CAP TODAY Pathology/Laboratory Medicine/Laboratory Management
Dr. Procop
A pathologist in a reference laboratory can download the HCV infection testing module and use the measures as a basis for gathering a hospital client’s HCV infection testing data over time, Dr. Procop says. “They can feed that back to the client and say, ‘Here are the clinicians who are routinely ordering repetitive tests that you really don’t need.’”
“The wise reference laboratories are not going to take the short view and just do tests for the dollar,” he says. “They’re going to reach out and try to help their clients optimize testing.”
In that way, the reference laboratory is providing a health care management service, Dr. Procop says. “Their client can then go talk to that clinician, and that clinician may not know it’s being done. It may be an order that’s buried in an order set. They can work together to optimize care so a patient isn’t being drawn a second time. That’s how they could decrease waste and decrease costs.”
If the examination of HCV infection testing data reveals that patients with a positive serology were not followed up with an RNA viral load, sharing that feedback can prevent those patients from falling through the cracks. “Population health management is where many of us are moving to,” Dr. Procop says. “This is actually using laboratory data and informatics to help population health management.”
The BNP module addresses the frequency with which BNP is used in patients who have congestive heart failure. “BNP is a test that is not only overutilized,” Dr. Brown says, “but inappropriately utilized by providers in terms of frequency of testing and how the result is interpreted.”
The modules will address testing overuse and underuse. “This program is not just about controlling utilization or cost containment,” Dr. Brown says. “It’s making sure the clinicians order the best tests to get to the right answer.”
Says Dr. Procop: “It has been our mantra from the start that this is not a cost-cutting activity. People get bored of cost-cutting activities, and when it’s purely a cost-cutting activity, you worry about cutting into quality.”
One feature of the Test Ordering Program to be added to the website is a feedback mechanism, which will make it possible for members to share their module experience or provide test ordering success stories based on their laboratory experiences.
“Our initial view of the program,” Dr. Brown explains, “was that not only would the committee be providing tools for the pathologist, but that ultimately the pathologists would be providing feedback and tips to each other.”
Dr. Procop hopes that feedback information will in time be subcategorized to allow members to scroll to their area of most concern, whether it’s send-out tests or hematology tests, for example. “A lot of it is, ‘I need a good idea. What might work in my place?’”
“This is a fantastic way for the College to add value for its pathologist members,” Dr. Brown says, “and in turn for the pathologists to add value in their practice setting.” The Test Ordering Program is a reflection of the CAP’s strategy to increase the profile of the pathologist as a more valuable member of the care team. “This program provides them with the tools to do that.”
Dr. Schifman
The laboratory at the Tucson VA has implemented two test utilization solutions that strengthen communication with clinicians, Dr. Schifman says. A middleware solution for the over-ordering of high-volume, low-cost tests, such as iron or lipid panels, has resulted in the cancellation of hundreds of tests per month. One such rule addresses hemoglobin A1c, which the laboratory and medical staff together have determined to be ordered too frequently. “The specimen is collected, but when it gets to the laboratory the middleware then takes over to check the frequency of tests and determine if the test is to be performed or not,” Dr. Schifman explains.
If the software finds the order frequency is an exception to the rule, “the sample will be not tested, and the result will be reported out as ‘not done’ with a comment as to why.”
While there are hard-stop systems that intercept the order at the time the provider is ordering the test, the Tucson VA system permits the patient’s blood collection to proceed as ordered for other tests that are needed and serves as a safety net to override the automatic cancellation, if needed.
The laboratory keeps specimens for six days, so if the physician felt the need to confirm a test, it could be done without affecting the patient’s care.
The laboratory uses a different system for the low-volume, higher-cost tests. “We call those red flag tests, or tests that have a tendency to be sound-alike tests. The common one is 25-hydroxyvitamin D and 1,25-dihydroxy vitamin D.”
A separate business process management system intercepts all orders for these types of commonly misordered tests, and the orders undergo manual review with other information from the patient’s electronic medical record. “We typically review about 25 tests a day,” Dr. Schifman says. “We work closely with the clinicians to make sure the correct tests are ordered.”
“About 20 percent of tests that are reviewed in this way are either changed or canceled,” Dr. Schifman says. “It helps us to be in touch with the clinicians and consult with them about what the best test might be.”
Dr. Schifman has expanded test use management to the national VA laboratory system with a patient registry for genetic and phenotypic tests, the results of which would not be expected to change over time. An order for a genetic or phenotypic test is checked automatically against the patient test registry. If the patient has already been tested, the laboratory from which the order originated receives a notification with the test results and can share them with the provider. About 65 VA laboratories around the country have opted to receive such notifications.
Dr. Schifman refers to this registry program as a “trifecta” of rapid results, cost-effectiveness, and quality. “We had thousands of duplicates in our registry before we started the program,” he says. “About two-thirds of duplicate orders are canceled by laboratories after receiving notifications, compared with fewer than five percent before the program began.”
Dr. Schifman sees pathology-driven test use initiatives as easing the way to a future in which pathologists play a more important part in population health and patient testing by collaborating with medical staff.
The CAP’s new Test Ordering Program, in suggesting to pathologists how they can partner with clinicians on test use, provides the most comprehensive approach to the problem of misapplied tests, he says. “There are a lot of practical suggestions, and I haven’t seen that in any other program.”
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Amy Carpenter Aquino is CAP TODAY senior editor. From the CAP website home page, click on the Member Resources tab and scroll down to the Test Ordering Program section.