Cleveland Clinic Lab Has Multi-year Test Utilization Success

In seven years, 160,000 fewer test orders!

CEO SUMMARY: Over the 24 months of a first-generation round of laboratory test utilization management projects, the Cleveland Clinic laboratories prevented more than 30,000 duplicate or inappropriate test orders, saving almost $2.7 million. Now implementing a second-generation of labtest utilization projects, the lab’s seven-year effort has prevented 160,072 tests and saved more than $5 million. The primary goals of the program involved more than cost-cutting, and included improved quality and patient safety, and enhanced patient care and patient experience.

IMPROVING HOW PHYSICIANS use laboratory tests is becoming a widely-used operating strategy in hospital and health system laboratories today.

This strategy is popular for two reasons. First, when a lab works with physicians to eliminate unnecessary or duplicate test orders, the cost savings are immediate. Second, when physicians get better at ordering the right test at the right time, patient outcomes and patient satisfaction scores improve.

in 2011, the Cleveland Clinic laboratories launched an initiative to improve lab test utilization that in two years prevented more than 12,000 duplicate or inappropriate test orders, saving almost $1.2 million. (See TDR, June 1, 2015.)

The lab test utilization projects in 2011 and 2012 went after the low-hanging fruit, such as reducing duplicate orders and aligning standing lab test order sets to eliminate outmoded or inappropriate tests. These early projects gave the lab team experience in how to approach physicians to gain their cooperation and how to sustain improvements from these projects.

In 2011 and 2012, Gary Procop, MD, the clinic’s laboratory Co-Chair of the Laboratory Stewardship Committee, oversaw the lab’s utilization management and then used the lessons learned from the first two years to launch a second generation of lab utilization initiatives in 2013 that produced more impressive results. In this second phase, the clinic prevented more than 80,000 test orders and saved $5 million.

“From our first initiatives in 2011 we saw how our utilization management efforts changed our standing at the Cleveland Clinic. This fueled our second generation of utilization changes,” he explained at THE DARK REPORT’S Lab Quality Confab in October 2017. “After starting this program, we learned that it’s about much more than saving money. It’s about adding value to the healthcare system.

“In our first-generation initiatives, we built trust in every lab throughout the Cleveland Clinic system,” he said. “From that experience we gained the confidence to escalate the lab test utilization management program so that today we are truly changing our practice for the better.

“Every lab in the United States needs to address affordability immediately and our lab test utilization management program does that,” he explained. “As pathologists and lab directors, we know that if we cut costs, we get almost an immediate positive response. But in addition to cutting costs, we also have to increase value for our healthcare system. I promise that by doing the right test, good things will follow— such as lower costs—but also by doing what’s best for patients.

“Consider what happens when lab directors ask a group of healthcare providers, ‘Who wants to do another cost-cutting project?’” said Procop. “You may not get a positive reply from everyone. But if you ask the same group, ‘Who wants to improve the rate of indigent women getting Pap smears?’ you get many positive replies.

Improving Patient Care

“When this happens, then your clinical lab has embarked on population health management and you’ll have staff members—particularly the physicians and nurses—invested for the right reasons and for the long term, both of which are more sustaining than simple cost cutting,” he advised.

“Our lab-test utilization management program is based on the universal principle of doing what’s best for patients,” noted Procop. “When our lab does this, we improve quality and patient safety while also enhancing both patient care and patient experience. At the same time, we increase our laboratory effectiveness and efficiency, cut costs, and save the clinic a lot of money.

“In addition, the projects are elevating the laboratory’s position in our health system,” Procop added. “Previously, no one from pathology or laboratory medicine was on the most important clinic committees. Now it’s significant that we’re sitting at the table when key decisions are made.

“All of this results from asking the question: Who’s going to be the leader?” advised Procop. “For lab directors and pathologists, now is the time to step up.”

Five Primary Goals

After challenging lab directors and pathologists to assume more leadership roles in hospitals and health systems, Procop explained the five primary goals of the lab test utilization management program:

  1. Improve quality and patient safety,
  2. Enhance patient care and the patient experience,
  3. Increase laboratory efficiency and effectiveness,
  4. Reduce costs, and,
  5. Enhance the lab’s position on healthcare delivery teams.

For his presentation at Lab Quality Confab, Procop explained that the program cut costs while improving quality and value by using evidence-based best practices. “When our lab does this each time we take on a project, that project is automatically patient-centered,” he said.

“In addition to being patient-centered, our interventions—except for our laboratory-based genetics counselor—are done through the informatics system,” explained Procop. “These interventions happen at the point of order entry. That enables us to communicate with ordering physicians at the exact moment when they are placing orders, not after the blood has been drawn and it arrives in the clinical laboratory.”

One of the first lab test utilization initiatives was an effort to stop same-day duplicate orders. “This happened as a result of a complaint to the former CEO about a patient being over-phlebotomized,” Procop explained. “That sounds like a problem for the lab, but, actually, it created an opportunity for us.

“This complaint opened an avenue for the lab to communicate directly to the top administrators in our health system,” he stated. “Now, we were talking with one of the system’s hospital CEOs (or at least the next one or two administrators in the hierarchy) about how the lab would fix the problem. In other words, we had top-level support and we were addressing why this problem happened.

“By working with physicians to not over-draw patients, our lab was fundamentally improving both the patient experience and patient care,” Procop said. “The added benefit was the lab was recognized for improving quality as well as cutting costs.

“That all sounds ideal,” he emphasized. “But the reality is that our lab team was attempting to change a culture that’s inherent in every hospital. Just a few years ago, physicians expected that if they ordered a test, the lab would run it—without question. In most cases, that paradigm continues in the prevailing culture.

“Therefore, when starting a lab test utilization management program, it’s likely that ordering physicians will look at you as if you’re from Mars,” he cautioned. “That’s what happened to me. Before that happens, labs need to answer the question: What will happen when our lab questions the need for a test a physician is ordering?

Vetted Ideas with Staff

“Keeping that question at the top of my mind made me wade into the water slowly,” recalled Procop. “I did so by discussing the lab’s approach thoroughly during grand rounds. I vetted our ideas with the medical staff so that we found agreement. We worked with our clinical colleagues to build evidence-based best practices to which we agreed.

“In our early projects to stop same-day duplicate orders, having those discussions first made us start slowly,” he said. “It meant our lab initially established soft stops within the EHR for test ordering, instead of hard stops,” Procop advised.

“Doing so allowed us to gather data showing why our laboratory needed to stop some test orders,” he said. “We needed to stop orders at order entry because the data showed physicians were not reading the messages shown to them during order entry.

“This point is important for any lab test utilization management program,” Procop said. “By engaging physicians in discussions first, it made us address the problem providers have when reading warning messages in the EHR. It caused us to devise a means to allow physicians to override interventions should the laboratory test be medically necessary.

“If a hospital lab makes physicians at the bedside call the laboratory to address a purportedly unnecessary test, then most of the time they will not call unless they really need to order that test,” he noted.

“The simple fact that physicians can override interventions by contacting the lab increases our level of safety,” he added. “And now we have published the data showing that our hard-stop intervention for same-day duplicate tests had no adverse effects on quality or patient safety.

“While devising the intervention to stop same-day, duplicate test orders, an informaticist who used to work in the laboratory suggested a great solution,” stated Procop. “If a physician is looking for the result from a test we already ran, we could simply embed that test result in the duplicate test hard-stop notification, providing feedback to the ordering physician in real-time. Physicians loved this solution.”

Success in Lab Test Utilization Projects Depends on Your Lab’s Ability to Gain Physicians’ Support

FOR ANY LAB TO SUCCEED in managing lab test utilization, it must establish support from the hospital or health system leadership,” stated pathologist Gary Procop, MD, Co-Chair of the Laboratory Stewardship Committee at the Cleveland Clinic.

“Our test utilization program started with a charge in the pathology department to enhance our utilization efforts throughout the health system,” commented Procop. “To do so, we obtained an appointment with our chief of medical operations and asked how the clinical laboratory could be more engaged at the systems level.

“If your laboratory is not engaged at that level, find the leaders and get on the calendar,” he advised. “Ask them how you can help. They want people who can make improvements. The traditional concept of pathologists and laboratorians being in a little box in the basement has to end.

“If your laboratory team is not ready, sow the seeds by talking about how you want to be more involved in enhancing patient care delivery,” he said. “In our meetings with leadership we discussed the need to improve patient care. When you focus on best practices and improving patient care, you will get the support you need. The dollar savings will come naturally and people will stay engaged.

“Also, you need to have doctor-to-doctor conversations, meaning it’s important to have a physician or other laboratory professional lead these discussions,” noted Procop. “For all of this work, you will also need good communication skills. And you will want to have all affected departments send representatives to your meetings.

“Plus, it’s absolutely critical to have strong partnerships with the staff and administrators in information technology. You will need them on your side, particularly if you plan to use clinical decision support systems to interact with the physicians at the point of order-entry.

“And, finally, I cannot stress this one enough because it will also be critical to your success with laboratory test utilization projects: You will need to monitor progress and report on the results of your interventions,” concluded Procop. “One underappreciated aspect of good communication skills is having the ability to analyze what you did and show your results in a way that everyone else can understand. Doing so will build the credibility of yourself and your stewardship team, and whenever you share your successes, you will gain support.”

Increased Size and Stature

In January 2017, Anita Reddy, MD, a Pulmonary Medicine Intensivist, joined Procop as co-chair of the Test Utilization Committee, which was rebranded as the Laboratory Stewardship Committee. At the same time, a cadre of providers from most of the clinical institutes joined the committee. “Today, the physicians are a part of our Laboratory Stewardship team,” Procop explained. “We do not tell providers what to do. Instead, we work together.”

The project to stop same-day duplicate orders produced an important insight. “During this phased implementation, we learned that 35% of our orders come from non-physicians,” Procop commented. “This statistic is important in our healthcare system because it shows that orders are placed by non-physicians. These individuals are following algorithms and do not have the flexibility to adjust to interventions. If that algorithm is broken, your lab will get misorders.

“When we instituted hard stops, there were institutional concerns regarding the interruption of care delivery,” he said. “Therefore, we started slowly with just 12 tests. Then it went to 78 tests.

“Today, there are hard stops on more than 1,200 tests on the same-day, duplicate hard-stop menu,” he continued. “To measure the effect of these hard stops, we track the number of times the intervention fires, the number of times physicians call the laboratory to override the hard stops, the absolute number of tests stopped, and our associated cost savings.

“In 2017, for example, this lab test utilization project stopped 4,563 unnecessary, duplicate tests,” he said. “From the start of the program in 2011 through the end of 2017, we stopped 33,949 unnecessary, same-day duplicate tests. Our success rate varies, but generally it ranges from 80% to 95%.

“Most of these lab tests are inexpensive, but those costs add up over time,” Procop advised. “You won’t save a lot of money, but, as Benjamin Franklin said, ‘a small leak sinks a great ship.’

“In one year (2017), we saved $54,516 with this effort, and from January 2011 through the end of 2017, we saved $522,622,” he stated. “Of equal or greater significance, the lab contributed to improved value and patient care and experience by not over-phlebotomizing patients.”

In addition to hard stops, Procop instituted a soft stop called Smart Alerts at regional hospitals. Physicians can override these alerts at order entry and do not require a telephone call to the laboratory. However, the hard stops were more effective. “Every time the hard stop fired, it saved $16 versus every time the smart alert or a soft stop fired, we saved $3.50,” he said.

Use of Smart Alerts

“With the Smart Alerts, we stopped only about 50% of unnecessary orders in the regional hospitals, meaning it was not as effective as the hard stop,” he explained. “When we presented the data to clinic administrators, they wanted to know why we weren’t doing hard stops in all regional hospitals. There are a number of reasons we implemented the soft stop rather than the hard-stop intervention for the regional hospitals, but now we may move in that direction.”

After 2013, the Laboratory Stewardship team launched new initiatives to control test orders, such as the expensive test notification program, extended hard stops, and a daily-orders program. The expensive test notification initiative alerts providers of tests costing more than $500. Last year, it stopped 131 tests for a savings of $186,849. and from 2013 through 2017, the program averted 654 tests, saving $974,683, said Procop.

The extended hard-stop initiative started in November 2014 to address inappropriate test ordering for C. difficilePCR, excessive HbA1c ordering, and HCV genotyping, as well as two molecular hematologic studies. Last year, this program prevented 13,140 duplicate tests, saving $71,718, and from November 2014 through the end of 2017, it prevented 37,974 duplicate tests, saving $205,075.

New Efforts Introduced

Most recently, the lab launched the daily-orders initiative that Reddy championed to reduce excessive and unnecessary daily orders. The team worked in concert with hospital informatics to construct the order so that the lab could choose a default of once, every other day, or every three days. If needed, the provider could override the default. This initiative was activated for the most common daily orders, such as CBCs and chemistries. Last year, this initiative stopped an estimated 38,000 daily orders, saving $117,951.

In 2017 alone, all nine of the stewardship committee’s initiatives prevented 81,517 tests and saved $841,729. And, from 2011 through 2017, these nine initiatives prevented 160,072 tests and saved $5 million, Procop reported.

In conclusion, Procop explained that “Physicians today are generally comfortable discussing new ways to utilize clinical laboratory tests. Our lab has built this trust because we progressed slowly with the utilization projects and engaged our clinical providers. Also, our data show how we influenced care delivery in a positive and patient-centered way.”

Contact Gary Procop, MD, at procopg@ccf.org or 216-444-8845.

Managing Orders for Expensive Genetic Tests

THERE ARE LAB PROGRAMS TO OPTIMIZE GENETIC TESTING. “We do so by restricting ordering to certain individuals, by having a laboratory-based genetic counselor, stopping duplicate genetic tests that are needed only once in a lifetime, and by using algorithmic testing,” explained Gary Procop, MD, Co-Chair of the Laboratory Stewardship Committee at the Cleveland Clinic.

“We’ve had a lot of experience with restrictive ordering (such as privileging), blocking duplicates, and engaging genetic counselors, and now we’re working on algorithms” he continued. “To date, the absolute numbers of stopped, unnecessary genetic tests are small, but these are all expensive tests, so the savings are great.

“In 2017, the genetic counselor stopped or changed 223 orders for a cost savings of $244,828, the restricted use intervention stopped 57 orders for a savings of $67,262, and intervening on repeat constitutional genetic testing stopped 350 repeat tests for a cost savings of $45,183,” he said.

“What we learned from this genetic test intervention is that we’re stopping unnecessary tests and we’re driving physicians into appropriate consultations with lab-based genetics counselors and medical geneticists when these tests are needed,” explained Procop. “Our genetic counselor, through her interventions alone, has saved the institution $1.7 million. We know that when she picks up the phone, 58% of the time the physician will decide the test in question is unneeded, and 18% of the time either the order was correct or the physicians were persistent because they can override her counseling.

“We also know that 24% of the time, physicians were ordering the wrong test,” he added. “Herein is the value added. She assists the provider in selecting the right test for the patient. This improves care because patients get the tests they need and decreases lab test costs.”

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