‘Doing more for less and with less’: Turning to IT

John, you are training pathologists and pathology informaticians. What are you doing at Yale to prepare pathologists for this new world we’re discussing?
Dr. Sinard (Yale): There are three facets to this that conflict with one another. One is that trainees are focused on the next step. They don’t want to look too far into the future if it’s not going to be on the boards. On the other hand, we try to mentor them to understand that the world in which they practice and will spend most of their career will be a little different from the world in which they’re training and give them the skills to recognize and adapt to those differences.

We are trying to introduce informatics training into the curriculum. It has two components. One is didactic, and I question the value of giving these lectures because I don’t know how much the trainees walk away understanding. More important is integrating these solutions into trainees’ day-to-day practice—using barcode scanners and whole slide imaging, accessing the EHRs routinely as part of their workup of cases. That’s when you start to have a better impact on their training for the future—you build workstations for them that are fully enhanced with these various capabilities.

The third pillar is the attitude of the trainees coming in, which varies significantly. More frequently the focus is on, “The institution is here to teach and train me, not use me to do the work.” There’s a conflict between doing the work and is it an educational activity? Trainees want more control over their own education. It has filtered down into medical schools, where students have a large say in the curriculum, and has continued into residency. Those three pillars are conflicting with one another to some degree, but we do what we can to make them work together.

A lot of us are excited about digital pathology seemingly maturing and becoming an ever-greater reality and about machine learning and artificial intelligence. There must be young men and women who want to go into pathology because it all seems so exciting. You have a lot of people who want to be surgical pathologists. Do you have a few who come with an informatics aspiration from the get-go?
Dr. Sinard (Yale): There are a few, and usually the first step for them is to do a level set and a reality check. There’s a lot of hype about what AI and machine learning will be able to do. A lot of the basis for the hype is true, but the time frame being portrayed is exaggerated. It will start to impact the careers of some of our trainees, but it’s probably a 10- to 20-year time frame before it plays a major role. There’s no reality to the thought that we won’t need pathologists in five years because computers will be doing everything. There are so many issues associated with the clinical use of machine learning and AI that have yet to be tackled and resolved that I don’t anticipate it will be a routine part of the remainder of my career.

Chad, as a vendor do you share that view of the timeline? Or are you more optimistic about the speed?
Chad Meyers (Clinisys): It’s going to take a while. When I came into the anatomic pathology industry from the medical imaging industry in 2010, Roche had just acquired BioImagene and was ramping up promotion of digital pathology scanners. Since then there’s been adoption from academic medical centers, but the smaller and mid-size labs I talk to are still trying to determine their path and how to make investments and business cases. It has promise and will be a great computer-aided approach to make pathology even more precise. But it will take time to build confidence in quality and accuracy, moving from having an individual person review to allowing diagnosis with just AI.

Joe Nollar (Xifin): I’d like to add to what John and Chad said—every time we’ve tried to predict when digital pathology is going to have a major impact, we’re disappointed. I would agree with John’s timeline, although with the FDA’s approvals of artificial intelligence algorithms—Paige and Ibex—we’re seeing fantastic technologies in play that will be wonderful assistants to pathologists. Speculation that AI will someday replace pathologists is completely overblown, but it will be a great asset to help triage cases, mitigate risk, and identify high-risk cases. As an LIS provider, it’s critical to fully integrate digital pathology into the workflow.

We’re seeing a dramatically different standard of care in many cases, particularly in oncology, between what’s provided in academic centers and by large laboratories of tertiary care hospitals and by the smaller community practices. I use some of the data coming out of ASCO as an example. They made the case that oftentimes in community practice not even 50 percent of patients get the basic frontline biomarker testing that would be dictated by their condition. I assume some of this feeds into what you already said about the TC/PC split and discussions around that, correct?
Joe Nollar (Xifin): Yes. We have seen an expansion of smaller community practice services due to consolidation that creates greater economies of scale and expansion of TC/PC services. These partnerships are a great way for smaller community practices to expand their test menu. Consultations are also an important consideration, including sharing of data and images using digital pathology and artificial intelligence algorithms to assist pathologists. The core to that is having the system capability to fully integrate for consultations and test add-ons with reference labs and academic medical centers so community practices can get the support they need. LISs need to support those endeavors. Our role is to integrate the latest technologies, make the process easier, and share and transmit data and facilitate test orders and consultations, ultimately leading to better patient outcomes.

Almost 95 percent of new pathologists are being trained at academic centers. If they go into a community practice, they will have expectations around an ease of technology use and an ability to consult and share important and complex data to take care of their patients. Suren, are you seeing that in your customer base?
Suren Avunjian (LigoLab): Yes, we are. Whole slide imaging technology contributes greatly to the consultation capabilities for these pathologists and the systems they work in. With the help of whole slide imaging, I’m seeing more organizations scale using TC/PC relationships. I learned recently that you don’t have to prepare a slide to bill for TC; you only have to do the gross and that’s technically considered a TC. With slide prep and scanning available to read remotely, it is a benefit for rural communities, pathologists who are looking for an extra consult, and organizations that have an entrepreneurial spirit to deploy this technology to help smaller practices.

There are new CPT codes for consultation in cancer cases, and CPT codes for digital pathology are being developed. Keith, it’s early innings, but are you seeing interest in these and an eagerness to get in on the ground floor so when they start paying off, your customers will be ready?
Keith McKinney (Orchard): We’ve always seen interest in how our system can help clients with their coding processes to make sure they’re keeping up with current billing guidelines and maximizing reimbursements. We’re also seeing interest in the coded diagnostic aspects of how that ties together to make sure they’re maximizing reimbursements for their work.

Ed, are you seeing interest in these two new categories of CPT codes as people prepare for them?
Ed Youssef (NovoPath): Yes. We have a lot of clients who ask us what’s new and what has and hasn’t been approved. Being able to tell them there has been movement along those lines is helpful to them. Regulators need to look deeper into and approve more technologies and come up with better ways to compensate laboratories. It’s great to have the technology, but it’s a question of, can I be reimbursed for it correctly? That’s a challenge for our clients—can I use the technology to help me more, or are there still regulations that don’t allow me to do that without challenges?

Chad, can you comment on the heightened interest in new CPT codes? At the same time, it’s more difficult than ever to get paid. We have difficulties with test preapproval, trouble with billing and collection. Where do you think this is going? Will there be a more vigorous, profitable practice of anatomic pathology three years from now?
Chad Meyers (Clinisys): Two things stand out. First, with these consultation codes there’s been discussion with a few sites I’ve talked to about whether they will create a second report, one that is more patient-focused, simpler to understand. I think they’re looking at how to maximize the customer experience with those consultations. Second, we’re starting to see AI converge into the billing space. We’ve recently done an integration with CodaMetrix at a site that is looking at applying AI to billing codes to help maximize efficiency, reimbursement, and potentially catch manual errors.

The complexity of precision medicine has made coding more challenging. A lot of labs are still figuring out how they can best use these codes and how to apply digital pathology coding and billing in the overall process. We need to make sure the systems facilitate that and automate as much as possible.

John, in this new world of CPT codes and preapprovals, are people struggling to figure out how to optimize department operations?
Dr. Sinard (Yale): We’re always focused on trying to optimize department operations because of the expectation that we do more for lower pay. A key element of being able to build consultation codes is a request for the consult. At large academic centers, most of our clinicians don’t feel they need to ask somebody else what test results mean; they can figure it out themselves. So there hasn’t been a huge demand here.

Digital pathology codes are in their infancy. My understanding of the maturation process of a code is that one needs to demonstrate widespread use of a technology before people will start thinking about paying for it. The reason for using these category three codes is to capture information on how widespread the use of digital pathology is for primary diagnosis. It will be interesting to see that data.

Preapproval, particularly for molecular testing, is difficult for a number of reasons. One, the time frame for these preapprovals is often not consistent with the time frame needed for efficient treatment of patients. In many instances you run the test and then hope the approval comes through. The other problem pathology departments face is that reimbursement is bad for many of the molecular tests. There are a lot of companion diagnostic tests that are required for treatment with a particular drug. So we have a developing dichotomy where pathology takes the financial hit for doing the test so that other departments like oncology can get the income from providing the treatment, if the test permits. The expenses are going in one direction and the income generated is going in another. That is driving people to look at centralized funds flow models where there might be mechanisms in place to correct the disconnect between appropriate reimbursements and the testing-related expenses.

If centralized funds flow is done intelligently and appropriately, it should enhance the finances of the pathology department, yes?
Dr. Sinard (Yale): Historically that has not been the case, but it depends on how the institution deals with centralizing the funds flow. Discussions about centralizing the funds flow, particularly at this institution, have been regarding the professional component as opposed to the technical. But the technical component is where opportunities exist for correcting some of these discrepancies, and it gives institutions an opportunity to look at whole programs rather than departmental division needs.

I’ll put my final question to all of you: Three years from now, will pathology departments be in better or worse financial shape than they are today?
Keith McKinney (Orchard): As we see the consolidation occurring, they won’t be worse than they are. Our goal is that with the efficiencies updated software solutions bring, the cost of doing business from an LIS vendor side will be more acceptable for them and support new reimbursement guidelines. Our larger lab customers will benefit from the efficiencies brought about by new LIS solutions.

Ed Youssef (NovoPath): I’m optimistic. I think they will be in better shape, but people will need to adapt more to new technologies and a new way of doing things.

Suren Avunjian (LigoLab): I’m also optimistic that the ones that have selected the right partnerships, especially that allow them to differentiate in the marketplace, will be able to become the future laboratories and find success.

Chad Meyers (Clinisys): As for any business, those that are savvy in their strategic planning, with the cloud, digital pathology, precision medicine, will be better off. Those that operate day-to-day and don’t do the strategic planning may have a harder time, given the climate.

Joe Nollar (Xifin): I agree with Chad. The key is for labs to leverage the technologies and adapt to the business environment they’re in. If they can do that, they’re going to be fine and they will continue to provide great service and probably be more efficient in doing so.

Dr. Sinard (Yale): Things are going to be stable. The adoption of many of these new technologies, the increased efficiency, is necessary to counteract the increasing expenses and decreasing reimbursements we’re facing. Those who are not looking at ways to improve their efficiency will be hurting, and those who are aggressively looking for these opportunities will be in a better position to cover losses in other areas.