CEO SUMMARY: Since the launch of a laboratory test utilization program in 2011 at the Cleveland Clinic, more than 35,000 duplicate or inappropriate test orders have been stopped. The test utilization team introduced five initiatives that are not designed to cut spending but to introduce evidence-based and consensus-driven methods to lab-test ordering. Another benefit is that needless blood draws are being eliminated, thus improving patient care and satisfaction.
THERE IS A NEW BUDGET-BUSTER for hospital and health system laboratories. It is the ongoing and sizeable increase in money spent on expensive reference and esoteric lab tests that must be sent out.
THE DARK REPORT is one of the first to report on the significance of this trend. Some major hospitals acknowledge that reimbursement from health insurers only covers one-third to one-half of the money they paid to the reference labs that performed the more expensive molecular and genetic send-out tests. (See TDR, April 20, 2015.)
For this reason, pathologists are finding that hospital administrators and medical staffs now welcome efforts by their lab teams to implement programs designed to improve how physicians utilize clinical laboratory tests.
As most pathologists know, even a modest lab test utilization management program can generate significant cost savings. Similarly, more sophisticated and long-running programs not only save substantial sums by eliminating needless testing but also improve the culture of lab test ordering, while increasing patient care and satisfaction at the same time.
This has been the experience at the Cleveland Clinic. Its lab test utilization program, established in 2011, is one of the longest-running lab test utilization management (UM) programs in the nation. Since its introduction, the program has saved multiple millions from the introduction of five separate cost-control initiatives.
According to Gary W. Procop, M.D., M.S., the Medical Director, Enterprise Test Utilization and Pathology Consultative Services, since the first initiative was implemented in 2011, the program has stopped more than 35,000 duplicate test orders and produced savings of almost $2.7 million.
But unlike UM programs in many labs, these five initiatives are not aimed at cutting costs, noted Procop. “Our guiding principle is best practice. We never talk about cost control.
“Instead, we talk about which evidenced-based and consensus-driven methods will be best to improve lab-testing ordering,” stated Procop, who is the Director, Molecular Microbiology, Virology, Parasitology and Mycology Laboratories at the Cleveland Clinic and Professor of Pathology, Cleveland Clinic Lerner College of Medicine.
His explanation of the Cleveland Clinic’s lab test UM program came during a webinar that Hospitals & Health Networks and the College of American Pathology sponsored last month.
“Once we find an initiative to improve care, we work with whatever area of the clinic that can implement that initiative,” stated Procop. “Then, as reimbursement declines, we also are decreasing unnecessary costs.
“Plus, just by eliminating needless blood draws, we have had a positive effect on patient care,” he continued. “No patient likes to get woken up in middle of the night for a needle stick, especially if it’s not needed. From the patient’s perspective, a blood draw at midnight or later leads to decreased patient satisfaction.
“From a physician’s perspective, when we eliminate unneeded blood draws, we decrease the chances that the patient will develop iatrogenic anemia, which can lead to poor wound healing and higher infection rates.”
Procop’s Enterprise Test Utilization Committee has introduced five utilization management initiatives since 2011. They are:
- Hard Stop Initiative
- Regional Smart Alerts
- Restricted-Use Initiative
- Lab-based Genetic Counseling
- Expensive Test Notification
“For the hard stop initiative, our medical team went through the entire test menu to determine which ones meet the criteria for a hard stop,” he said. “These are lab tests that never need to be ordered more than once a day. There are more than 1,200 tests on the same day Hard Stop list. If any of these lab tests are ordered more than once a day, then on the subsequent times, the provider gets a pop-up warning notice on the computer screen.
“The warning explains that the test was ordered that day, and-in most casesanother one is unneeded,” noted Procop. “But if the physician does require another of these tests, he or she must call client services to tell us why.
Unique Twist to Lab Orders
“When programming this warning feature, the informatics team added information to the warning that is just genius,” he noted. “We know these doctors are looking for results. Thus, the IT team suggested displaying the previous test results for the test the physician wants to order. The screen shows the date and time of the test, who ordered it, and the results.
“Thus, not only do we stop the needless test, but we give them the lab test results they want,” stated Procop. “Therefore, the informatics team is helping these physicians to improve their workflow processes. That’s a brilliant addition.
“Since we put in this hard stop, we have tracked every time the intervention fires electronically,” he continued. “We record the first time and then each subsequent attempt to order a duplicate test. We can see that some doctors don’t read the popup warning and continue to try to order the test without calling us.
“Cumulative data from January 2011 through December 2014 show that we stopped more than 23,000 unneeded duplicate orders,” said Procop. “Because we know the material cost and cost of the labor to do these tests, we calculated a cost-avoidance figure. Over this time, the savings totaled just over $361,000.
“This intervention is live every day,” he added. “Over the past three years, it has become embedded in our culture. It’s part of the way we practice.”
The second initiative involved developing a partnership with our regional hospitals to reduce duplicate testing,” he stated. “All the physicians at our main campus are employed. However, the regional hospitals have a mix of employed and affiliated doctors. So those hospitals face different challenges than those we have at the main campus.
“For example, in the regional hospitals, the computerized physician order-entry system is not always used,” noted Procop. “CPOE is available, but some doctors prefer to write out lab test orders on paper and have a nurse enter the order. We didn’t want to put nurses in the middle, if a physician ordered a test and the computer system didn’t allow its placement. Also, when this initiative went live in the regional hospitals, we did not have the ability to allow the ordering doctor to bypass the warning.
“So, for the regional hospitals, we built a different system, which we called a Smart Alert,” he said. “It functioned just like a hard stop, but the difference was that physicians could bypass the warning at the computer screen without calling the lab to request an override.
“That’s why this intervention has only a 41.7% success rate compared with the 93% success rate of the hard stops at the main campus,” explained Procop. “Still, for the period of March 2013 through December 2014, we averted 11,000 duplicate tests for a savings of over $90,000 with this intervention.
Expensive Molecular Tests
“The third initiative is designed to improve the ordering of expensive molecular tests,” he said. “Almost every hospital and health system today is hemorrhaging costs from sending out expensive molecular tests. For this initiative, we looked at how other departments manage high-cost orders.
“In cancer care, only oncologists can order certain chemotherapy medications and other physicians are restricted from ordering those drugs,” noted Procop. “Similarly, infectious disease specialists can order certain antibiotics for certain patients, but other physicians cannot. We argued that, similarly, certain complex and expensive tests should be restricted to other providers who are qualified to interpret and use the results from such tests. That’s why we call it the restricteduse initiative.
At Cleveland Clinic, Only Deemed Physicians Are Allowed to Order Certain Clinical Lab Tests
AS CLINICAL LABORATORIES DEVELOP test-utilization methods, one of their goals is to limit the ordering of duplicate, incorrect, and expensive tests while continuing to work collaboratively with all ordering physicians.
Clinical laboratory directors certainly don’t want to antagonize treating physicians and they are not interested in arguing clinical appropriateness over every test. Instead, these pathologists would prefer to improve the culture of test ordering.
Gary W. Procop, M.D., MS, Medical Director, Enterprise Test Utilization and Pathology Consultative Services at the Cleveland Clinic, said the lab test utilization management (UM) program at the Cleveland Clinic is designed to improve patient care. “It’s about finding common ground for the patient’s benefit,” he said.
“When we started this program we didn’t want to exclude some physicians and include others,” he said. “We also did not want to start having academic arguments either.
“So we took the approach that, if some physicians commonly order these tests in their practices, then they know how to use them,” stated Procop. “Those physicians became our deemed users.
“Additionally, if a complex and expensive lab test is one a physician orders extremely infrequently, or orders it just out of interest, then that physician probably shouldn’t be ordering that test,” he explained. “But there are other ways these physicians can order tests. They can consult with a geneticist or get a consultation from the deemed users group. For these tests, they would need to justify the order.
“When we looked at who was ordering highcost tests, it was often medical genetics, neurology, or pediatric neurology,” he commented. “They were ordering these tests frequently and so it was natural to put them into the deemed-users group.”
What comes next for utilization management at the Cleveland Clinic? “We’ve considered implementing more restrictions, but further restrictions create more challenges,” noted Procop. “In addition, we don’t want to end up micromanaging physicians’ decisions. That is not the role of our pathologists, since ordering physicians should have some autonomy within reason. It’s their patient, after all. And remember, our goal is a utilization management program that is a win-win for everyone.
“This is why our emphasis is on patient care, not cost control,” concluded Procop. “If we are collaborating to deliver the best care for each patient, then we will always find common ground with physicians as to how to use clinical lab tests most appropriately.”
“The lab tests targeted with this third initiative are so expensive and complicated that some physicians are not well versed in the use of these tests,” he explained. “They could give a patient the wrong test or they could misunderstand the results or both. In other words, there are patient-care and patient-safety aspects to this initiative.
Expensive, Complex Tests
“To restrict these tests only to those physicians who are experienced in ordering these tests and in explaining the results, we created a list of deemed users,” he commented. “These are mostly medical geneticists and some specialists.
“If a physician is not one of the deemed users, then we require a consult from a medical geneticist or another deemed user,” Procop said. “Because this is an electronic intervention, it operates without any additional work on the lab’s part.
Improved Test ordering
“We started this program in November 2011 and through December 2014, we stopped 349 tests and saved $784,127,” he stated. “Not only were there fewer tests ordered, but often, the geneticists recommended a different test.”
In the May issue of the Journal of Molecular Diagnostics, Jacquelyn D. Riley, Procop, and colleagues published an article on this initiative, “Improving Molecular Test Utilization through Order Restriction, Test Review, and Guidance.” (J Mol Diagn 2015, 17: 225-229; http://tinyurl.com/pr9wwje)
“Our data show that when a nondeemed physician orders a test in the ambulatory setting, about half (48%) are abandoned,” noted Procop. “In other words, they drop the order.
“When there’s a referral to a clinical geneticist, 31% of the orders go through,” he said. “We have about 13% of restricted use tests that are re-ordered by a deemed user. And only 8% are reordered by the non-deemed user. For inpatient orders, 75% of orders are canceled and the rest are referred for a clinical geneticist consult.
“What’s important here is we are pushing patients to the appropriate subspecialists,” emphasized Procop. “Those patients who need genetics counseling now get that counseling and that translates into better patient care.
“For our fourth intervention, we hired a lab-based genetic counselor,” Procop said. “Each day, this person goes over the sendout list and calls up the ordering physician if there is an issue with the test being ordered. The genetic counselor must have
great communication skills and good emotional intelligence.
“She reviews the patient history, the ordering physician, and the test being ordered,” he continued. “If everything looks fine, the order goes right through. And if she has a question, she calls the ordering physician. Since September
2011, this counselor has made 452 interventions and cleared more than $1 million in savings.
“Currently, we are considering the expansion of the genetic counseling group,” observed Procop. “The employment of a lab-based genetics counselor not only saves the hospital money, but most importantly this individual can help guide less experienced physicians to the appropriate genetic test.”
Genetic Counseling Program
In fact, the return on investment for this position is swift. “Evidence shows that the genetics counselor covered her salary in the first two months of work,” he added. “This makes for a good argument with hospital administration if your lab wants to expand a similar genetic counseling program.
“Since September 2011, the data we collect shows that out of 152 test orders, 88 (58%) were canceled after a consult with the genetic counselor, 37 orders (24%) were changed, and 27 (18%) orders were sent through,” recalled Procop. “In the 24% of the tests that were changed, she helped direct the ordering physician to a more appropriate test. In that way we are contributing to a team-based care approach, which is the future of medicine.
“When we looked back to 2007, we saw that genetic test volume was mostly flat until 2011 and that costs were rising steadily,” observed Procop.
“Following introduction of genetic counselor intervention in 2011, both cost and volume dropped sharply.
“One reason both costs and volume decline is physicians are no longer ordering the wrong test,” he said. “That means we are not double paying because the lab would pay for the first test and then-if that was wrong-our lab would need to order the correct test and pay for that one too.
Effect of Restricted Use and Genetic Counselor/MGP Triage Interventions
Chart courtesy of Gary Procop, M.D. M.S., at Cleveland ClinicIMPLEMENTATION OF THE THIRD INITIATIVE within the Cleveland Clinic’s lab test utilization management program involved improving patient care through better collaboration in the ordering of expensive molecular and genetic tests.
Physicians familiar with these expensive tests were put on a “deemed user” list and could order these tests as needed. Physicians who are not deemed users must consult with a medical geneticist, triggered by an electronic notice at time of test order. The lab employs its own genetic counselor. As shown by the chart above, following implementation of electronic restrictions on lab test orders and the genetic counselor review requirement in 2011, both the volume of expensive molecular tests and the costs of this testing plummeted substantially.
Speedier Patient Diagnosis
“In such a situation, the lab pays twice, and there is a lot of time lost before the patient gets the right diagnosis,” stated Procop. “So this intervention is helping physicians order the right test and-if it isn’t the right test on the initial order-we help them find the right test for their patients.
“Our fifth and final intervention is our expensive test notification initiative,” noted Procop. “This program is for tests that exceed a certain monetary threshold. Clearly this intervention is badly needed. For any of these tests, the CPOE system shows a warning that says, ‘Please consider carefully if this test is absolutely necessary.’
“The warning also explains that the test costs the Cleveland Clinic more than $1,000 (or $2,000, $3,000, etc.) and the patient’s insurer may not cover it,” he continued. “If the insurer does not cover the test, then the patient may be billed directly. For these tests, the ordering physician can proceed or not. Since we implemented this initiative in April 2013, we have stopped 165 tests and saved $262,221.
“For these five types of interventions, we prevented 9,436 duplicate laboratory test orders last year and saved $706,495,” Procop commented. “And, the cumulative totals through last year were 35,338 duplicate test orders stopped, saving almost $2.7 million.”
Contact Gary Procop, M.D., at email@example.com or 216-444-8845.