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