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longtime proponent of reducing tests and improving patient care, Gary W. Procop,
MD, MS, FASCP, is an expert panelist for the ASCP 2013 Chicago general
session on the Choosing Wisely campaign. He shares his perspectives on
how laboratories can lead their organizations in promoting appropriate test
utilization. As Chair of Molecular Pathology at the Cleveland Clinic, Dr. Procop
led the Clinic’s highly successful review process of duplicative testing, which
has become a model for the health systems across the country. A link to the
Cleveland Clinic’s Test Utilization Committee Final Report is below.
What are some ways in which pathologists and lab professionals can encourage
laboratories to promote the Choosing Wisely campaign in their
hospitals, practices, or
A: The first step
is awareness. Pathologists and laboratory professionals need to engage the
medical leadership in their institutions. Hospital administrators, the chief
medical and surgical operations officers, and department chairs are usually
interested in evaluating best practices, particularly when they also involve
cost-savings measures. These individuals are important allies for the
system-wide implementation of test utilization initiatives. If a robust Test
Utilization Committee does not exist at your institution, sharing the
Choosing Wisely campaign to the medical leadership at your institution would
be a great way to introduce the concept of test utilization, and perhaps to
start a local committee. If a robust test utilization committee does not exist
at your institution, then a thorough review of the local utilization of the
tests listed in the Choosing Wisely campaign would be worthwhile,
particularly since these have obtained such a high-level of consensus.
Q: What are a few of the key messages you will share at ASCP 2013 Chicago on
the topic of appropriate test utilization?
A: The first
message I would like to convey is that implementing best practices for test
utilization is a team effort. It is important to not dictate to clinicians, even
if you are correct. It is important to utilize competency skills in the realm
of communication and professionalism to work within a team structure toward
implementing best practices for patient care. In many instances, the path toward
best practice implementation includes some kind of compromise.
As Chair of the Cleveland Clinic’s Test Utilization
Committee, which focused on reducing
duplication test ordering, you led the Committee in developing a successful
test utilization initiative. What strategies were used to achieve this?
A: The team
should include laboratory professionals, one of which I would recommend Chair
the committee. I recommend having an open committee with broad representation
from many clinical services.
It is important that the
committee has support from hospital management and medical leadership. The
impending actions of the test utilization committee should be communicated with
the medical staff, and, whenever possible, feedback should be sought. This
approach is important to gain and retain the confidence of the medical staff and
to decrease-to-eliminate a negative backlash from this group. In addition, the
feedback may prove useful to modify the effort and improve the ultimate outcome.
Whenever new processes are implemented, there is a possibility that changes will
not go as planned. It is important to consider these possibilities and to
formulate contingency plans.
The vast majority of the
interventions that we have undertaken have in some way involved the computerized
physician-order entry (CPOE) system. As the mandated implementation of the
electronic medical record proceeds with the need to demonstrate meaningful use,
there will be great opportunities for us to help guide testing and implement
best practices. The implementation of CPOE affords the opportunity for the
laboratories to interact with the physician at the time of order entry, rather
than after the specimen is collected and sent to the laboratory. This is the
ideal time to guide testing based on evidence-based best practices.
Q: As part of this initiative, what does the Cleveland Clinic’s test-ordering
process look like?
A: The Cleveland Clinic invested early in a complete electronic medical record for the Cleveland Clinic
Health System (CCHS). This system includes computerized physician order entry (CPOE),
so the physicians enter the test orders directly into the system. This type of
an entry system allows physicians to create order sets for commonly
disorders encountered in there practice. It also allows for laboratory
professionals to review ordering patterns throughout the healthcare system.
These types of reviews often disclose variability in ordering patterns. These
discoveries are the first step in beginning conversations concerning optimal
test utilization. Electronic interventions linked with CPOE affords an
opportunity to notify and even block duplicate orders; to restrict orders, such
as expensive molecular genetic tests, to certain groups; and, to provide testing
ordering guidance. One of the comments we have received from a physician
concerning the Smart Alert, which we implemented in the regional
hospitals of the CCHS to avert duplicate test orders, was, “Finally, the
computer is working for me.”
What were the lessons learned from this process and
what are the next steps?
A: Many lessons
have been learned on our journey in improving test utilization. Usually, when
one considers “Lessons Learned,” they usually mean, “What did we do wrong?”
whereas, it is just as important to share what we did right.
A. What we did right?
1. We have remained focused
on improving patient care and best practices, rather than on cost.
2. The Test Utilization
Committee is an open committee and all interested in determining and promoting
best practices are welcome. We communicated with all Institute and Department
Chairs and invited them to send representatives to the Test Utilization
3. We made strong allies in
Medical Operations and the Medical Informatics group.
4. Our colleagues in Medical
Informatics were able to rapidly address issues that arose that were not
anticipated and could quickly remove items from the intervention list, if
needed. This demonstrated our responsiveness to the medical staff and helped
retain their support.
5. We have sought input
and/or approval from the medical staff prior to interventions, and communicated
the “whats” and “whys” associated with each intervention.
6. Restricting molecular
genetics tests to physicians who routinely use these in their practice.
7. To employ a genetics
counselor to work with the molecular genetic pathologist to review send-out
genetic test requests, and consult with physicians to guide testing.
8. We have consistently
shared successes with all involved.
B. What we did wrong?
1. We largely report our
successes in terms of cost, since financial data is easy to obtain and is not
complicated. Outcome data, length of stay data, and patient satisfaction data
would be useful to obtain; this data, however, is complicated by many variables
and it is more difficult to determine the impact of a single test utilization
initiative and the associated outcome.
2. We initially did not have
a project manager assigned to the Test Utilization Committee initiatives, which
limited the agreement of project priorities among groups and the pace at which
interventions could be made.
Q: Do you think laboratories fully realize the critical role they have in our
healthcare environment? If not, how can laboratories improve?
A: I do not believe
laboratories fully realize their critical role in the changing healthcare
environment. Laboratory professionals often are the most knowledgeable
individuals in the institution concerning tests in their areas of expertise and
oversight. The challenge is for our groups to get out from behind the microscope
and out of the sub-basement, and exercise their communication and interpersonal
skills muscles, and interact with hospital leaders. Approaching poor test
utilization with the attitude of “how can they be so stupid?” while the
laboratory professional shows them the errors of their ways will never work. A
professional approach that seeks dialog and agreement on a best practice
approach for optimal patient care should be used. It is important to remember
that this is not about “getting your way,” even if your way is correct.
Compromises need to be considered, unless patient care and safety is at risk,
which can never be compromised.
The opportunities for
laboratory professionals to be at the hospital leadership table will increase as
healthcare reform initiatives increase and reimbursement substantially
decreases. It is an unfortunate truth that finances are important drivers in
healthcare. It is important to recognize these challenges of decreasing
reimbursement as opportunities to decrease wasteful testing practices that
negatively impact patient satisfaction, and possibly outcomes, as well as
learn more about the work of the Cleveland Clinic’s Test Utilization Committee,