As choices mount for patient testing and treatment, diagnostic management has arisen at Vanderbilt University Medical Center to address two closely related questions that clinicians must ask themselves more and more often: have I ordered the right tests for this patient; and, taken together, what do these test results imply for the best treatment of this patient?
“Why not have diagnostic specialists from the care team and from pathology routinely convene and synthesize their findings and establish diagnoses, especially in complex cases?” said clinical pathologist and blood coagulation specialist Michael Laposata, M.D., Ph.D., who conceived of diagnostic management for coagulation disorders back in 1984 as a first-year resident at Washington University in St. Louis.
In 2008, following appointments at Penn and Harvard, Laposata joined Vanderbilt as director of the Division of Laboratory Medicine and holder of the Edward and Nancy Fody Chair in Pathology.
In the last couple of years at VUMC, diagnostic management teams have formed for coagulation disorders, blood cancers, infectious diseases, endocrine-related hypertension and transfusion medicine. Teams are developing for breast cancer and neurologic diseases, to be followed by teams for additional cancers, autoimmune diseases and toxicological diseases.
Diagnostic management is among VUMC’s signal clinical innovations. It’s being adopted here as nowhere else, and for that Laposata particularly credits the leadership of Sam Santoro, M.D., Ph.D., professor and chair of the Department of Pathology, Microbiology and Immunology, Mary Zutter, M.D., assistant vice chancellor for Integrative Diagnostics, and Bill Stead, M.D., associate vice chancellor for Health Affairs and chief strategy officer at VUMC.
“The reason this happened at Vanderbilt is that coagulation diagnosis management was developed with backing from Sam, Bill Stead and Mary Zutter, who together then said, ‘Oh, we can also do this for these diseases and those diseases.’ I showed up with a kernel of an idea, but that kernel just became an entire farm,” Laposata said.
Under diagnostic management for complex patient problems at VUMC, clinicians and their doctoral-level counterparts in clinical pathology constitute a diagnosis management team, or DMT. Together they develop guidelines for patient testing and interpretation of test results. Certain test orders from the care team trigger closer analysis by pathologists in the clinical lab.
To support this analysis, select parts of the patient history are automatically channeled to the lab.
With this working relationship in place, team members in the lab order further tests as needed and issue an overall interpretation of test results.
Interpretation in some cases is accompanied by treatment recommendations. The DMT may also evaluate the patient’s response to treatment and recommend any follow-up tests.
The hematopathology (blood cancers) DMT has codified its testing and interpretation agreements into an algorithm, a set of explicit rules. With the aid of clinical information technology, the algorithm is used to fashion automated support for testing decisions. As tests are run, the system automatically folds results together to produce interpretations. The algorithm is continuously updated based on ongoing evaluation of testing and treatment patterns.
The hematopathology DMT, which represents the most standardized, systems-based and commercially exportable version of DMT, has begun supporting clinical decision-making outside of VUMC. They have two clients in Memphis, Tenn., and are in discussion with prospective additional clients in the region and across the nation.
“People at Vanderbilt will build the knowledge source behind the diagnostic management system but people all over the country will be able to use it,” Zutter said.
VUMC hasn’t fully measured the benefits of diagnostic management but already it’s clear that it’s helping speed delivery of effective treatment, save time for clinicians, reduce the length of patients’ hospital stays and stem unnecessary testing.
Establishment of the coagulation DMT in August 2010 is thought to be responsible for much of the 25 percent reduction seen that year in average hospital lengths of stay for pulmonary embolism.
Following the February 2011 launch of the hematopathology DMT there was a large decrease in omissions of recommended tests (per the new bone marrow testing algorithm); nevertheless, tests performed on these patients’ bone marrow decreased 25 percent overall in terms of total charges, representing a savings of approximately $1.1 million in charges per year. An equivalent drop in national rates for this testing would save an estimated $399 million in charges.
What’s more, oncologists saved 10 to 15 minutes per patient ordering and reviewing results of bone marrow test panels.
Routinely looping in pathologists to add swiftness and rigor to the diagnosis of complex patient problems may sound natural and obvious, but not when you consider how these services are traditionally structured.
As Laposata points out, the pathologist’s role in the hospital and clinic has been to perform or certify results of tests ordered by clinicians. Public and commercial payers are used to paying medical specialists to select tests and interpret results — never clinical pathologists; so, in some cases, adopting DMT means reducing perfectly legitimate opportunities to collect fees for specialty consultations.
The institutions at which Laposata spent his earlier career were largely unable to see beyond this downside, but, with health care reform looming, VUMC has found its way to taking a broader view.
“DMT can be considered representative of the kind of health care reform we would all like to see,” Stead said. “It’s helping us routinely pool expertise and apply the best available evidence to reduce unnecessary testing and achieve new reliability and speed in clinical decision-making.”
Laposata summed up: “Some other institutions say they do diagnosis management — not like this they don’t. In a unique way, Vanderbilt is willing to embrace innovation with resources.”
Along with Zutter, Adam Seegmiller, M.D., Ph.D., assistant professor of Pathology, Microbiology and Immunology, has had a key roll in developing the algorithm-assisted version of DMT.
The key contributors for DMT from the Department of Biomedical Informatics include Ed Shultz, M.D., and Mia Levy, M.D., Ph.D. Shannon Rich, a health information systems consultant with the Informatics Center, is also a contributor. Commercialization of DMT is led by Ed Marx, a director in the office of the vice chancellor for Health Affairs, and Lauren McConville, program director for Integrative Diagnostics.
Stead holds the McKesson Foundation Chair in Biomedical Informatics, Santoro holds the Dorothy Beryl and Theodore R. Austin Chair in Pathology, and Zutter holds one of several Louise B. McGavock endowed chairs.