Case Examples

 

Test Utilization Improvements Drive Change for Better Patient Care

Gary W. Procop, MD, MS, FCAP
Gary W. Procop, MD, MS, FCAP

The Test Utilization Committee of the Cleveland Clinic is a multidisciplinary task force of clinicians, pathologists, administrators, and other caregivers who innovate to ensure that test utilization supports best practices and boosts patient satisfaction. Their initiatives have met those objectives while enabling cost savings or cost avoidance of $1.9 million since the first projects went live in January 2011.

According to its chair, Gary W. Procop,MD, MS, FCAP, the team materialized in response to an invitation broadcast four years ago to all of Cleveland Clinic's institutes and departments. Hands-on leadership from pathologists at the systems level has been key, he says, because pathologists understand testing better than anyone else. Meetings are open to all caregivers, who are encouraged to contribute. The multidisciplinary nature of the group, which integrates clinicians in direct patient care as well as other caregivers, has also been critical to its success.

Dr. Procop is professor and chair, Department of Molecular Pathology, section head for clinical and molecular microbiology, and director of the parasitology and mycology laboratories at the Cleveland Clinic. He has held leadership roles within the CAP, the American Board of Pathology, and the Accreditation Council for Graduate Medical Education that have conferred opportunities to observe and reflect on what might be called the medical professional's mindset. He also currently chairs the CAP's Microbiology Resource Committee.

"You've got a lot of altruistic thinking in medicine at all levels," Dr. Procop says. "If you can say that we're going to do this because it's the right thing to do, that it helps the patient, that fewer blood draws mean lowering the chance of iatrogenic anemia and improving patient satisfaction, then people will stay up late to figure that out. But if you say instead, how can we save a buck, well, you're always going to want to save a buck. Patient care has to be the true motivator."

At the same time, durable change requires institutional leadership and investment in IT support, software, and staff education— and there are always competing demands for limited funds. In making the case for smarter test utilization tools, serendipitous but significant financial benefits can be extremely helpful.

Actions/Solutions

Examples of the committee's test utilization initiatives include:

  • Same-day hard-stop: Unnecessary duplicate phlebotomy is a major patient stressor. This clinical decision support tool flags 1,200 tests that should not be ordered more than once on the same day. "So now," Dr. Procop says, "someone who orders a second one on the same day gets a report of results from the test performed earlier that day (if available) and a block that indicates that the test has already been performed." The system offers a workaround (a referral to client services); last year, only 5.1% of those who were blocked pursued it. "It's real behavior change," Dr. Procop says. "We have said that as a medical community, the Cleveland Clinic, we do not believe that these tests are needed more than once per day, and we're going to block them." Between inception in January 2011 and May 2013 (all data in this report reflect costs as of May 2013), the hard-stop tool prevented 14,829 duplicate tests and saved $235,393.

  • Restrictive use: This project limits outpatient molecular genetic test orders to "deemed users" who use them routinely in their practices. Inpatient genetic tests require a consult with Medical Genetics. The program, launched in November 2011, had saved $651,465 as of May 2013.

  • Laboratory-based genetic counseling: A laboratory-based genetics counselor frees the section head of molecular genetic pathology (who is available to her for guidance) to focus on more complex tasks. The genetics counselor participates in sign-out of complex genetic test results and responds to questions about preanalytic test selection and triage, advises on the need for genetic counseling and follow-up testing, and reviews send-out requests. Between September 2011 and May 2013, the counselor's intervention prevented 191 unnecessary orders for a total cost avoidance of $644,308.

  • Expensive test notification: Tests that cost more than $1,000 are now flagged on the order screen. Between March and May 2013, providers who received the notification discontinued 212 expensive test orders, saving $387,516.

Summary

The Cleveland Clinic Test Utilization Committee has generated interest and action around best practices and patient satisfaction. Its successes can be attributed to collaboration across the entire staff and to the hands-on participation of a pathologist who chairs the committee, interacts at the systems level, and continues to drive change. Its innovations have also generated what Dr. Procop calls "great serendipitous financial benefits"— measurable efficiencies and economies that are clear proof of concept for "doing well by doing good."


Hear the CAPcast