Transcript: Laboratory Stewardship

Transcript

Triona Henderson: OK. Good afternoon, everyone. My name is Triona Henderson, and I'm a clinical pathologist and the facilitator of this ECHO Model™ pilot project. I extend the warm welcome to you from the Division of Laboratory Systems at the Centers for Disease Control and Prevention in Atlanta, Georgia. Thank you for joining us. The topic for this interactive web discussion today is laboratory stewardship, and our subject matter expert is Dr. Heather Signorelli, who will present today's topic. Dr. Signorelli is a pathologist and currently the vice president and chief laboratory officer at HCA HealthCare in Denver, Colorado.

Here is some technical information for these sessions. Before introductions and the presentation, I'm going to highlight some technical details to our ECHO sessions. If possible, use your video. As you can see, some of us have spiced it up with backgrounds. It's very helpful to put a name to the face, and it will enhance the interactivity of this session. All your microphones are currently muted. During the discussion, please unmute yourself to speak. If you are connecting by phone line only, please announce yourself by name and organization when beginning to speak.

If you're experiencing technical difficulties during the session, please send a private message to Johanzynn Gatewood labeled as DLS ECHO Tech. She will do her best to respond to your issue. And finally. We design relevant sessions based on your evaluation responses. We would like to encourage everyone to continue completing the post-session evaluation. For those who require them, P.A.C.E.® credits are being offered for this session. At the end of completing this evaluation, you will receive either a certificate of completion or a P.A.C.E.® certificate. If you have additional questions or comments, please send a private chat message to Johanzynn or email directly to DLS ECHO. That's DLSECHO@CDC.gov.

How are these ECHO sessions different from your regular teleconferences? So these are actually discussions of cases of a clinical laboratory challenge or issue as the main feature. The subject matter expert hopes to share some of their work that may be translatable to all of you in your individual laboratories. These ECHO sessions will focus exclusively on clinical laboratories in the United States and US territories. Once again, we value the discussion amongst all of you that will ensue and want to encourage you to share your own experiences and challenges on this topic. We thank you for your interest and participation.

Here's a brief overview of the process. There will be a case presentation by the subject matter expert. I will ask clarifying questions to the subject matter expert, then we'll open up for ideas, and shared experiences, and comments from the subject matter expert. We'll have closing comments, reminders, and then we'll adjourn. Today's session is being recorded. If you do not wish to be recorded, please disconnect now. Closed captioning will also be provided, and you can find that link in the Zoom chatbox. The audio and transcript will be shared on our ECHO website after the session. We will also send the slides from the presentation via email to registered participants after the session.

Dr. Heather Signorelli graduated from The Medical School of Touro in the University of California, and then went on to complete residency in Anatomic and Clinical Pathology at the University of Colorado. Dr. Signorelli did a fellowship in Clinical Chemistry at ARUP at the University of Utah. She is board certified in Anatomic Pathology, Clinical Pathology, and Chemical Pathology. Currently, she is the vice president and chief laboratory officer for HCA, responsible for developing and overseeing the laboratories stewardship program for the entire HCA enterprise.

Now, we'll invite Dr. Signorelli to begin her presentation. Please be thinking about similar situations that you've encountered at your institution and how you might apply what Dr. Signorelli presents at your own institutions. We hope for a robust discussion. Please offer your questions and feedback during the discussion period. Thank you, Dr. Signorelli. You may go ahead.

We can't hear you.

Heather Signorelli: There we go. Can you hear me now?

Triona Henderson: Yes.

Heather Signorelli: Yes, thank you so much. I appreciate everybody being on today. I'm excited to share something that's not only really important for our health care system but something I'm extremely passionate about.

There we go. So first, I really like to share a case presentation of something that is a great example of how laboratory stewardship can begin. Something that I think is a really good starting point if you want to look at laboratory stewardship for your health care system or your hospital. And then I'll spend some time going a little bit over why do we do laboratory stewardship, how can you structure that committee, work within a hospital or a network of hospitals? Why is it important to set up a laboratory stewardship program? And then really some of the goals overarching that is important to think about as we move this forward.

So first, I'd like to talk a little bit about CK-MB. So as you guys know, this is a marker that was previously used to diagnose heart attacks or acute myocardial infarction. Within the HCA system as of two years ago, we actually had not done anything from a utilization standpoint when it came to CK-MB. Even though there was the Choosing Wisely and American College of Cardiology recommendations that really said that CK-MB was an old diagnostic tool that had largely been replaced by troponin. So in 2018, across our hospital system, which we have 186 hospitals across HCA, we saw over 800,000 tests. So huge opportunity for us to really understand why do we continue to have that type of utilization and what can we do to improve it.

So what did we do? So we first set up laboratory stewardship committees. That was across our entire company. So like I mentioned, HCA is a network of hospitals, 186 hospitals, those are broken down into 15 divisions, which are then further broken down into markets which contain typically six to nine hospitals, and then the facilities are part of that. So the facilities are part of the market, are part of the division, are part of the enterprise. So hopefully, that gives you some background as to how HCA is structured.

So we developed our laboratory stewardship committees, which I'll go into more detail later on in the talk, but what we did is we looked across our company, and we said, OK, let's work to get medical staff buy-in so that we can remove this test from our test menu, and really either limited it completely or allow it in very rare circumstances. So as you can see from the graph here, this shows test volume on the left, by month on the bottom. And so this is a view of July of 2017 through March of 2020. We were doing by month over 70,000 tests. Again, we have a lot of hospitals, but also a lot of tests for CK-MB being performed. As of March 2020, we had under 5,000 tests per month. So still some utilization and potentially some opportunity, but a huge improvement with a 94% decrease.

So why is it important to do laboratory stewardship? And you know, when we began this journey, we really wanted to think, what does the lab offer with regards to patient care and to our hospitals? And so as many of us laboratorians on the phone today, we know that a laboratory is an essential part of how we diagnose, how we treat, how we manage our patients. There are billions of tests that are performed every single year. And within the HCA system, in 2018, we were doing roughly 80 million tests per year, climbing at 5% to 10% per year.

So we all know that tests drive the majority of the medical decisions we make, and actually, in 2019, the ECRI Institute named this as one of the number one patient safety concerns. So diagnostic errors and improper test management is a key focus, not only for our health care system but for many others as well. While the laboratory spend is only a fraction of total health care costs, it's still a lot of money. And at the end of the day, we want to make sure that those resources are used to improve patient care and change the lives of those that we treat in our hospital.

Laboratory stewardship is not new. We certainly are not the first to do it. I would actually say that Mayo Clinic, Mass Gen, Cleveland Clinic were really the first pioneers with regards to laboratory stewardship. HCA started its journey with lab stewardship in one of our divisions out of the Denver area in 2016.

So why are labs misordering? And I think those of us on the phone have seen the exponential growth of laboratory test options for our physicians. So there are over 3,500 general tests available. And when I go out and actually do similar talks to practicing physicians, I like to probe them. I like to ask, OK, so there's 3,500 general lab tests that are available. How many are you comfortable with? And oftentimes, the answer I get is around 30 or 50 different tests that they are comfortable ordering, comfortable interpreting. And so with this growth in test menu, I think we all recognize that it's the time to partner together so that we can provide better care for our patients.

In addition, there's over 75,000 different orderable genetic tests, and that is rapidly growing at ten new tests per day. So we recognize that it's even more important to partner together and understand what these tests mean and how we should be ordering them. Many of us recognize that in medical school, we are oftentimes getting less and less training when it comes to laboratory medicine. We also see huge bundles of tests when it's in a single panel, so the physician can check one box, and next thing you know, they've got 20 different tests to interpret.

There's also a lot of pressure from patients, whether it be in the inpatient setting or the outpatient setting, to order all kinds of different tests whether or not they impact their care or not. And I think that that's an important piece that we should be educating our patients to as well. There's also the mantra that that's just the way it's always been done. And unfortunately, especially with physicians who've been in practice for a long time, there may be old habits or habits that used to mean a lot clinically now that don't provide as much clinical value. And so partnering with them to understand why they find value in certain tests was critically important for CK-MB. We certainly had a group of cardiologists really in pockets across the United States that really relied on that, and it's showing them the data, showing them the evidence, showing them the outcome data that the quality of care of patients isn't impacted by moving to a component only assay.

So how does laboratory stewardship impact our patients? And I think that was important because it not only impacts our patients in terms of unnecessary blood draws, which can lead to iatrogenic anemia. When patients are in the ICU, 70 to 80 milliliters of blood are drawn per day from the patient. So as much as we can to make sure that every single one of those tests is critically important, it's going to be key to making sure that the blood that we are drawing from them is absolutely necessary.

In addition, all of us on the phone know, as clinical pathologists know, there are oftentimes misleading results. So if we understand how a reference interval is determined with the 95% range, we know that 5% of abnormal results can be seen in an absolutely clinically normal patient. And so it's important to understand that when physicians order a huge battery of tests if one comes back slightly abnormal, it may not mean that the patient is clinically suffering from a disease. And so even more important that every time we order a test, we know what we plan to do with a result. In addition, there's numerous literature articles that show up to 30% of laboratory tests are actually unnecessary, and that laboratory tests could cost the hospital around $2 million a year that would not be necessary or contributing to patient care.

So again, like I mentioned, certainly laboratory stewardship is nothing new. It's following the pattern of success from numerous other institutions and organizations. Antimicrobial stewardship is something that we all recognize as an important piece. I hope one day that laboratory stewardship becomes a need for every single one of our hospitals, much like antimicrobial stewardship is. There are numerous formularies that have been developed within the pharmacy world, and I'll share a little bit about how that applies to the laboratory world. In addition, blood utilization, we've all focused on blood utilization for many years now. And of course, the Choosing Wisely campaign which started in 2012. It's really the guiding force in much how we set up our laboratory stewardship programs and the targets we decided to go after in the beginning.

So, what are our goals? What are our missions? So, across HCA, really, our mission with laboratory stewardship was, of course, to decrease the risk to our patients, improve how we order, and interpret tests to make sure that those results actually get back to the patients, and they're actually acted on. This was really fascinating to me that to find out that we had so many tests being ordered on the day of discharge that were being sent out to our reference labs, and we really didn't have a great process to make sure that those results got back to our patients, and oftentimes, they weren't even addressed.

In addition, we want to make sure that we're providing cost-effective health care across our entire system, and this is really important for our kids, and our grandkids, and different generations that follow us that we are responsible with the resources at hand. Within HCA, we did develop a laboratory service line as of January 2019 which is really a group effort both at the corporate and division level to ensure that we are driving best practices within HCA Healthcare so that we continue to provide the highest quality of patient care and safety that we can.

So, what does that committee look like? How does our structure look like? And I think this is important to have those of you on the phone contemplate. Gosh, how could I do this for my hospital? How could I set this up? So, we are fortunate with a large organization, so we do have that corporate committee, again, that division structure, and then we have the facilities that are part of that division.

So, what you're looking at on the screen right now is really our corporate structure. So, we have different buckets of work going on in order to contribute and support the facility level. So, of course, we have our clinical committees, so that's what I oversee. It's laboratory stewardship, it's how can we make sure we're selecting the right tests and using them in the right cases. Of course, there's data. You can't really do laboratory stewardship without some sort of data support.

And then we have our operational committee, which is really looking at how can we standardize equipment? How can we share testing where it makes sense? And then, of course, contract. It's important to make sure that when you're out there looking for services that as much as possible, you're having a standardized approach to who you contract so that can actually benefit the health care system and make it easier to negotiate and get faster turnaround times and of course, the better deals on the services you do need.

And then next, before I go to the next slide, I'll talk a little bit about the division structure. So, within each of our divisions, we built laboratory stewardship committees. So, these were often structured so that we had one or two physician leaders, we have laboratory directors, we have pathologists that really sit on that committee. But just as important, we had different medical subspecialists who represented the medical staff. So we had OB, we had surgery, we have ER, we have a subspecialty oncologist, hematologist, and so forth. So the list goes on and on. I think we have 12 to 15 subspecialists that are recommended to sit on these committees, and they may not go to every meeting, but certainly their input on, hey, do you use this test? How does this test change management? Is this still felt to be value? Is a really important part of this.

And so even if you had only one hospital and you didn't need this corporate structure, you would need that structure of a stewardship committee. So this is medical staff, this is pathology, this is laboratory, and oftentimes, administrative support is really important. We're lucky within HCA that we have full administrative support to do this, so that helps with physician conversations, that helps support the lab and making sure that we're all aligned on the goals that we want to accomplish. So, I'm certainly able to answer questions more about that at the end but just wanted to get that brief overview.

So, what were our first goals? So, like I said, 2019 January, we started this lab service line. We asked all of the divisions across all of our company to set up those lab stewardship committees. And then we had to think, OK, now what are we going to go after first? And so first we went after obsolete and limited use tests. So, what I mean by this? That's like that CK-MB test. These are your classic Choosing Wisely targets, which are really good for foundational work.

So as you can see here, I've listed the goals. The quality is really a score of how does that impact quality of care? Does it impact the safety of care next? And then does it provide any efficiency balances within the hospital? So that was our first number one goal. Then we looked at ER send out. So how often are we sending out tests to our reference labs in a patient who's in the ER getting discharged from the ER, which really is a concern, because again, those results are oftentimes not getting back to those patients. And then, of course, looking at genetic testing and how can we partner with our physicians to make sure we're ordering those at the right time at the right place. Looking at our C. diff testing practices as well as urine culture reflexes.

So last, we went over send out tests. So, these are types of tests that, again, are sent out to the reference lab, then we set up a laboratory formulary. So, this is a way that we can manage our send out testing, and it's something that is actively part of what we're working on now. And it is certainly a slow and steady, we certainly didn't just publish out the lab formulary for every send out test we have, I wish. But it's been a slow progress, so I'll start actually from the bottom here. So, I'm going to talk about the five different formulary types, and some examples are on the right-hand side.

So, at the bottom, you see non-formulary. So these are tests that are outdated, we shouldn't be using, they've been replaced by other tests, and we've just said are not formulary. So that can't be done in a hospital. We aren't offering them on our outpatients. It's really education to say there's a better test, and we can do better for our patients. The next category up is called the review category. So, this is a category where pathologists and/or genetic counselors really partner together to say gosh, is that the right test at this time for this patient, and could we do better, or is there a better time that we should be doing that test?

Next is the restricted tests, so these are tests that really have no place in the hospital. They don't change inpatient care. It's really something that's better served on the outpatient side where we can manage those results. They often are results that take a time to come back, and so we really suggest that that be done on the outpatient side. Next are tests that are in the limited category, and these are really specialized tests that should be ordered by certain subspecialists. And this is a group of tests that we have recommendations on right now but have not really implemented within HCA just because of the time it takes, so we're kind of starting at the bottom and moving our way up.

And last but not least is unrestricted where the majority of our tests fall, and these can be either in-house tests or send out tests that would have zero restrictions because they're important. And we are working on duplicate rules, so these are rules where we can tell the provider, hey, that was just ordered, are you sure you want to have that? Which is going to be something that we tackle in 2021.

So I'll say a few things about genetic and molecular testing, and then we can open it up to questions. So this is a big part of an important focus for us because we recognize that genetic tests, 30% of which are ordered inappropriately. And actually what the scariest thought was 7% of these test results are actually never retrieved or acted on. We saw a huge variation in how one test could cost a certain price at one hospital, and a hospital down the street had a very different cost to it. And so it's important for the exact same test that we work with our contracted vendors to say, hey, that should be one price, and so that was part of this exercise.

In addition, we started building a team of genetic counselors that we can work with to help roll out appropriate testing recommendations in the pediatric population. So again, our goals here were to help make sure that we weren't ordering the wrong test, that we were retrieving on the tests that we had, and we weren't misinterpreting any test. So we did set up and are in the process of setting up a pathology review process, which was modeled after Seattle Children's, where a test result– or excuse me– a test request comes in. We have a team of individuals who help identify who should be reviewing that test. There's discussion with the ordering provider, and then either the test is approved, or it's modified, or it's canceled. And again, we track those in order to help support the teams that are doing that.

I want to caution that this was done with CMO support. It's certainly not meant to say that a pathologist or a genetic counselor is out there on their own to fight the good fight. We wanted to make sure that our CMO who really can help have the conversations went ahead of time that hey, we're implementing this. This is what this means. We want to serve our patients well, and that's certainly the intent of this. And that has been extremely helpful, and it's extremely important as you think about rolling this out.

So again, in summary, I started with CK-MB. This was an example of an important initiative that really can help jumpstart any laboratory stewardship program because there's a lot of literature to support it. Choosing Wisely is there. It's something that many physicians agree that this is not a test we should be using. So that can help as a foundational activity through your stewardship programs. Anytime you have a stewardship program, you're going to need to have a stewardship committee to help address evidence-based practices, get medical staff buy-in, and it needs to incorporate many different multiple subspecialists.

Again, our goal is right test right time. We want to decrease the risk to our patients, whether that be blood draws, unnecessary testing, or the outcomes of what that testing may mean for future tests or procedures if that test is interpreted incorrectly. And last, we wanted to build a laboratory formulary similar to the pharmacy formulary, which was supported by guidance documents so that we can improve test ordering interpretation and, of course, monitor that data. And with that, I have my contact at the bottom of the slide. I'm happy to take any emails or share in detail any questions anybody has afterwards. So with that, I'll hand it over and see if there's any other questions.

Triona Henderson: Thank you so much. I think this presentation is just so timely as there changes– despite COVID– there are changes in payments for DRG payments in hospitals, and laboratories and hospital systems really have to look at changing their structures of how test ordering is happening. So I do have a couple of questions– despite my dogs barking in background– so how have you modified and/or have you modified your stewardship setup after the onset of COVID and everything that's going on? Especially you have such a huge hospital system that spans such a large geographic area.

Heather Signorelli: You know, and that brings up such a great point. So, when we first started stewardship in 2019, there were some individuals were like, gosh, is this really something we should be doing? I don't know. And one of the great things is we got it started, we started working hard, and then when COVID hit, we were actually able to leverage these committees and instead of focusing on stewardship, we turned them all into COVID committees. I mean literally, how can we manage test capacity, equipment, who do we need to share testing with?

I mean, we really were able to flip that structure and utilize those teams and are just now– actually starting next week– starting to return back to some other stewardship activities. So, we recognize that life will probably never be quite the same, but we have to pivot into getting back on track with our goals and initiatives. Obviously, COVID is still taking up much of our time, but we are grateful for those teams and all of the work that our laboratories have put in.

Triona Henderson: Perfect. Thank you. Another question, I know you mentioned that you have a lot of non-laboratory non-pathology subspecialists either participating some of the stewardship committees or being part of them. Did you ever experience any pushback from them or concern as to why you wanted to include them?

Heather Signorelli: Yeah, and it's certainly been a journey. I would say in the beginning, you know, the idea of this, and we certainly didn't want to come across like we were telling physicians how to practice medicine, and so we're very sensitive to that topic. And certainly, there was a little push back in the beginning, and every once in a while, we'll have a physician who really wants to express their concerns. And so one of the ways that we oftentimes deal with that is we bring them into the fold. Like OK, so what committee would you like to sit on? How can we have you as part of our team? So that really we can address their concerns.

We've also had, I think one of the things that's been really helpful is while our corporate lab stewardship is obviously led by a pathologist, myself, we have numerous people who sit on both our corporate teams as well as our division teams who either lead the teams or contribute heavily, and they are not biologists. So there's our hospitals, our intensives, our ID docs, you know, other subspecialists that are important on key initiatives so that it's not us telling anyone else how to practice, but it's certain subspecialties providing recommendations to their colleagues and their co-workers. And so that's been extremely important in how we structure ourselves.

Triona Henderson: Perfect. And finally, as this is– we're almost through the halfway mark of the pilot actually, but a common theme or question that we've seen is I can't get my administration on board, or what do I need to do? And you explained how your lab administration and your administration in general is so supportive, and your chief medical officer. What advice would you have for a community clinical laboratory or practice who are kind of halfway down the road but realize that they're not being successful because their admin is not on board?

Heather Signorelli: You know, I think you have to turn on your admin hat for a minute, and whether that's having support with a pathologist or another administrative team, the lab director. Go and meet with either your CMO, or your COO, or your CEO to really give them the numbers. They are a number of people, so show them the misuse. Show them the opportunity. Oftentimes, showing it in a financial way, while that's certainly not meant to be the purpose of this, and it should not be the driving force, it does speak volumes, and there are cost savings.

And in this environment, especially within the COVID era and over the next several years where healthcare is going to change quite a bit, you can show that A, here's the value of this test that it brings to patients, and this is why this is important. Or hey, this is a group of tests that we're just not using correctly, how can we improve patient care with this test? And lastly, a group of tests that just really show hey, we just shouldn't be ordering this at all. Here's the volume of it. Here's your ordering providers. Here's the cost savings. So you kind of have to tackle it from different angles, but I do think it's important that you get a seat at the table, you bring that to your C-suite, and you have to have that conversation so that then they see why you're doing it, and then they can help support you. You have to do that first.

Triona Henderson: Perfect. So now we're going to open up the floor for feedback, for questions or discussion from the group. Please remember to unmute yourself before speaking. If your camera's on or not on, please raise your hand so that we can identify you before speaking. You also have the option to type your question in the chat box. However, we'd love you to use your audio.

JZ, you want to go ahead?

Please remember to unmute yourselves. So if you're speaking, we can't hear you, because nobody has their camera on.

Ren Salerno: This is Ren Salerno at CDC. Can you hear me?

Triona Henderson: Yes, we can.

Heather Signorelli: Hi.

Ren Salerno: First of all, Dr. Signorelli, I thought that was a fabulous presentation, so thanks so much for doing that on a Friday before Memorial Day weekend. I have lots of questions, and I don't want to hog all the time, but really interesting data you showed at the beginning of your presentation about the decline that you were able to manage with the CK-MB test.

Heather Signorelli: Yes.

Ren Salerno: Between July '17 and March of '20. I'm wondering for other tests that you all identified as perhaps over-ordered, were you as successful, or did that happen to be the poster child for a reduction in test orders?

Heather Signorelli: So, I would say we had numerous other tests that had that same level of decline. I would say that they didn't start as high, so the graph doesn't look as pretty, but we got actually lower than 4,000 a month. So some other things that we've tackled, thrombus cilia on the inpatient side, heavy over-ordering for that. Really primarily does not impacting patient management. We're looking at respiratory viral panels; procalcitonin is a favorite. So some we've already accomplished. Certainly, did a great job with the 10 obsolete tests.

You know, there are some there's room for improvement. I think all of us can recognize that, but we've had good success so far in our second year in getting back started again on that now that COVID has ended. And you're certainly welcome to email me any other questions that you have if we don't have time to go over them today.

Ren Salerno: Can I just ask one follow up question? Were you able to also show data to administrators about cost savings associated with those test ordering reductions? And then also, were you able to tie– you know, I liked the way in your presentation you related all this to patient safety and diagnostic error, and I'm wondering whether or not you were able to tie reductions in some of these orders for unnecessary tests to patient outcomes, or patient care, or reduction and diagnostic error in any way?

Heather Signorelli: So two things. So yes, we do focus on tying everything to a cost savings, and so we're also careful to understand that if there was a decrease in CK-MB, was there an increase in troponin? You have to make sure that you're doing your math correctly, right? And then we do that for every single one of our initiatives. We also kind of look at OK, what's the patient care impact supposed to be if we remove this, and then what is the cost savings. So we're kind of juggling both of those at the same time.

I would say that when we removed CK-MB, we didn't do a huge amount of data analysis to see how did that impact patient care. Though with some of our other initiatives, and I would actually say procalcitonin is the one that we're really focused on right now, we are closely looking at how is this impacting care, and we're doing that through identifying de-escalation of antibiotics. So while grander scale analysis of outcomes is a little bit more challenging to do, and we don't quite have the data support to do that as you guys can imagine, we are trying to capture as much as we can with regard to impact to patient care.

Ren Salerno: Great. Thank you.

Triona Henderson: So we have some more questions coming in, and I guess I'll alternate. So we have one typed question. Have you used EMR ordering system and clinical decision support to reduce unnecessary test orders? If so, could you please share some of your experiences?

Heather Signorelli: Yes. Huge. I mean, I have a slide on this, but the presentation was a little short for this, so we use a multitude of ways that we impact our test ordering. So education, of course, clinical decision support within the EMR is critical. Also just removing tests from the test menu works really well. We just take it away, just gone. And so there has been some of those initiatives where you just have to remove it, and you have to get medical staff buy-in and go through the entire process to do that.

But I mean, that is also a way– so with clinical decision support, we have a couple of different ways that we manage that. So we've done C. diff order screens where we're really asking the question to make sure that the patients appropriate to be ordering a C. diff on. We've done that for urine culture reflexes where we're asking them, is the patient symptomatic? And in certain patient populations, we also manage– actually quite a bit of our stewardship activities are managed through clinical decision support. I could probably go on for quite some time now. So yes, that's a huge part.

Triona Henderson: Perfect. I think we have somebody on the line. Brian.

Brian: Yes. Thank you, Trina. I have a question regarding the presentation on CK-MB. Thank you. I really appreciate that presentation. I was in several similar committees. The costs associated with the testing, were you able to attribute overhead, and employee costs, and reagents to demonstrate cost accounting for the test, and did you face any questions from administration on what the actual reimbursement changes would be?

Heather Signorelli: So a couple of things. So for us, costs, we really only focus that on reagents or the direct send out costs of say at a reference lab. We don't input FTE savings in there, because unless we're taking those FTEs away, we've got a lot of push back on including that, so just made it simple. We recognize that there's probably other costs that are associated with taking CK-MB away, but we didn't incorporate that other than just true reagent costs. Obviously if you're taking away a piece of equipment and you're getting those service contracts and so forth, that changes that picture a little bit.

But in general, just taking one test off a platform is really more about the reagents savings. And for CK-MB was nominal. I mean, I'll be honest with you that– I mean, across 186 hospitals actually was a good savings. But in general, when you take in-house testing away, it's not a huge cost thing. This was more of a foundational exercise. So for other tests, that our send outs is a lot easier. It's OK, we pay x amount to the send out lab. We've taken it, we've gone from this number to this number. That's easy to calculate. In terms of, I'm sorry, what was your question? Pushback?

Brian: Oh, the reimbursements. Did the administration have any questions on what the reimbursement changes would be?

Heather Signorelli: So for most of our tests that we've done, it's not going to change our DRG payments, right? So the likelihood of it hitting stop loss where you've gone over the allotted amount for a payment for a specific patient is infrequent. So the fact that a test would determine whether or not you hit stop loss within a DRG payments unlikely.

Brian: Thank you.

Heather Signorelli: I think that the important one– I just need to add– the important part is I think anybody who's sitting at this table and understanding and having this conversation with administration needs to also understand DRG payments, and how we get paid for things, and your repair contract, and how the repair contracts work on your inpatient side versus ED side, which can be different. Because oftentimes when we do get pushback, as long as we're able to have that dialogue, that's been extremely important. And oftentimes going to finance beforehand saying hey, here's what I want to show? Does this make sense to you, or what questions do you have? Before you get into a huge room with people has been extremely helpful.

Brian: If I could ask a follow up question on the removing tests from the menu. So in the EHR that you used, did you have any challenges with removing specific tests from physician profiles preference lists?

Heather Signorelli: Essentially, our labs' stewardship committees have deemed status in most of our divisions and over MEC. Meaning the MECs approve the lab stewardship committees to make a decision, and so if it was decided the test was going off the test menu, it was removed from physician favorites too. It's like inorderable. Now, that was easy in our order system, because we have Metatext and Cerner. In our hospitals with Epic, little more challenging, because you have to hide things. So it depends on your EMR how easily that can be done.

Brian: Thanks.

Triona Henderson: That was also part of my question, Brian.

[LAUGHTER]

How do you exactly, because with such a large hospital system, and Brian and I both know when you have multiple hospitals and multiple pathology groups or physician groups, your process of just removing– and I face that challenge where we're saying that we're removing a particular test, and the team goes up to the medical executive above the hospital laboratory committee and administration and say no, we want it. And how do you reconcile that, and have you ever had that challenge?

Heather Signorelli: Oh, yes. That's a fun one. I mean, I certainly don't want to pretend that this has been all roses and puppy dog tails.

[LAUGHTER]

But you know, I think the important thing, again, is getting your physician buy-in first. Our laboratory stewardship committee, most of our division are actually were deemed by the medical staff. And in the medical staff bylaws for many of our hospitals, they don't require approval for a lot of this. We have approval for reflex test and approval for order sets. So removing a test actually technically we want to get support, don't get me wrong, we want to make sure everybody believes what we're doing and it's the right thing to do.

But truly getting it approved by all MECs, depending on the structure that the division set up is not something that they have to do. They let them know, they communicate, we get medical staff buy-in, but it is not an approval that happens at MEC. And so you kind of have to structure your lab stewardship committee. And then also relay on your CMO. They have to go have this conversation. It cannot just be the pathologist and the lab director out there. It has to be a team effort.

Triona Henderson: Perfect. Some comments and a couple more questions. So you noted that the laboratory stewardship is not as common as anti-microbial stewardship. CDC has had a large antimicrobial stewardship program for many years, but CDC does not have a similar laboratory stewardship program. Would CDC guidance on laboratory stewardship be helpful, and what kinds of support would CDC provide to the community on this subject?

Heather Signorelli: I mean, I'm not a CDC employee, but I will say that I would be happy to support the CDC in developing that assessment, because I do think that something like that would be helpful. And actually, I do think that that's where our system will go. Much like antimicrobial stewardship started out as home grown, hospitals building this, they knew it was important. Laboratory stewardship developed that way in joint commission has recommendations with regards to how important antimicrobial stewardship is for the hospital accreditation, and I think we're going to see similar trends with laboratory stewardship. Again, we did kind of got to get the years under our belt to really show the impact to patient care.

Triona Henderson: Exactly. The lines are open. I know we have quite a few of our community hospitals from across the country on the line. You guys can unmute yourself.

Jerry, any questions?

1. Any final comments, Heather?

Heather Signorelli: You know, I think the important thing as you're starting to build this is selecting the right physician partners who really believe in what this is meant to serve as. You're changing a culture. This isn't just going in there and taking CK-MB off the test menu. This is changing a culture. Everything that we order should have– A, you should have an idea of what you're going to do with the results. And B, the test that we order need to impact the patient care in the hospital that we're serving, because most of the time this idea of well, I just click, click, click, or it's pre-checked on an order [? such. ?]

You know, I think it just leads to an overuse and an expense in healthcare, and I mean, healthcare as a whole, that really is going to impact how we treat our patients 30 years from now. And so that's really the importance of this. And so when you start these kind of committees, when you start having these kickoff calls or kickoff meetings with physicians, really framing it as we're changing a culture, we're partnering together, and having not right message I think is absolutely critical to the success of these types of initiatives.

Triona Henderson: Perfect. Thank you so much for this. Can you advance to the last slide please before we adjourn?

Heather Signorelli: Oh. of course.

Triona Henderson: Thank you.

Heather Signorelli: One second. Oh, sorry.

Triona Henderson: Perfect. Thank you. So next month, we'll still be continuing with our ECHO sessions. We will have Dr. Yael Heher from Beth Israel Deaconess Medical Center in Boston, Massachusetts with a discussion area around patient safety and quality improvement. So that's going to be over the entire laboratory, not just clinical and anatomic pathology. Please visit the DLS ECHO website to register for this session and to view all future sessions.

Thank you for taking part in our discussion today. We hope you found it valuable in the important work you're engaged in with your individual laboratories. We look forward to your participation in future sessions, and we'll keep you posted on any changes. And again, Dr. Signorelli, we want to really thank you. This is so timely and such a robust discussion today.

Heather Signorelli: Thank you, guys.

Triona Henderson: Thank you. Thank you for joining us.

Additional resources and related publications

1. Phillips KA, Deverka PA, Hooker GW, Douglas MP. Genetic Test Availability And Spending: Where Are We Now? Where Are We Going? Health affairs (Project Hope). 2018;37(5):710-716.
2. Alvin MD, Jaffe AS, Ziegelstein RC, Trost JC. Eliminating Creatine Kinase-Myocardial Band Testing in Suspected Acute Coronary Syndrome: A Value-Based Quality Improvement. JAMA internal medicine. 2017;177(10):1508-1512.
3. Dickerson J. Transforming Laboratory Utilization Review into Laboratory Stewardship: Guidelines by the PLUGS National Committee for Laboratory Stewardship. Amer Assoc for Clin Chem 2017.
4. Olson J, Hollenbeak C, Donaldson K, Abendroth T, Castellani W. Default settings of computerized physician order entry system order sets drive ordering habits. Journal of pathology informatics. 2015;6:16.
5. Hickner J, Thompson PJ, Wilkinson T et al. Primary care physicians' challenges in ordering clinical laboratory tests and interpreting results. Journal of the American Board of Family Medicine: JABFM. 2014;27(2):268-74.
6. Fang DZ, Sran G, Gessner D et al. Cost and turn-around time display decreases inpatient ordering of reference laboratory tests: a time series. BMJ quality & safety. 2014;23(12):994-1000.
7. Bridges SA, Papa L, Norris AE, Chase SK. Duplicated laboratory tests: evaluation of a computerized alert intervention abstract. Journal for healthcare quality : official publication of the National Association for Healthcare Quality. 2014;36(3):46-53.
8. Probst CA, Shaffer VA, Chan YR. The effect of defaults in an electronic health record on laboratory test ordering practices for pediatric patients. Health psychology : official journal of the Division of Health Psyc
9. Ferguson TB, Jr. The Institute of Medicine committee report "best care at lower cost: the path to continuously learning health care". Circulation Cardiovascular quality and outcomes. 2012;5(6):e93-4.hology, American Psychological Association. 2013;32(9):995-1002.