Flip the Dialogue: Using Information Management for Better Clinical Integration

Cordelia E. Sever, MD, FCAP, has been known to apologize for getting carried away. Ask for an opinion, and you'll get a gestalt—one that is broad, deep, succinct, and pragmatic. And when she starts to talk about quality improvement tools that are hardwired, synoptic, and integrated, prepare to clear your mind and sharpen your pencil. You're about to get a big-picture view from the vice president and director of clinical pathology for Pathology Associates of Albuquerque (PAA), medical director of the Presbyterian Hospital Laboratory and branch laboratories, and co-medical director of the clinical laboratory, hematology, for Tricore Reference Laboratories.

"My focus is to manage the information, to really make it clinically useful," Dr. Sever says; and that's doable.

Dr. Sever thinks in systemic terms, sees the value of cross-fertilization, and knows how to make novel ideas relatable. For example, she says, consider workforce. As pressures of time and volume siphon clinicians’ energy into the most challenging and technical aspects of patient care, midlevel providers are taking on more responsibility and learning on the job. Everyone is working harder and faster, and a lot of people feel buried under an unending data dump.

"You have to have a plan to manage all the new information," Dr. Sever says. "Divvy it up, do some subspecialization, and monitor the constant stream of new knowledge that may or may not be actionable."

Eventually, the right architecture to access and maintain that information will be built. In the meantime, plan, train, and monitor.

It has long been clear that most of what is called laboratory error refers to what happens to specimens in what are now being called the pre-preanalytic and post-postanalytic phases. Dr. Sever's team is finding opportunities to refine the ebb and flow of teamwork with the clinical staff. They are coming to grips with the need for more refined, targeted, and dynamic information management.

Synoptic guidelines are about "reeling it in and getting the important stuff out every time," says Dr. Sever, a board-certified anatomic, clinical, and hematopathologist with an affinity for quality systems. As the person who led the expert panel of pathologists and hematopathologists that wrote the evidence-based CAP Pathology and Laboratory Quality Center guideline on bone marrow synoptic reporting for hematologic neoplasms, Dr. Sever has come to understand the value of a synoptic format.

"Creating the bone marrow synoptic guidelines changed my perspective," she says. "The process focused me very intensely on what is clinically important. And I can tell you that it's not my bone marrow differential count!"

"We want to start with the clinical question and make it orderable so people can get what they want [from the laboratory]," Dr. Sever says. In the pre-preanalytic, it's cleaning up ordering. In the post-postanalytic, it's adjusting how we report things so people can actually understand the information. That's what ties it all together."

There's no doubt that we sometimes see what we want to see. Enough people looking to realize the same vision can make it happen.

For example, much of the discussion about putting a number on the value of a pathologist’s services has employed a cost-control vocabulary. Dr. Sever is not the first person to flip the dialogue from cost to utilization, but she is also one who persistently circles back to patient benefit. This is culturally consistent in the Presbyterian system, she says, which has a long tradition of interspecialty collaboration. Plus, they've become creative out of necessity.

"One of the interesting aspects of working in New Mexico is that it's extremely resource constrained," says Dr. Sever, who is also a clinical associate professor at the University of New Mexico School of Medicine, which operates clinical outreach programs to treatment centers and clinics across the state. "About half of the population is Medicaid and Medicare, so there are very limited dollars to go around," she says. "That's why we've practiced utilization review in our testing for a long time: to try to deliver value rather than low cost. But it’s interesting. Keeping a tab on utilization automatically keeps costs for tests down as well, without a concerted effort."

Concerted effort, though, is a relative term. Does it count if the behavior is a natural outgrowth of the culture? What if it's just an evolutionary response that occurs when people realize that the laboratory, the middle ground that touches all other specialties without a vested interest in any, is in a great position to leverage its ubiquity to drive systemic change?

Dr. Sever, who has learned a few things about change agency through her involvement with the CAP Center (before the bone marrow guidelines, she had chaired the CAP 15189 Committee; currently, she leads the expert panel on diagnosis of lymphoma), has some thoughts about that. First, nothing happens overnight. Second, it's all about working more closely with clinical colleagues to refine and target the clinical question at hand.

These insights have also grown out of what Dr. Sever has learned from becoming active in the local medical society. This year, she is the president of the Greater Albuquerque Medical Association (GAMA). That means visiting Santa Fe to talk to legislators about bills of interest to medicine and what matters most to patients (their constituents), writing a monthly letter on clinical topics for the newsletter, and brainstorming with other medical specialists.

None of which would have felt comfortable, Dr. Sever says, had Presbyterian not instituted a physician leadership academy 15 years ago and a clinical leadership team in 2015. As the only pathologist to participate in either one, she’s been active in both. Each has taught her to step back, skip the granular details, collaborate, and think ahead.

"One of the most important ingredients that pathologists already have is curiosity about how things work," she says. "The key is to leverage those talents."