October 20, 2017

How Cleveland Clinic, Weill Cornell, and other health systems are improving diagnostic testing

Daily Briefing

    Providers at Cleveland Clinic, Weill Cornell Medicine, and other health systems are increasingly collaborating on ordering and receiving diagnostic tests to make the process more efficient and patient-focused, Geri Aston reports for Hospitals & Health Networks (HH&N).

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    According to Aston, Medicare in January 2019 is expected to start requiring physicians to use qualified clinical decision-support tools when ordering advanced diagnostic imaging services, such as CT scans, MRIs, and MRI scans. Currently, the requirement only applies to certain outpatient scenarios, Aston reports.

    In response, several health systems have adopted new approaches to ordering advanced diagnostic scans to better prepare physicians for the changes.  

    Weill Cornell's approach

    For instance, Weill Cornell Medicine is implementing appropriateness criteria and decision support for certain advanced scans, Aston reports.

    Specifically, the hospital is using a decision-support tool that mines EHR data to see if a physician's order meets appropriateness criteria. If the order meets the criteria, it goes through automatically. If not, the ordering physician receives a pop-up notification about the issue—however, the system does not include a hard stop on the ordering process; rather, it aims to encourage ordering physicians and radiologist to discuss why the scan is needed. As Geraldine McGinty, a radiologist at Weill Cornell and vice chair of the American College of Radiology board of chancellors, put it, "We're not trying to second-guess our colleagues."

    Cleveland Clinic's approach

    Meanwhile, Cleveland Clinic earlier this year revamped a long-standing panel committed to fostering efficient and effective diagnostic testing. The panel, formerly called the Test Utilization Committee, was initially comprised of pathologists and lab medicine professionals, Aston reports. Now, half of the renamed Enterprise Laboratory Stewardship Committee are clinicians, including specialists, nurses, and PAs.

    As committee co-chair Anita Reddy explained, "We felt it was important to incorporate clinicians as a part of this process to get their insights from the bedside and learn how they care for patients."

    According to Aston, the committee has launched several initiatives to foster appropriate test ordering. For instance, a project launched in August aims to address high-volume daily labs, such as blood counts. As part of the project, Cleveland Clinic's EHR instructs doctors to select one of three options when ordering a lab: perform test once during the patient's stay, perform tests daily for three days, or perform tests every other day.

    If physicians think the patient needs labs for more than three days, they can submit the request; however, they will get an alert to confirm the necessity of doing so, according to Reddy. The EHR also includes exceptions for patients who may automatically require daily labs, such as those receiving chemotherapy.

    The committee is also working on an initiative in which an expert reviews any orders for tests that cost more than $500 to determine whether the test is necessary, whether a less costly test could provide the same data, and whether the test must be done in an inpatient setting versus an outpatient setting. According to Reddy, another project aims to assess whether new tests should be included in the Clinic's lab formulary.

    According to the committee's 2016 annual report, the committee's current and prior initiatives—such as hard stop on same-day duplicate test orders for tests that not be performed more than once a day—have since 2011 prevented 78,555 tests, saving an estimated $4.2 million.

    University of Oklahoma Health Sciences Center's approach

    Meanwhile, the University of Oklahoma (OU) Health Sciences Center has—under the leadership of Yaolin Zhou, director of molecular pathology—streamlined the test process for patients suspected of having chronic myeloid leukemia.

    Previously, ordering physicians had to pick from several, potentially confusing test options, with some providers opting to order all of them to be safe and others selecting the test they were most familiar with—even if it wasn't the best option for the patient. Now, every eligible patient is tested to identify whether there's been a genetic change and the particular gene arrangement. Depending on the results, the lab will automatically conduct a follow-up test to inform treatment options. 

    Zhou has also sought to improve care for patients with different types of tumors. For instance, the center changed how it orders BRAF mutation tests for patients with metastatic melanoma so that instead of pathologists waiting on oncologists to submit the request, the pathologists will automatically order the test as soon as metastatic melanoma is found. The process decreases turnaround time on spotting the BRAF mutation, which enables clinicians to begin life-saving treatment that targets the BRAF protein specifically.

    Zhou also conducts presentations on appropriate ordering using recommendations from Choosing Wisely, an American Board of Internal Medicine Foundation-sponsored initiative aimed at encouraging appropriate testing, as well as other materials. "I decided to talk about this from different angles with different individuals, and maybe I'll slowly but surely be able to make some type of impact," Zhou said (Aston, Hospitals & Health Networks, 10/10).

    Join us next week: How to achieve quality in diagnostic imaging

    To prove their value in today’s competitive environment, imaging programs and radiology groups must move beyond productivity metrics and differentiate on quality.

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