CEO SUMMARY: Collaborative care is an essential element of accountable care organizations (ACO) and other emerging models of integrated clinical care. At MedCentral Health System, one clinical chemist has held a key place on the physician team that develops order sets and clinical alerts. He is using this opportunity to leverage the clinical laboratory into an added value asset that includes more consultations and regular interaction with MedCentral’s physicians and other caregivers.
MANY HOSPITALS AND HEALTH SYSTEMS are promoting collaborative care in which clinicians in various specialties are encouraged to work together. The goal is to improve patient outcomes and reduce readmission rates.
This is exactly the type of clinical interaction which plays to the strengths of pathologists and Ph.D.s. In fact, it was six years ago when one health system in Ohio took this path. It has a clinical chemist working closely with referring physicians to offer advice on how to use laboratory test results most effectively.
The early adopter of this strategy is MedCentral Health System, a cancer and heart hospital in Mansfield, Ohio. In 2006, MedCentral saw the opportunity to develop a proactive consultative service for physicians. Health system administrators encouraged clinical chemist Eugenio H. Zabaleta, Ph.D., to consult with ordering physicians in an effort to improve patient outcomes and cut costs.
Since then, Zabaleta has worked with referring physicians, nurses, and other clinicians at MedCentral to develop a computerized physician order entry (CPOE) system and an electronic alert system. The goal is to identify patients who are at high risk of developing complications, the types of conditions that raise the cost of care.
When the alerts work as expected, clinicians can act to minimize complications, thus keeping costs down. One clinical decision support alert is for physicians treating patients with congestive heart failure (CHF). Another alert is for physicians treating patients who show signs of having a heart attack.
Improvement in how MedCentral’s physicians treat CHF patients has helped MedCentral cut the length of stay for Medicare patients with CHF. MedCentral’s heart attack alert project saved Medicare an estimated $300,000 annually by alerting providers to clinically significant changes in cardiac troponin levels in real time. Similar savings have accrued to private health plans as well, but those savings are more difficult to calculate.
Developing ‘Smart Systems’
Zabaleta is one of a handful of laboratory scientists and pathologists in the nation who are at the forefront of developing “smart systems” that help physicians improve patient outcomes in two ways.
First, patient outcomes improve when physicians get better at ordering the right test at the right moment. Second, patient outcomes also improve when physicians become more proficient at interpreting lab test results and developing the most appropriate therapeutic approach for patients.
“There are several important healthcare trends which play to the strengths of pathol- ogists and clinical chemists,” noted Zabaleta. “One trend is Medicare’s program that penalizes hospitals for high rates of readmissions. Another trend is the development of accountable care organizations (ACOs).”
These are reasons why Zabaleta’s work at MedCentral is instructive. It demonstrates how pathologists, Ph.D.s, and other lab scientists in ACOs can play an essential role in improving patient care that is cost-effective.
Collaborating with the Lab
Further, physicians are open to working in closer collaboration with their laboratory medicine specialists. This is particularly true as physicians practicing in ACOs feel the pressure to show continuous improvement in how they achieve ever-higher patient out- comes. These dynamics are playing out at MedCentral Health.
“Doctors want to order the right tests at the right time, and, in ACOs, the value of all lab tests is becoming more important,” declared Zabaleta. “Here in MedCentral’s clinical lab, we see what doctors need for their patients and believe we can help them improve care. That is why we are striving to go beyond reporting clinical data in the form of lab test results. We want to create added value by delivering actionable information that improves patient care.
“The concept of having teams provide care to a patient is evolving,” he noted. “Our lab team now does formal consultations with ordering physicians. Via actual clinical practice, we are demonstrating how the laboratory can help doctors improve patient care by consulting with them and by developing alerts for them. “This effort is focused on two priorities,” Zabaleta explained. “The first priority is to expand the ordering of laboratory tests through the computerized physician order entry (CPOE) system.
Creating Order Sets
“By writing and implementing evidence-based order sets, we standardized what physicians could request when ordering each laboratory test,” he commented. “An order set is one form of clinical decision support and is the foundation of MedCentral’s CPOE.
“When evidence-based medicine is used to develop an order set for laboratory orders, the right test will be performed on the right patient at the right time,” added Zabaleta. “This improves quality while reducing errors and clinical variability. In turn, this improves patient and physician satisfaction.
“The second step is to help improve the interpretation of laboratory results,” he said. “Our strategy here starts with the delivery of accurate test results in a timely manner. We consider it imperative that there be effective and efficient integration between information systems and laboratory diagnostic technology.
“This integrated informatics capability is the foundation for our consultative service,” stated Zabaleta. “It is how alerts are sent to the clinicians, for example.”
Zabaleta is a part of the team of physicians who write the order sets for MedCentral’s CPOE system. The alerts are electronic communications generated by middleware from Pacific Knowledge Systems in Sydney, Australia.
The payback from the alerts and order sets happened quickly. “After creating the order sets, the cardiologists noticed that the emergency room did not always identify every patient who was having a heart attack,” explained Zabaleta. “This problem occurred with patients who have comorbidities and who present with chest pain, which can have many causes.
“One way to diagnose a heart attack is to do serial troponin level measurements,” he said. “Troponin is a protein released into the bloodstream when heart muscle is damaged, such as during a heart attack.
“However, simply reporting a patient’s troponin level is not enough,” he continued. “That is just data. We produce lots of data in the lab, and sometimes we just spit it out to the ordering physicians. The physicians will benefit from having someone point out in real time what is clinically relevant and what is not. Having that information makes them more efficient and effective.
Alert Is Processed Data
“This is an important distinction,” Zabaleta added. “We emphasize to clinicians that the alert is more than data. The alert is itself a product of processing data and turning it into useful, actionable information.
“The problem in most clinical labs is that they are too detached from physicians and patients,” he noted. “That’s why MedCentral created my position as a bridge between the lab and the ordering physicians. In this position, I can accommodate physicians who are providing patient care. I spend equal amounts of time both inside and outside the lab.
“To be an effective consultant, I closely watch how our physicians use lab results,” Zabaleta added. “Lab scientists usually know more about lab tests than most clinicians. But we often don’t know what physicians do with our lab tests or why they order tests in a certain way versus the correct way to order tests. That has to change and we can help!
“One approach that we use is to profile doctors on their lab test utilization,” he stated. “As we understand what types of lab tests they are ordering, we then provide them information about which tests may be best to order for their patients and how they can use the resulting lab test data to improve patient outcomes.
“These utilization profiles are an effective tool to help physicians learn which are the most appropriate tests for their individual patients,” continued Zabaleta. “This educational and consultative process also is designed to provide them with a better understanding about how to interpret the test results.
A Work in Progress
“We have made a lot of progress since the CPOE system became fully functional just last month (December 2012),” Zabaleta said. “But we are not finished. Even though we are still learning, there are several lessons that we can pass along.
“First, pathologists should get involved in developing order sets for CPOE systems,” he recommended. “At first, physicians may balk at the idea, but in the end, they will appreciate the improvements in clinical performance that results.
“Second, the lab team needs to go outside the laboratory more frequently and engage personally with the clinicians,” he added. “It is surprising how quickly most physicians warm up to the availability of this specialized knowledge in laboratory medicine and diagnostics. Physicians recognize that no one in the hospital knows more about the analytical characteristics of the tests, and the limitations and clinical uses of each diagnostic assay.”
There is another insight Zabaleta wanted to offer. “It is quite enlightening to follow physicians around and see how and why they select the lab tests for their different patients,” he observed. “At the same time, this closer interaction opens the door for pathologists to gain an understanding of how to create solutions that make communication between the lab and provider more efficient and more clinically meaningful.”
In other words, there is a significant opportunity for pathologists to become more involved with clinicians by breaking down the silos that exist in almost every hospital. MedCentral’s initiative demonstrates the value of having lab professionals collaborate with clinicians to improve patient outcomes.
Lessons Learned in Developing Order Sets That Help Physicians Improve Outcomes
AT MEDCENTRAL HEALTH SYSTEM, administrators recognize the importance of leveraging clinical laboratory test results to achieve improved patient outcomes. It is why a clinical chemist was included on the team that develops clinical guidelines.
“This initiative began in 2006, when Michael Patterson, D.O., MedCentral’s VP and Chief Medical Officer, wanted a laboratorian to be on the physician-advisory committee drafting the CPOE order sets,” Zabaleta said. “He asked me to do it.
“It took much effort and some detective work on my part,” he continued. “Before I could write the order sets for each laboratory test, I had to shadow ordering physicians to see how they worked. I saw that some tests were underused, some were overused, and sometimes physicians ordered the wrong test or off-label use of tests.
“One important finding was that it would be relatively easy to create order sets for routine lab tests and procedures,” he said. “But it was more challenging when it came time to create order sets for esoteric tests. For one thing, it was clear that we couldn’t prohibit physicians from ordering tests. Therefore, it was necessary to develop a way to advise physicians without stepping over that line that could be considered telling them how to do their jobs.
“Our approach was to be educational,” continued Zabaleta. “By showing physicians what we are able to do in our clinical laboratory, we got their attention. Doctors want to do the right thing for patients.
“Another lesson we learned is that, as physicians better understand the different ways that our laboratory experts can help them, they are eager to work collaboratively,” concluded Zabaleta. “That’s what led to the alerts we developed for troponin levels in patients with chest pain and for acute myocardial infarction. These alerts have already helped improve patient outcomes.”
MEDCENTRAL HEALTH SYSTEM in Mansfield, Ohio, has 351 beds in two facilities, one of which is a critical access hospital. It also has seven outpatient centers.
The two hospitals specialize in open heart surgery and cancer treatment. Its competitors include the Riverside Methodist Hospital and the Ohio State University Medical Center, both in Columbus, and the Cleveland Clinic.
The MedCentral lab does 1.5 million tests annually, 40% of which are for inpatients. The balance is for outpatient testing and a laboratory outreach program that serves physicians’ offices and 54 nursing homes in the Mansfield area. MedCentral’s laboratory has 113 full-time equivalent employees.