lessons learned and successes from lab test utilization ......ordering lab tests . study of 1,768 us...

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Lessons Learned and Successes from Lab Test Utilization Initiatives at Mount Sinai Hospital

Ila Singh, MD, PhD Vice Chair of Clinical Pathology Director of Clinical Laboratories

Mount Sinai Health System New York , NY

Casey Leavitt, MBA Director, Consultative Services

ARUP Laboratories Salt Lake City, UT

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The Mount Sinai Hospital Mount Sinai Queens Mount Sinai Beth Israel Mount Sinai Beth Israel Brooklyn Mount Sinai Roosevelt Mount Sinai St. Luke’s New York Eye and Ear Infirmary of Mount Sinai 3500 beds 55 ambulatory care centers 2.6 million outpatient visits 170,000 inpatient admissions 18 million billable tests/year

The Mount Sinai Health System New York

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ARUP Laboratories More Than a Lab

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70 medical directors and consultants provide

collaboration

• Privately held

• Nonprofit enterprise of the University of Utah and its Department of Pathology

• Does not compete with clients for physician office business

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Institute of Medicine study

"Unnecessary lab tests cost an average hospital

$1.7 million a year."

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ABIM Foundation Survey

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73% 72%

53% 47%

the frequency of unnecessary tests and procedures is a very or somewhat serious problem

the average medical doctor prescribes an unnecessary test or procedure at least once a week.

that even if they know a medical test is unnecessary, they order it if a patient insists

their patients ask for an unnecessary test or procedure at least once a week

Physicians reported:

ABIM Foundation. Survey: Physicians Aware Many Tests and Procedures are Unnecessary, See Themselves as Solution. 2014. http://www.abimfoundation.org/News/ABIM-Foundation-News/2014/choosing-wisely-survey-release.aspx

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Physicians appear to be uncertain when ordering Lab Tests

Study of 1,768 US primary care physicians reveals 1 :

1. Primary Care Physicians’ Challenges in Ordering Clinical Laboratory Tests and Interpreting Results, Journal of the American Board of Family Medicine, Mar-Apr, 2014

of the time they are uncertain about which test to order

15% 8%

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of the time they are uncertain about interpreting the results

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With more than 500 million primary care patient visits each

year, this potentially affects

23 million patients per year

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Why the uncertainty?

Laboratory tests More than 3,500

Lab Medicine teaching hours in medical school

Reduced, sometimes to zero

How do clinicians compensate for this uncertainty? Order more tests Use the ‘H and L’ approach

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Slovic, P. Unpublished manuscript, cited in Hueur R.J., Psychology of Intelligence Analysis

Horseracing Handicappers

Graph courtesy of Brian Jackson, MD, CMIO, ARUP Laboratories

But is more testing better?

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Road Map

utilization management

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Vitamin D

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25 hydroxy-vitamin D the best indicator of Vitamin D status in routine screening for deficiency

1, 25 dihydroxy-vitamin D and can be misleading in screening for deficiency major

forms in the body

2

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Vitamin D Testing at Mount Sinai

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$80,733* *based on medicare allowable

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Multiple Vitamin D Orders

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Orders/Tests Per Admission #

Patients Avg # of Ordering

Providers Patients with 3 orders 90 1.9 Patients with 4 orders 28 2.1 Patients with 5 orders 8 2.5 Patients with 6 orders 4 2.3 Patients with 7 orders 4 3.3 Patients with 8 orders 2 4.0

Medicine/Cardiogy

Medicine Hospitalist

Medicine /Hematology and Medical Oncology

Rehabilitation Medicine

Medicine/Mulomnary, Critical Care and Sleep Medicine

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Multiple Vitamin D Orders

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Medicine/Cardiogy

Medicine Hospitalist

Medicine /Hematology and Medical Oncology

Rehabilitation Medicine

Medicine/Pulomnary, Critical Care and Sleep Medicine

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How extensive is the duplication problem?

Test Name Acceptable Interval

Total Tests Done

% Duplication

MCR allow.

per test

Potential Savings

Hemoglobin A1C Once per admit 12,930 17% $13.21 $29,037

Iron, TIBC Once per admit 4,156 13% $94.99 $51,321

Lipid profile Once per admit 7,458 13% $18.22 $17,665

$98,000

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• Result not easily found in EMR • Not enough time or know-how • Multiple physician orders • Physician preference list • Wrong test in preference list • Multiple names for same test • Default panel • Search Engine Quirks

Reasons for Duplicate/ Inappropriate Orders

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Benchmarking

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per 1,000 patient days

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Road Map

utilization management

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Governance

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• Develop mission statement, scope and objectives

• Determine Steering Committee membership

• Meet two to four times

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Governance

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• Oversee implementation of policies and formulary

• Create and execute communication plan

• Develop lab ordering policies

• Oversee formulary development

• Govern new tests, retired tests, reference labs, etc

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Mount Sinai Test Utilization Steering Committee

Strong IT presence and support

Executive leadership

Clinician-led Initiative

Communication

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ARUP • Director, Consultative

Services

• Senior Consultant, UM

• Senior Consultant, Analytics

• SVP, Business Innovations

Mount Sinai • Vice Chair, Clinical Pathology

• CMIO

• CMO

• EMR Informaticist

• Director of New Technology

• SVP, Corporate Affairs

• Chief Ambulatory Officer, Chief of ACO

• Chief Communications Officer

• Vice-Chair for Clinical Effectiveness

• Clinical Resource Management

• Senior Director, EPIC

• Director, Pathology IT

• Director, LIS

Mount Sinai Test Utilization Steering Committee

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Our Approach to Test Utilization Management

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Create the mechanism and processes Optimize the number and types of tests being ordered

Create a culture

Clinicians taking a thoughtful approach to test ordering

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Didactic Training Physician scorecards

Our clinical pathologist to clinician ratio = 1:400

Our Approach does not consist of…

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Road Map

utilization management

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Questions to Consider

Should the test be on the menu?

What do ordering providers need to know about the test?

Should the test be available to every provider?

What do ordering providers need to know about the test in this situation?

Should the ordering provider be educated about this test?

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Formulary Development Experiences

Focus on INPATIENT; outpatient poses risks to relationships and reimbursement

Measure RESULTS Pathology SUPPORTED not driven

Little PHYSICIAN resistance

Disseminating information to providers is difficult; implement in CPOE and deal with a few calls

it is strangely

addictive has endless

opportunities

fun

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Common Tests

High-Cost, Low-Volume Tests

Obsolete

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More sensitive/ specific replacemzent test available Little clinical utility rT3 uptake, T3, Free

Tiers in Formulary

80% of test menu, 95-97% volume Mostly Inexpensive Hemoglobin A1C

Send-out tests Analytes that change slowly Most frequently ordered by specialists EBV Quant PCR, Blood

Tier 1

Tier 2

Tier 3

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Formulary Subcommittee Vice Chair of Clinical Pathology Lead Technical Informaticist • CMIO

• Assistant Director of New Technology

• Senior Director, Epic Applications

• Hospitalist

• Chief Resident, Medicine

• Rehabilitation Medicine

• Liver Diseases and Transplantation

• Nephrology

• Hematology

• Surgery, Surgical Oncology

• Director, Epic Applications

• Director, Infection Control

• Other specialists as needed

Co-Chairs

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of the tests in our test menu were Tier 2 or 3

27%

20% Reduction in ordering

High-Cost, Low-Volume Tests

Obsolete

= $1.5 M cost savings/year

Tier 3

Tier 2

Potential Savings

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Road Map

utilization management

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Implementation

Engage IT early and often

Sometimes it’s better to ask for forgiveness than permission

Physician education yields mixed results

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hard to order the wrong ones

Make it easy to order the right tests and

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Options Considered with Vitamin D

Change the display name

for "1,25 DIHY VITAMIN D” so it does not appear at the top of a

search list.

Remove "VITAMIN D, 1,25 DIHY"

from all preference lists, except for specialists.

Limit ordering

"VITAMIN D, 1,25 DIHY” to endocrinologists.

Program a pop-up

alert

for “VITAMIN D, 1,25 DIHY” -- "Not for routine assessment of Vitamin D

status--choose VITAMIN D, 25-HYDROXY instead”.

Remove "VITAMIN D, 1,25 DIHY”

from CPOE and require a paper or telephone order only.

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After discussing with our Endocrinologists, the Formulary committee chose to:

What We Chose…

Rename the tests

Vitamin D 25-OH (Vitamin D deficiency test)

Vitamin D 1, 25 dihydroxy

(NOT for deficiency screening)

Implement duplicate checking

for less than 2 months

Changes in CPOE made on June 17, 2014

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Reflex testing Algorithms

Other Strategies Considered and Used

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Experts

Evidence-based recommendations

Look-back for duplication

Panels Preference lists

Display Test Costs ($-$$$$)

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Testing for Celiac Disease Managed before the Lab Utilization Committee was set up

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Reduction In Costs

• Without the algorithm

Average cost per patient $266.51

• With the algorithm

Average cost per patient $18.74

Annual Cost Savings in 2014

$1.5 Million

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Some Lessons Learned

Pick tests that make most

sense

Make decisions at the formulary

level

Use CPOE as much as possible

Be aware of pop-up fatigue

Duplicate checking has a

limited look-back

Longer check periods - more time to place an order

Preference lists

oversight into how they are set up and managed

Project Management

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Road Map

utilization management

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Direct Measures Indirect Measures

Measuring Success

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• Reduction in inappropriate analyte/method of testing

• Increase in correct testing • Reduction in duplicate

testing

• Fewer cancelled tests due to QNS

• Greater clinician satisfaction on surveys

• Length of Stay

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Effectiveness of Change in Vitamin D Orders

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Ratio of D 25 to D 1,25 D 1,25 Drop

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Vitamin D tracking

$18,261 in savings*

*based on MCR allowables

Inpatient orders for Vitamin D are less than 10% of our total Vitamin D orders When applied to outpatients across the health system,

projected savings of $700,000/year

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Roadblocks

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Hidden processes that stymie interventions orders linked to medication change orders placed on paper

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When the test is part of a panel, duplicate checking doesn’t work

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Experts come to agreement quickly it’s the non-experts who do not

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Everyone has a day job Data extraction is time consuming and continuous

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It’s about more than cost savings.

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As we make the transition to value-based care, we must experience a behavioral and cultural shift so that we are practicing medicine in a much more thoughtful and efficient way.