is limited to specialists, senior fellows, or consultants. The third tier consists of tests that can be ordered only upon approval of the pathologist or the pathologist’s designee.

In that third tier are, among others, flow cytometry, fluorescence in situ hybridization, and cytogenetic orders. In some of these areas, ordering physicians had taken a shotgun approach that meant big costs and posed a “horrible problem,” according to Serrano.

“You might have oncologists who’d sit there and check off every box on the requisition before they even had the bone marrow or had the flow cytometry done,” he says.

The formulary committee decided that for such tests it would be up to pathologists to decide which ones to order in accordance with guidelines from the American Society of Clinical Oncology and others.

The final element of the Broward approach is perhaps the most basic and yet indispensable—making pathology a tangible presence in the lives of the other physicians who work in the system. That has taken predictable forms, such as responding to physician requests for test-ordering algorithms that lab leaders drew from Mayo Clinic and ARUP Laboratories and customized for in-house use. But the outreach effort also has included a periodical publication called “Lab Info for Physicians” that addresses common test-ordering dilemmas and profiles lab leadership so that doctors can put a name to a face and know where to go with questions.

Outreach also has meant getting the pathologists out of the lab and onto the floors to be involved with multidisciplinary committees where their expertise can come in handy, says the medical center’s lab director Dr. Reineke.

“It’s very important that the pathology group embed themselves within the overall medical staff to establish the credibility to be seen as consultants to lead the staff to more efficient utilization,” he says. “That personal interaction is very, very important. Once physicians realize that we’re really not in this to impede their practice but to improve the efficiency of their practice, and realize that just like everything else in life tests have costs…then you really get the ball rolling.”
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Kevin B. O’Reilly is CAP TODAY senior editor.