Cleveland Clinic Leader Paves the Way for Reducing Tests,
Improving Patient Care
(FULL VERSION)

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A 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.

 

Question:  What are some ways in which pathologists and lab professionals can encourage

      laboratories to promote the Choosing Wisely campaign in their hospitals, practices, or

      labs?

 

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.

           

Q:   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.”

 

Q: 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 Committee.

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 changing

      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 costs. 

 

 To learn more about the work of the Cleveland Clinic’s Test Utilization Committee, click here.


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