A Focus on Effective Test Utilization to Demonstrate Lab Value in the New Healthcare Model

Transcription

1 A Focus on Effective Test Utilization to Demonstrate Lab Value in the New Healthcare Model Kim Futrell, MT (ASCP) Products Marketing Manager Orchard Software Corporation Page 1

2 Objectives Understand the changing terrain of healthcare and the lab s role in the future of healthcare Learn why proper test utilization is becoming more important as our healthcare system changes. Review how and why tests are misordered. Discuss the important role laboratorians play in better test utilization. Explore other ideas for labs to contribute to better patient outcomes. Page 2

3 Audience Survey Page 3

4 Our Changing Healthcare Environment Page 4

5 Healthcare Reform PPACA PCMHs, ACOs Bundled payment plans MU PAMA Healthcare touches all of us. Work together to make improvements. Where can the lab make positive contributions? Page 5

6 Healthcare Costs at Nearly 18% of GDP Page 6

7 Shift from Volume to Value Triple Aim Goals Improve Patient Experience Improve Population Health Decrease Costs Page 7

8 The Lab in the New Healthcare Model Healthcare is in the midst of unprecedented change. Labs will no longer be reimbursed for each test performed. Currently in a transition between FFS and valuebased environment. Page 8

9 Better, Smarter, Healthier Source: HHS.org: US Department of Health & Human Services Page 9

10 Wrongly Aligned Incentives FFS model Creates an incentive to order more tests and more treatment. Payment is dependent on the quantity of care, rather than the quality of care. Does not support alignment of financial incentives between providers. Page 10

11 Lab s Evolution in Healthcare Expand your reach. Increase clinical effectiveness. Contribute to positive patient outcomes. Integrate and collaborate with other departments. Page 11

12 Expand the Lab s Reach Improve Testing Methodologies: MALDI TOF Radiology: POC creatinine for patients with contrast studies Pharmacy: Antibiotic stewardship - Dr. Brad Brimhall, University of Mississippi Medical Center Page 12

13 Support of rapid, accurate diagnosis Maximum efficiency Eliminate waste One of the most effective ways to do this is by monitoring laboratory test utilization. Lab s Future Role: Greater Impact on Patient Care Page 13

14 Overriding Goal Accurate Right Test Results Right Cost Cognizant Patient Test Utilization Right Time Plan Page 14

15 Test Utilization: How and Why Lab Tests are Misordered Page 15

16 Room for Improvement Laboratory testing is healthcare s highest volume activity billion tests/year Increasing awareness: Errors in lab test selection and interpretation can have significant consequences. Page 16

17 How Providers Use Lab Tests 70-80% of clinical data in the EHR comes from the lab. Data used for: Screening Diagnosis Disease monitoring Two-thirds of results contribute to a change in diagnosis, therapy, prognosis, or understanding of a disease. - Wertman, Bradley G. MD., et. al. Why Do Physicians Order Laboratory Tests? A Study of Laboratory Test Request and Use Patterns. JAMA. 1980; 243(20): Page 17

18 Overuse, Underuse, & Misuse Nearly one-third of all lab testing is unnecessary. Approximately, the same number of tests that could potentially be useful are not ordered. Source: Beth Israel Deaconess Medical Center Labs may not be promptly reviewed or not communicated to the patient. Page 18

19 Costs of Lab Testing Lab portion of healthcare spending is approximately 3%. In overall costs, ordering a few more or less does not make a big difference. However, what happens to the patient downstream based on those results can be expensive (imaging, surgery, hospital stays, etc.). Page 19

20 The Big Take Home It s not about ordering more or less tests. It s about ordering the right tests. And in this area there is much room for improvement. And the lab can help! Page 20

21 Why Lab Tests are Misordered That s the way it s always been done. Pressure from internet-educated patients Page 21

22 Why Lab Tests are Misordered 2 Concern over missing something that can lead to litigation - or patient harm Physicians have been taught to leave no stone unturned. Page 22

23 The presentation of test order options influences order patterns. Providers are moving at a fastpace. Other Influential Factors Page 23

24 The Role of CPOE Confounded by EHR limitations Provide useful information at the time of order Pop-up (e.g., for duplicate tests) Online decision support Page 24

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26 Providers Uncertain CLIHC survey PCPs uncertain about best test order in 14.7% of cases. Uncertain about interpretation in 8.3% of cases. What this means Approximately 23 million times/year, PCPs are uncertain about the best use of diagnostic tests. Page 26

27 Overutilization $750 billion spent in U.S. on unnecessary healthcare services IOM Report Costly tests are easy to order in the EHR With no indication of costs Or medical evidence to support use Page 27

28 Overutilization 2 Most frequent instance of overuse occurs at the initial patient evaluation. Beth Israel Deaconess Medical Center Study Hospital settings often have inpatient SO: convenient but wasteful Large majority of tests being ordered have no impact on patient care Univ. of CA, SF Medical Center Study Page 28

29 Underutilization/ Preventive Testing >70% Increased of Medicare Lab Testing $$ are is spent a vital on only 14% component of patients of early who have chronic 6 or disease more that chronic can save conditions. $$. Page 29

30 Underutilization Example MC Consider beneficiaries the with Hgb diabetes A1c account for 32% of MC spending. costs about $13 Source: Congressional Diabetes Caucus Page 30

31 Doctors Don t Turn to the Lab for Guidance Providers are aware of deficiencies in test utilization. Yet when searching for guidance, the last place they turn is to the lab. Page 31

32 CLIHC Survey Results % of physicians: it is useful to ask the lab for test 35% interpretation guidance % of physicians that were actually able to ask a 6% lab leader for advice Page 32

33 Test Utilization: Where to Start Page 33

34 Questions to ask Are you aware of unnecessary test requests or know of test utilization areas that can be improved upon? Do you have an LIS capable of providing the necessary tools to promote proper test utilization? What test utilization data are you able to collect? Is that data in a structured, useable format? Page 34

35 Questions to ask 2 Do you have provider support? At the time of the order, does the provider have algorithms and guidelines to use? Does your CPOE process include appropriate pop-up alerts, such as duplicate testing notification? Page 35

36 More Questions Have you unbundled tests to provide the flexibility necessary for an effective test utilization strategy? Do you review requisitions/orders and standing orders, looking for redundancy and testing frequency? Do you have an annual review process for test volumes comparing year-to-year volume shifts? Page 36

37 More Questions 2 Do you have a test formulary or review process for sendout testing, keeping an eye on expensive, esoteric tests? Do you have a hold process to ensure proper specimen storage until an initial test is completed and a subsequent utilization decision is made? Page 37

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39 Internal Variation Analysis Examine your provider ordering patterns. Focus on a specific diagnosis. Compare the amount of variation to costs and patient outcomes. Share this data with providers. Find a physician champion who is willing to be involved. Use this data to develop best practice ordering guidelines. Page 39

40 Source: Crystal Run Healthcare Page 40

41 Think Outside of the Black Box CLIHC Physician survey When consulting with radiology or pharmacy, they felt they were consulting with a colleague. When consulting with the laboratory, they felt they were talking to a black box. Using a test utilization plan can improve the laboratory s input into patient care. Page 41

42 Provider collaboration is a must. Create opportunities for an ongoing dialogue. Physicians respond to data. Provide Data & Dialogue Page 42

43 Testing Formularies Management of a test menu Page 43

44 Duplicate Testing Alerts Implement a duplicate testing alert in the EHR at the point of CPOE. Savings at Univ. of Mississippi Medical Center By monitoring 2 tests (CBC, BMP) Same tests ordered within a 4 hr period Saved $146,675 annualized Page 44

45 Johns Hopkins Bayview Reduces Overuse of Cardiac Tests Grant from ABIM Foundation Project reduced lab tests used to assess acute coronary syndrome Use Troponin alone and no more than three times. More than $1 million saved - LaRochelle, et.al. Journal of Internal Medicine, June 2014 Page 45

46 Unnecessary Testing Groups Determine (with your providers) scenarios where it does not make clinical sense to order certain test combinations. Do not need a test until you know results of another Another test has greater diagnostic accuracy Testing only recommended for specific diagnoses Page 46

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49 Testing Algorithms Provider orders the cascade, rather than each test. Based on initial results auto-reflexes to the next logical test. Develop in tandem with ordering providers. Page 49

50 Benefits of Testing Algorithms Eliminates the need for providers to choose from an overwhelming test menu. Ensures that only necessary tests are ordered. Getting the right test done at the right time improves patient care and reduces unnecessary spending. Page 50

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52 Track test utilization/ variation analysis Configure algorithms Provide data analytics for providers & managers Powerful LIS = Crucial Tool Page 52

53 Opportunity to Make a Difference Disruption in healthcare Opportunity for laboratory leaders to refocus efforts Align goals with overriding healthcare reform goals Thrive in a value-based reimbursement model Alleviate downstream costs Page 53

54 New Paradigm Make the most of limited resources Each member of the healthcare team s input to the top of their skill/ education level Lab professionals Page 54

55 Seek out Opportunity 1. Get to know those in your organization who have access to financial data, particularly net revenue and cost accounting figures. 2. Integrate information you have in the laboratory with information obtained from colleagues in other departments. Page 55

56 White Papers to Help Download at Page 56

57 2015 Orchard User Group & Symposium June 17 th & 18th Caribe Royale in Orlando, FL Page 57

58 Old Paradigm to New Provide utilization management, Providing clinical high-quality, effectiveness, cost-effective and data integration results - Curtis A. Hanson, MD, Mayo Clinic Page 58

59 It Won t Be Easy Page 59

60 Final Words of Wisdom Because laboratory tests play such a crucial and ubiquitous role in medicine, efforts to identify opportunities for improvement in the selection of tests have the potential to contribute greatly to the care patients receive. - William Taylor, MD, BIDMC Page 60

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62 Thank You Questions?