Building Brain-to-Brain Bridges from the Clinical Laboratory

Pathologists are creating three complementary approaches to complex clinical laboratory testing—multidisciplinary diagnostic teams, standardized order protocols, and synthetic test reports. Each has been shown to improve the quality of care and patient experience while educating clinicians and reducing the over-and underutilization of laboratory tests.

Diagnostic management teams (DMTs) made up of pathologists, clinicians, and informaticists collaborate to write guidelines for appropriate testing related to specific conditions, reducing "shotgun orders" in clinical laboratories. Interpretive synthetic reports, which include a patient- specific narrative paragraph from the clinical pathologist that synthesizes all clinical and laboratory findings, enable clinicians to understand what tests reveal in the context of each patient's condition. These cost-effective measures educate the entire medical team about effective, efficient use of complex tests and shorten the time to diagnosis.

Michael Laposata, MD, PhD, FCAP, who became chair of pathology at the University of Texas (UT) at Galveston on July 1, 2014, came to UT from the Department of Pathology, Microbiology, and Immunology at the Vanderbilt University School of Medicine, where he had been executive vice chair and professor of pathology and professor of medicine since 2008. Before Vanderbilt, Dr. Laposata had seen these tools successfully applied in complex coagulation testing at the Massachusetts General Hospital (MGH). There, about 70% of MGH clinicians surveyed had said that interpretive reports had helped to reduce the number of tests ordered and/or helped prevent a misdiagnosis.¹

Pathologists whose education and experience in clinical pathology are not extensive will need to build the relevant skills to participate in these endeavors, Dr. Laposata says, but the dividends realized are robust. Pathologists should build bridges between themselves and treating physicians to encourage the necessary consultative relationships.

"Care is delivered locally," Dr. Laposata says. "Expert pathologists have to educate the local pathologists."

Tech Tools Enhance Utility and Bolster Credibility

Dr. Laposata says that biomedical informaticians and health economists have contributed substantially to the success of these approaches. The informaticians have built a database that makes the electronic health record a dynamic educational tool that continually reveals clues to the efficacy of tests and meaning of results. Health economists have employed those metrics to put everything in context, generating support across the institution.

DMTs develop diagnostic test panels with clinicians who then leave the rest to their pathologists. A team of hematopathologists at Vanderbilt reported on an 18-month trial comparing before-and-after experience with test panels for hematologic malignancies. Clinicians chose to use diagnostic test panels for just 13% of their bone marrow biopsies during weeks one through five post-implementation, but that metric moved with experience. Over the last 42 weeks of the trial, 84% of bone marrow biopsies were evaluated by using pathologist-driven testing, and the average cost had dropped by $442 per patient evaluation.

Based on an estimated yearly institutional volume of 1,800 bone marrow tests, the authors concluded, introduction of standardized order protocols (SOPs) for all bone marrow biopsies would save payers between $522,000 and $1,069,200 per year. If extrapolated to the estimated national annual bone marrow volume of 666,000 cases, SOPs could save the US health care system between $191 and $392 million annually.²

As evidence accumulated, DMTs picked up speed at Vanderbilt, which now has teams in six medical areas and counting that enable and embrace genuine, patient- centered partnerships. As of July 1, 2014, DMTs at Vanderbilt were up and running in coagulation, hematopathology, microbiology, and blood transfusion. The endocrine group was using DMTs for patients with hypertension. On the anatomic side, neuropathologists had launched teams for diagnosis of glioma. DMTs for toxicology and autoimmunity were in the wings.

Summary

DMTs, diagnostic test panels driven by pathologists, and interpretive synthetic reports form an elegant bridge from brain-to-brain for clinicians and pathologists who collaborate to manage complex testing in the clinical laboratory. The strongest truss in that bridge is a shared commitment to evidence-based, collaborative, multidisciplinary approaches that generate high-quality, patient-centric care that is both efficient and cost effective.

1. Laposata ME, Laposata M, Van Cott EM, Buchner DS, Kashalo MS, Dighe AS. Physician survey of a laboratory medicine interpretive service and evaluation of the influence of interpretations on laboratory test ordering. Arch Pathol Lab Med. 2004;128(12): 1424–1427.

2. Seegmiller AD, Kim AS, Mosse CA, Levy MA, Thompson MA, Kressin MK, et al. Optimizing personalized bone marrow testing using an evidence-based, interdisciplinary team approach. Am J Clin Pathol. 2013;140(5): 643–650.