LABORATORY LABORATORY UTILIZATION & QUALITY UTILIZATION & QUALITY

OUTCOMESOUTCOMES

What Are The Issues?What Are The Issues?

Impetus For Greater Control

Cost of health careCost of health care Solvency of Medicare programSolvency of Medicare program Medical necessity rulesMedical necessity rules Consumer demandsConsumer demands

Employers and patientsEmployers and patients

Failures In U.S. Health Care System

No coordination between major No coordination between major playersplayers

Vested interests drive medical Vested interests drive medical decisionsdecisions

Little interest in “whole Little interest in “whole person”, prevention and person”, prevention and wellnesswellness

Limited resourcesLimited resources No systemNo system

Dartmouth Studies

The level of physicians and hospital The level of physicians and hospital beds drive demandbeds drive demand

Physician and hospital preference, Physician and hospital preference, not patient need, drive health care not patient need, drive health care services in a communityservices in a community

The number of surgical procedures The number of surgical procedures vary geographicallyvary geographically

Likelihood of a diagnosis varies by Likelihood of a diagnosis varies by locationlocation

Support Study

Many Americans die in Many Americans die in hospitals, alone and in pain, hospitals, alone and in pain, after receiving treatment after receiving treatment regimens undertaken with regimens undertaken with knownknown unfavorable odds unfavorable odds

Regional Variations in Diagnostic Practices

There is substantial regional There is substantial regional variability in test ordering variability in test ordering practices that cannot be practices that cannot be explained by case mixexplained by case mix

Song, Y. et al. (2010). Song, Y. et al. (2010). – New England Journal of Medicine.

http://www.nejm.org/doi/pdf/10.1056/NEJMsa0910881

Diagnosis And Management Of

Polycythemia Vera In the era since the Polycythemia

Vera Study Group formulated its formulated its recommendationsrecommendations

Significant variations in diagnostic and therapeutic approach were evident by region, practice type, specialty, and clinical experience.

Streiff et al. Blood February 15, 2002 vol. 99 no. 4 1144-1149

Future Needs

Baby boomers demanding Baby boomers demanding disease preventiondisease prevention

Controversies about a variety of Controversies about a variety of environmental effects on healthenvironmental effects on health

Obsession with weight Obsession with weight Obsession with exerciseObsession with exercise Popularity of self-testingPopularity of self-testing Internet access to range of medical Internet access to range of medical

informationinformation

New Attitude

Emphasis on prevention and Emphasis on prevention and wellnesswellness

Skepticism for physicians and Skepticism for physicians and health care systemshealth care systems

Reluctantly aging population Reluctantly aging population

Primary Questions

How do we control utilization of How do we control utilization of our services?our services?– Control, not limitControl, not limit

What knowledge do healthcare What knowledge do healthcare providers need to use laboratory providers need to use laboratory services appropriately?services appropriately?

What We Know

FactsFacts AnecdotesAnecdotes StudiesStudies

Overutilization

Study in APRIL 1998 Issue of Study in APRIL 1998 Issue of American Journal of MedicineAmerican Journal of Medicine

Supported by Agency for Health Supported by Agency for Health Care Policy and ResearchCare Policy and Research

Many clinical laboratory tests Many clinical laboratory tests redundantredundant

Review of 6,000 charts looking for Review of 6,000 charts looking for 12 standard tests12 standard tests

Chart revealed no clinical need for Chart revealed no clinical need for 92% of repeats92% of repeats

Abnormal Test Results

Study in February 1996 Study in February 1996 Archives Archives Of Internal MedicineOf Internal Medicine

36% of physicians do not always 36% of physicians do not always notify patients of abnormal lab notify patients of abnormal lab resultsresults

Some wait till next visitSome wait till next visit Most don’t document Most don’t document

communicating the results to the communicating the results to the patientpatient

Abnormal Test Results

28% of physicians always notify 28% of physicians always notify patients of normal and abnormal patients of normal and abnormal resultsresults

72% let patients assume that “no 72% let patients assume that “no news is good news”news is good news”

Lack of follow-up can have a Lack of follow-up can have a negative effect on patient carenegative effect on patient care

Physician Ordering Patterns

Quest to collect dataQuest to collect data Gather information to justify Gather information to justify

decisionsdecisions Avoid criticism for not Avoid criticism for not

ordering a testordering a test Traditional ordersTraditional orders

– How they were taughtHow they were taught

Physician Ordering

Many studies to change Many studies to change behavior have been behavior have been conductedconducted

Most work during the Most work during the intervention but behavior intervention but behavior reverted after study stoppedreverted after study stopped

Benchmark Information

Many common preoperative Many common preoperative tests not of valuetests not of value

Drug utilization costs drop with Drug utilization costs drop with lab informationlab information

Cost to diagnose and treat Cost to diagnose and treat suspected MI reduced with lab suspected MI reduced with lab teststests

Benchmark Information

Lifetime expenses/diabetic Lifetime expenses/diabetic decrease with control of decrease with control of disease through close disease through close monitoring of glucose and monitoring of glucose and glycohemoglobinglycohemoglobin

PAP testing - more than 20 PAP testing - more than 20 years of data support years of data support screening benefitsscreening benefits

Benchmark Information Needed

Focus diagnosesFocus diagnoses Disease/organ specificDisease/organ specific Effectively prescribeEffectively prescribe

Direct optimal therapyDirect optimal therapy Disease progressDisease progress Drug levelsDrug levels Treatment responseTreatment response

Optimize wellnessOptimize wellness

Successful Strategies

Provide test costs at order Provide test costs at order entryentry

Change order formsChange order forms Algorithms, reflex testing, Algorithms, reflex testing,

pathways, case managementpathways, case management Financial incentivesFinancial incentives Physician Physician

education/consultationeducation/consultation

Evidence-based Medicine

Support some strategies?Support some strategies? Use current, best evidence to Use current, best evidence to

make patient care decisionsmake patient care decisions Conduct research & meta-analysesConduct research & meta-analyses Clinician must know how to Clinician must know how to

access, read and interpret valid access, read and interpret valid researchresearch

““First, payers want appropriate utilization for First, payers want appropriate utilization for expensive genetic and molecular assays,” expensive genetic and molecular assays,” observed Zubiller. observed Zubiller.

““Labs are perfectly positioned to work with Labs are perfectly positioned to work with clinicians at the time of a test order to determine clinicians at the time of a test order to determine if that genetic test is appropriate for that patient. if that genetic test is appropriate for that patient. Doing so could have a dramatic impact on the Doing so could have a dramatic impact on the follow-on care decisions. follow-on care decisions.

This will require labs to be more interactive with This will require labs to be more interactive with their client physicians, and integrated informatics their client physicians, and integrated informatics for clinical for clinical decision support is one way to deliver is one way to deliver this added value service. this added value service.

Matthew Zubiller, Vice President and Matthew Zubiller, Vice President and General Manager of General Manager of Advanced Diagnostic Management, a , a business unit of McKesson business unit of McKesson Corporation. Corporation.

That is why we see payers beginning That is why we see payers beginning to implement utilization management to implement utilization management requirements like pre-authorization requirements like pre-authorization and notifications and notifications

MuirLab is the core laboratory and outreach MuirLab is the core laboratory and outreach laboratory service of the laboratory service of the John Muir Health System..

It has implemented an evidence-based It has implemented an evidence-based automated diagnostic platform that enables it to automated diagnostic platform that enables it to collaborate in real-time with providers and payers collaborate in real-time with providers and payers and ensure that the most appropriate tests were and ensure that the most appropriate tests were being ordered by physicians at the point of care. being ordered by physicians at the point of care.

This resulted in improved utilization of clinical This resulted in improved utilization of clinical tests and increased revenues, thanks to a tests and increased revenues, thanks to a marked decrease in claims denials. marked decrease in claims denials.

CDC CDC Projects

2007 CDC Institute Integration Workgroup to focus on

better integration of laboratory medicine in the health care continuumNeed to optimize utilization of laboratory

services for better patient care Now called Clinical Laboratory

Integration into Healthcare Collaborative

(CLIHC)TM

CLIHCTM Workgroup

Co-Lead: John Hickner, MD, MScCo-Lead: John Hickner, MD, MSc University of ChicagoUniversity of Chicago

Co-Lead: Michael Laposata, MD, Co-Lead: Michael Laposata, MD, PhD PhD

Vanderbilt University HospitalVanderbilt University Hospital Paul Epner, MEd, MBAPaul Epner, MEd, MBA

Paul Epner, LLCPaul Epner, LLC

Marisa B. Marques, MDMarisa B. Marques, MD University of Alabama at Birmingham University of Alabama at Birmingham

Jim L. Meisel, MD, FACPJim L. Meisel, MD, FACP

Boston Medical CenterBoston Medical Center

Elissa Passiment, EdMElissa Passiment, EdM

American Society for Clinical American Society for Clinical Laboratory Science Laboratory Science

Brian Smith, MDBrian Smith, MD

Yale School of MedicineYale School of Medicine

CLIHCTM Workgroup Support

CDC:CDC: Diane BosseDiane Bosse MariBeth GagnonMariBeth Gagnon Maryam DaneshvarMaryam Daneshvar Anne PollockAnne Pollock Julie Taylor*Julie Taylor* Pam ThompsonPam Thompson Nancy CornishNancy Cornish

Others Participating in CLIHCOthers Participating in CLIHCTM TM ProjectsProjects

Samir Aleryani, PhDSamir Aleryani, PhDVanderbilt University Medical CenterVanderbilt University Medical Center

Julian Barth, MDJulian Barth, MDUniversity of Leeds, United Kingdom University of Leeds, United Kingdom

Allison Floyd, MDAllison Floyd, MDVanderbilt University Medical CenterVanderbilt University Medical Center

John Fontanesi, PhDJohn Fontanesi, PhDUniversity of California at San Diego University of California at San Diego

George A. Fritsma, MS MT (ASCP)George A. Fritsma, MS MT (ASCP)University of Alabama at BirminghamUniversity of Alabama at Birmingham

John A. Gerlach, PhDJohn A. Gerlach, PhD Michigan State UniversityMichigan State University

Robert D. Hoffman, MD, PhD Vanderbilt University Medical Center

Katherine Kahn, MDRand Corporation and UCLA

Mario Plebani, MDUniversity of Padua, Italy

Mitch Scott, PhDWashington University

Oxana Tcherniantchouk, MDCedars-Sinai Medical Center

CLIHCTM

Key ProjectsKey ProjectsClinician Test Selection & Clinician Test Selection & Result InterpretationResult Interpretation

– Diagnostic AlgorithmsDiagnostic Algorithms– Nomenclature ProjectNomenclature Project– Survey of Clinicians’ ChallengesSurvey of Clinicians’ Challenges– Medical Errors related to Laboratory Medical Errors related to Laboratory

TestsTestsMedical School curriculum Medical School curriculum content pertinent to laboratory content pertinent to laboratory servicesservices

The reports showing that errors in test The reports showing that errors in test selection and result interpretation can selection and result interpretation can jeopardize patient safety are on the rise jeopardize patient safety are on the rise

Allison Floyd, MD and Michael Laposata, MD, PhD, Vanderbilt University Medical Center, unpublished data

Review of the Literature

Diagnostic Algorithms

Goal:Goal: Demonstrate complexity of Demonstrate complexity of

selecting the appropriate selecting the appropriate laboratory testlaboratory test

Understand the most effective Understand the most effective testing strategiestesting strategies

Diagnostic Algorithms

Three clinical pathologists with expertise in Three clinical pathologists with expertise in coagulation created diagnostic laboratory test coagulation created diagnostic laboratory test algorithms to guide evaluation of patients with a algorithms to guide evaluation of patients with a prolonged Partial Thromboplastin Time (PTT) and a prolonged Partial Thromboplastin Time (PTT) and a normal Prothrombin Time (PT)normal Prothrombin Time (PT)

The 6 algorithms addressed: The 6 algorithms addressed: – age (adult versus newborn)age (adult versus newborn)– patient location (inpatient or outpatient)patient location (inpatient or outpatient)– symptoms (none, bleeding or thrombosis) symptoms (none, bleeding or thrombosis) – timing of the abnormal PTT result (recent versus extended timing of the abnormal PTT result (recent versus extended

period of time)period of time)

Diagnostic AlgorithmsDiagnostic Algorithms

CDC has developed an app for iPhones that physicians can use to determine what coagulation tests to order for some of the algorithms– Working on remaining ones

Need to now address algorithms for new drugs prescribed

Expect to produce 25 apps

Pathways

Originate from professional Originate from professional societies, federal & state societies, federal & state agencies and managed careagencies and managed care

28 states require guidelines 28 states require guidelines for health plans serving for health plans serving MedicaidMedicaid

Success depends on Success depends on implementation processimplementation process

Pathways

STUDY IN STUDY IN PEDIATRIC ANNALS, PEDIATRIC ANNALS, APRIL 1998APRIL 1998

Guidelines must be implemented Guidelines must be implemented with education, reminders, & with education, reminders, & incentivesincentives

Must be consistent with current Must be consistent with current practicepractice

Do not always have desired impact Do not always have desired impact on savings or improvement of careon savings or improvement of care

Nomenclature

Goal:Goal: Demonstrate the complexity of test selectionDemonstrate the complexity of test selection

– Multiplicity - Hepatitis B surface antibody Multiplicity - Hepatitis B surface antibody HBs Antibody, Hepatitis Bs Ab, HBG, Anti-HBs HBs Antibody, Hepatitis Bs Ab, HBG, Anti-HBs

– Complexity - lupus anticoagulant – not for lupusComplexity - lupus anticoagulant – not for lupus Developed a flow chart and tables Developed a flow chart and tables

demonstrating:demonstrating:– Complexity – Vitamin DComplexity – Vitamin D– Breadth – Commonly ordered testsBreadth – Commonly ordered tests

– Depth – CoagulationDepth – Coagulation

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NomenclatureNomenclature

Test naming could be based on:Test naming could be based on:– Disease associationDisease association– Method used to perform the testMethod used to perform the test– Name of developerName of developer– Inappropriate names (i.e. no link between Inappropriate names (i.e. no link between

name and what is being tested)name and what is being tested) Multiple test name abbreviationsMultiple test name abbreviations

– Many evolved from implementing Laboratory Many evolved from implementing Laboratory Information SystemsInformation Systems

Existing nomenclature options for vitamin D Existing nomenclature options for vitamin D and its multiple formsand its multiple forms

::

Vitamin D2Vitamin D2ErgosterolErgosterolVitamin D3Vitamin D3CholecalciferolCholecalciferol25-0H vitamin D225-0H vitamin D225-0H vitamin D325-0H vitamin D325-0H vitamin D25-0H vitamin D25 hydroxy vitamin D225 hydroxy vitamin D225 hydroxy vitamin D325 hydroxy vitamin D325 hydroxy vitamin D25 hydroxy vitamin D1,25 (OH)2 vitamin D21,25 (OH)2 vitamin D21,25 (OH)2 vitamin D31,25 (OH)2 vitamin D31,25 (OH)2 vitamin D1,25 (OH)2 vitamin D1,25 dihydroxy vitamin D21,25 dihydroxy vitamin D21,25 dihydroxy vitamin D31,25 dihydroxy vitamin D31,25 dihydroxy vitamin D1,25 dihydroxy vitamin DVitamin D 25 Hydroxy D2 and Vitamin D 25 Hydroxy D2 and D3D3Vitamin D 1,25 DihydroxyVitamin D 1,25 Dihydroxy

In addition –

The number of abbreviationscreated for laboratory informationsystems for vitamin D and itsmultiple forms is almost limitless

In addition –

The number of abbreviationscreated for laboratory informationsystems for vitamin D and itsmultiple forms is almost limitless

Article Published

Journal of General Internal Medicine Decoding Laboratory Test Names: A

Major Challenge to Appropriate Patient Care– March 2013

Article cited on the Agency for Healthcare Research and Quality (AHRQ) Patient Safety Network (PSNet)

Next StepsNext Steps

Summit to connect IT minds and Summit to connect IT minds and needs of all users of clinical needs of all users of clinical laboratory testinglaboratory testing

Working towards a Google-like Working towards a Google-like search tool to present users with search tool to present users with the correct test namesthe correct test names

Clinicians’ Challenges in Test Ordering and

Results Interpretation

Goal:Goal: Raise awareness of the challenges clinicians face Raise awareness of the challenges clinicians face

in test ordering and result interpretationin test ordering and result interpretation   Phase 1 - Conduct three focus groups targeting Phase 1 - Conduct three focus groups targeting

internal, family, and general medicine internal, family, and general medicine practitionerspractitioners

Phase 2 - Using information from focus groups in Phase 2 - Using information from focus groups in Phase 1, conduct a national survey of cliniciansPhase 1, conduct a national survey of clinicians

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To understand primary care needs and issues, To understand primary care needs and issues, three focus groups were conductedthree focus groups were conducted

The results are suggestive of actions that The results are suggestive of actions that laboratory professionals can take to improve laboratory professionals can take to improve clinician performanceclinician performance

To validate findings and gain greater insights To validate findings and gain greater insights into needs, the CDC commissioned a national into needs, the CDC commissioned a national survey of primary care physicianssurvey of primary care physicians– National sample of Family Practice and Internal National sample of Family Practice and Internal

Medicine physicians: target sample size of 1600 Medicine physicians: target sample size of 1600

– Results collected in 2011Results collected in 201142

FocusFocus GroupsGroups SummarySummary

Primary care physicians are comfortable selecting Primary care physicians are comfortable selecting from a small working repertoire of common testsfrom a small working repertoire of common tests

““Interpretation and ordering tests, I usually Interpretation and ordering tests, I usually don’t have a problem with that. For the don’t have a problem with that. For the most part I know what to order.”most part I know what to order.”

““I may order 20 tests commonly and I may I may order 20 tests commonly and I may order an additional 10-20 tests order an additional 10-20 tests [occasionally], so I may be using 40 tests [occasionally], so I may be using 40 tests that I feel comfortable that I’m not wasting that I feel comfortable that I’m not wasting time or money or resources.”time or money or resources.”

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Challenges/ BarriersChallenges/ BarriersTest OrderingTest Ordering

Insurance and cost limitationsInsurance and cost limitations Issues with accessing and Issues with accessing and

communicating with laboratoriescommunicating with laboratories Variations in test names Variations in test names Variable and nebulous practice Variable and nebulous practice

guidelinesguidelines

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EnablersEnablersTest OrderingTest Ordering

Electronic resourcesElectronic resources Access to peers and colleaguesAccess to peers and colleagues Access and relationships with Access and relationships with

laboratory professionalslaboratory professionals Availability of practice guidelines, Availability of practice guidelines,

algorithms, etc.algorithms, etc.

45

Challenges/ BarriersChallenges/ BarriersResult InterpretationResult Interpretation

Insurance and cost limitationsInsurance and cost limitations Varying practice guidelines and Varying practice guidelines and

methodologiesmethodologies Difficulties in accessing and Difficulties in accessing and

communicating with laboratory communicating with laboratory professionalsprofessionals

Inconsistency of laboratory test results Inconsistency of laboratory test results with clinical presentationwith clinical presentation

Inadequate laboratory reporting and Inadequate laboratory reporting and documentationdocumentation

46

EnablersEnablersResult InterpretationResult Interpretation

Access to electronic results and Access to electronic results and resourcesresources

Access to peers and colleaguesAccess to peers and colleagues Access to laboratory professionalsAccess to laboratory professionals Follow-up testing information and Follow-up testing information and

reflex testing, when appropriatereflex testing, when appropriate

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Focus Group SummaryFocus Group Summary

Physicians are comfortable with selecting from a Physicians are comfortable with selecting from a small working repertoire of common testssmall working repertoire of common tests

When results did not fit their suspected diagnosis, When results did not fit their suspected diagnosis, physicians relied on combination of patient physicians relied on combination of patient presentation and own diagnostic instincts more presentation and own diagnostic instincts more than the laboratory resultsthan the laboratory results

Laboratory consultation was a useful resource Laboratory consultation was a useful resource when the physician had effective and consistent when the physician had effective and consistent access to laboratory services and were access to laboratory services and were comfortable with laboratory professionalscomfortable with laboratory professionals

Electronic resources are becoming more Electronic resources are becoming more important, with level of utilization dependent on important, with level of utilization dependent on ease of availability and a culture that encourages ease of availability and a culture that encourages their usetheir use

48

Focus Groups SummaryFocus Groups Summary

When results did not fit their suspected diagnosis, When results did not fit their suspected diagnosis, physicians relied on combination of patient physicians relied on combination of patient presentation and own diagnostic instincts more than presentation and own diagnostic instincts more than the laboratory resultsthe laboratory results

““Patient symptoms trump the lab Patient symptoms trump the lab results”results”

49

Focus Groups SummaryFocus Groups Summary

Laboratory consultation was a useful resource when the Laboratory consultation was a useful resource when the physician had effective and consistent access to laboratory physician had effective and consistent access to laboratory professionals but this was not commonprofessionals but this was not common

“Most of us don’t call the lab, we call a specialist”

“It hasn’t even occurred to me to call a pathologist to ask what test to order. I wouldn’t have even considered It as an option”

You’re lucky if you have someone answer you but most of the time you have a machine or they’ll put you on hold for an extended time period 50

Focus Groups SummaryFocus Groups Summary

Laboratory consultation was a useful resource when the Laboratory consultation was a useful resource when the physician had effective and consistent access to physician had effective and consistent access to laboratory professionals but this was not commonlaboratory professionals but this was not common

“Most of us don’t call the lab, we call a specialist”

“It hasn’t even occurred to me to call a pathologist to ask what test to order. I wouldn’t have even considered It as an option”

You’re lucky if you have someone answer you but most of the time you have a machine or they’ll put you on hold for an extended time period

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Phase 2 - Clinicians’ SurveyPhase 2 - Clinicians’ Survey

Methods:Methods:– National sample of Family Practice and Internal National sample of Family Practice and Internal

Medicine physicians drawn from AMA Master Medicine physicians drawn from AMA Master FileFile

– Target sample size of 1600 Target sample size of 1600 – Survey delivered via WebSurvey delivered via Web

Status:Status:Manuscript submitted to a few journalsManuscript submitted to a few journals

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What we don’t know

What is the prevalence of diagnostic errors What is the prevalence of diagnostic errors impacted by the testing process?impacted by the testing process?– Failure to order necessary testsFailure to order necessary tests– Ordering of unnecessary testsOrdering of unnecessary tests– Inappropriate utilization of test resultsInappropriate utilization of test results

What are effective interventions that reduce What are effective interventions that reduce diagnostic errors and could be initiated by diagnostic errors and could be initiated by laboratory professionals?laboratory professionals?– What settings are appropriate for these What settings are appropriate for these

interventions?interventions?– What limitations exist in the use of these What limitations exist in the use of these

interventions? interventions? – What new sources of errors are created by the What new sources of errors are created by the

interventions?interventions?Paul Epner, Diagnostic Errors in Medicine, October 25, 2010

Improvements in Clinicians’ Test Improvements in Clinicians’ Test Selection and Result Interpretation (ITSRI) Selection and Result Interpretation (ITSRI) Lead – Paul Epner, MEd, MBALead – Paul Epner, MEd, MBA

Goal:Goal: Demonstrate the effect of improvements in Demonstrate the effect of improvements in

laboratory test selection and result interpretation laboratory test selection and result interpretation on diagnostic errors on diagnostic errors

  Methods:Methods: Develop methods to measure the effect of Develop methods to measure the effect of

laboratory test selection and result interpretation laboratory test selection and result interpretation on diagnostic errorson diagnostic errors

Conduct pilot studies to determine the effect of Conduct pilot studies to determine the effect of improvements in laboratory test selection and improvements in laboratory test selection and result interpretation on diagnostic errorsresult interpretation on diagnostic errors

Vanderbilt University Medical Vanderbilt University Medical Center Center Unpublished StudyUnpublished Study**

Reviewed one week of consultation requestsReviewed one week of consultation requests 53 cases total53 cases total

– 29 cases had appropriate test orders (55%)29 cases had appropriate test orders (55%)– 19 cases had incomplete test orders (36%)19 cases had incomplete test orders (36%)– 5 cases had inappropriate test orders (9%)5 cases had inappropriate test orders (9%)

Of 24 cases where tests were added or Of 24 cases where tests were added or deleted following consultation, the diagnosis deleted following consultation, the diagnosis was impacted in 2 cases. was impacted in 2 cases.

The timing of the diagnosis in the other cases The timing of the diagnosis in the other cases was not impacted only because of the near was not impacted only because of the near real-time addition of tests.real-time addition of tests.

*Information and analysis provided by Jennifer M. Giltnane, MD, PhD and *Information and analysis provided by Jennifer M. Giltnane, MD, PhD and Michael Laposata, MD, PhD, Vanderbilt University Medical CenterMichael Laposata, MD, PhD, Vanderbilt University Medical Center

Outcomes Vs Indicators

Outcomes require Outcomes require measurementmeasurement

Measurements, to be Measurements, to be accurate, must compare accurate, must compare large, like populations over a large, like populations over a period of timeperiod of time

Few health care plans are Few health care plans are that comparablethat comparable..

Challenges

Characteristics of population, Characteristics of population, such as age, health status, such as age, health status, comorbidities, etc. Differcomorbidities, etc. Differ

Need to follow patients five to Need to follow patients five to twenty years and few patients twenty years and few patients stay with one health plan that stay with one health plan that longlong

Challenges

Illness is rare in the general Illness is rare in the general population so the number of population so the number of individuals needed to conduct individuals needed to conduct a valid study may not be a valid study may not be available in each health planavailable in each health plan

Health informatics poor; Health informatics poor; clinical information not clinical information not capturedcaptured

Laboratory Medicine Education in U.S. Medical

Schools

Required courses in 57% (68/120) of schoolsRequired courses in 57% (68/120) of schools Few schools report no training at all (2 -4%)Few schools report no training at all (2 -4%) An ad hoc committee of The Academy of Clinical An ad hoc committee of The Academy of Clinical

Laboratory Physicians and ScientistsLaboratory Physicians and Scientists Proposed medical student laboratory medicine Proposed medical student laboratory medicine

curriculumcurriculum Developed:Developed:

Goals and objectives for trainingGoals and objectives for training Guidelines for instructional methodsGuidelines for instructional methods Examples of how outcomes can be assessedExamples of how outcomes can be assessed

Smith, Brian R, et. al.; Educating Medical Students in Laboratory Medicine A Proposed Curriculum; AJCP; 2010: Smith, Brian R, et. al.; Educating Medical Students in Laboratory Medicine A Proposed Curriculum; AJCP; 2010: 133: 533-542133: 533-542

Survey of U.S. Medical SchoolsSurvey of U.S. Medical SchoolsProject Leads –Brian Smith, MD and John Project Leads –Brian Smith, MD and John Hickner, MD, MScHickner, MD, MSc

Goal:Goal:    Raise awareness to the gaps in US medical school Raise awareness to the gaps in US medical school

curricula and laboratory medicine training curricula and laboratory medicine training

Methods:Methods: Survey all 133 allopathic and 26 osteopathic U.S Survey all 133 allopathic and 26 osteopathic U.S

medical schoolsmedical schools Recruit one medical student (via AMSA) per Recruit one medical student (via AMSA) per

school to help complete the surveyschool to help complete the survey

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Clinical Pathology Residency Education

Goal: Goal: Establish the nature and amount of clinical Establish the nature and amount of clinical

consultation education provided to clinical consultation education provided to clinical pathology residentspathology residents

Raise awareness to the gaps in, and solutions to Raise awareness to the gaps in, and solutions to improve clinical pathology residency educationimprove clinical pathology residency education

Method: Method: Conduct observational study of academic Conduct observational study of academic

institutions assessing clinical pathology resident institutions assessing clinical pathology resident training activitiestraining activities

Clinical Pathology Residency Education

Results:Results: 14 Accredited programs contacted – invited to visit 314 Accredited programs contacted – invited to visit 3 Some training programs have focal areas of consult Some training programs have focal areas of consult

activityactivity Many programs not prepared to develop meaningful Many programs not prepared to develop meaningful

consultative roles for residents in laboratory medicineconsultative roles for residents in laboratory medicine Obstacle - Limited # of doctoral level laboratory Obstacle - Limited # of doctoral level laboratory

directors to teach residentsdirectors to teach residents Need to obtain more data to substantiate the results Need to obtain more data to substantiate the results

and identify model programsand identify model programs

Successful Strategies

Physician involvementPhysician involvement Laboratory professionals Laboratory professionals

commitment and involvementcommitment and involvement Laboratory utilization Laboratory utilization

committee committee Track by physician, pathway, encounter, Track by physician, pathway, encounter,

like pharmacy and surgerylike pharmacy and surgery

The Future Is Bright

Laboratory testing provides patient-specific information necessary for the prevention, diagnosis, treatment, and management of disease or establishment of health.

Other InitiativesOther Initiatives

Development of evidence-based Development of evidence-based methods to identify and evaluate methods to identify and evaluate Best Practices in Laboratory Best Practices in Laboratory Medicine.Medicine.http://wwwn.cdc.gov/dls/bestpractices/LabBestPractice.pdf