UM Department of Pathology Leading Efforts to Bring Healthcare into 21st Century

In a push to bring healthcare further into the 21st Century at the Miller School of Medicine and UHealth, Richard J. Cote, M.D., Professor and Joseph R. Coulter Jr. Chair of Pathology, is leading a transformation in the Department of Pathology that is redefining a sustainable and successful model for healthcare services across UHealth.

Cote’s efforts were featured in the July issue of the College of American Pathologists’ CAP TODAY, the largest trade publication for pathology. The magazine’s Senior Editor, Kevin B. O’Reilly, spoke extensively with Cote about how, with the Affordable Care Act in full swing, he is leading the department’s transition away from the traditional fee-for-service payment model – a strategy he presented at this year’s Executive War College, the world’s largest annual gathering of laboratory and pathology leaders.

During his presentation, Cote, who also is Director of the Dr. John T. Macdonald Foundation Biomedical Nanotechnology Institute, told colleagues from across the globe, “Volume, increasingly, is no longer king. … We’ve all run our healthcare delivery systems based on the proposition that increasing volumes of any type — an increasing number of patients, or an increasing number of laboratory tests — is a good thing because we get reimbursed on a per-unit basis. This is shifting, and the shift that’s taking place in the marketplace is one we need to be able to respond to.”

Re-assessing how pathology services can contribute to the health system’s larger mission of improving results over simply increasing volume is essential for success in the pay-for-value world, Cote told O’Reilly.

“We’re talking about improved care coordination across the continuum of healthcare with an emphasis on prevention,” Cote said. “We also have outcome-driven and evidence-based measures in the clinical practice, and the lab has a place in managing overall healthcare costs. These are areas where pathology can play a major role and add value to healthcare delivery.”

Before Cote joined the Miller School in 2009, there were more than 20 separate labs providing pathology service to patients on the campus. By consolidating services, laboratory efficiency has improved immensely, saving the University millions of dollars along the way. The overhaul also helped strengthen revenue by insourcing the lab work for UHealth’s 57 affiliated clinics — work that had previously gone to commercial labs. The insourcing has now begun, further strengthening the lab delivery system and improving patient care.

Another significant undertaking Cote discussed was streamlining the process for ordering tests. For Cote and his team, that means prioritizing areas with high costs and high variability. Test requisition forms for hematopathology, for example, can include nearly 50 tests for physicians, fellows or residents to choose, making it easy for clinicians to select more tests than needed, overuse the system and inflate cost.

To identify the waste and take the information to clinicians, Cote teamed up with lab leaders across UHealth, including Merce Jorda, M.D., Ph.D., Vice Chair and Chief of Anatomic Pathology, and Joseph Zeitouni, M.D., Director of Pathology Informatics and assistant professor of pathology.

“Our clinicians were just really stunned and really impressed, and very eager to do something about it and change what needed to be changed to get better service out of us,” Zeitouni said. “They had stressed our system so much that we were sending off extra specimens to reference labs.”

Working with the hematology-oncology team at Sylvester Comprehensive Cancer Center, the pathologists developed more than two dozen algorithm-based protocols for hematopathology ordering that are based on specific clinical scenarios.

In the article, Cote called the endeavor a “real partnership with clinicians,” adding that the new protocols have led to a 25 percent decrease in costly cytogenetic tests, quicker turnaround times, more standardized reporting and improved physician satisfaction.

Several other UHealth initiatives highlighted were described as “a more expansive approach to the laboratory’s role in cutting costs while improving care and patient safety.”

In 2010, UHealth launched MyUHealthChart, a component of the UChart electronic medical records system that allows patients of the University of Miami Health System to manage their healthcare online from anywhere, at any time.

The electronic health records system, Cote explained, plays a crucial role in advancing continuity of care. Soon, he said, anatomic pathology results that meet certain criteria, such as a new or unexpected cancer diagnosis, will get flagged in the system, ensuring that both patient and physician get the results and that appropriate follow-up appointments are made. Another project seeks to use laboratory data stored in the system to help improve chronic disease care.

As Cote told the magazine, pathology already tracks how well UM ambulatory clinics are doing in meeting population health goals. For example, one of the metrics tracks the proportion of a clinic’s type 2 diabetics whose glycated hemoglobin is below the 7 percent target. Those measurements are then used for Medicare’s Physician Quality Reporting System and the National Committee for Quality Assurance’s patient-centered medical home certification standards.

“These are quality assessment tools that will be critical for pricing and credible for quality assurance,” said Cote. “We not only give a general assessment regarding overall performance, we’re now moving to provide specific alerts on individual outliers for appropriate intervention, identifying those patients who need better or more specialist management.”

But in the case of diabetic patients, management is particularly significant, and that’s why Philip Chen, M.D., Ph.D., Chief of Clinical Pathology and Vice Chair of Pathology, says the first target for intervention is patients whose glycated hemoglobin (A1c) levels are beyond the goal and have stayed that way for an extended period.

“With diabetes patient management, at some point it gets so complicated that the patient needs to be referred to endocrinology specialists,” Chen said. “This is one approach where we said, as a laboratory, ‘We have the data. We know what the patients look like because we’re following them. How do we use our data and informatics tools to identify these patients who have been out of control for so long with primary care physicians that it’s time to go to a specialist?’”

In this scenario, the patient’s primary care physician would be notified of the unmanageable results, along with easy referral to a UHealth endocrinologist through the UChart system. Though there are still some technical hurdles to overcome, Cote said the protocol is fast becoming the future of managed healthcare.

“It’s just that closing of the loop,” he said. “Let’s not miss these patients and let them fall through the cracks. If we were practicing medicine in a perfect world, and we as individuals never missed anybody, and we always saw that bad lab result and acted on it, then we wouldn’t need this. But that’s not how it works. Often, the patient comes in, then the lab results come in, and you see them back in six months and that’s when the doctor sees the lab results. Using informatics tools can help us — the pathologist-clinician partnership — deliver best practices consistently all the time.”

Back at the Executive War College, Cote told colleagues about another important initiative aimed at identifying patients he referred to as “time bombs,” recognizing their potential need for costly care.

It is generally understood, Cote said, that 20 percent of patients account for 80 percent of healthcare costs, while five percent tally 50 percent of medical expenses. Of that five percent, two thirds go from being low-cost patients to high-cost patients, year-over-year.

Chen further explained how UM, using a basic questionnaire that asks about age, sex, weight and basic medical history, will be able to identify these patients so a care coordination team can encourage them to see a physician.

“We have about three million patients in our EMR database,” Chen said. “With almost every clinical visit, whether you have a little cut on the finger or a little cough and go to the clinic, we collect this kind of data. Using a scoring system, we can identify the people at high risk, and looking to the EMR to see if they have an existing diagnosis of diabetes along with laboratory markers, we can really narrow down the list to those people who are at high risk but don’t know about it.”

The article notes that the initiative makes sense from a population-health-management perspective and aligns well with the idea of accountable care, but also makes sense short-term under the predominant fee-for-service pay model.

Although UM may be slow to embrace the brave new world beyond fee-for-service, Cote told the magazine the steps that pathologists are taking to prepare for this monumental healthcare transformation are worthwhile, regardless of the outlook on payment.

He wrapped up the piece this way:

“Decreasing costs, controlling utilization, performing evidence-based medicine – these are all good things to do, even in the absence of being in an at-risk reimbursement model,” Cote said. “As scary as the move toward pay for value may be, it also presents an opportunity for pathology and laboratory medicine. We know that fee-for-service is being challenged. We know those arrangements will go away, and when we do have fee-for-service, we know those rates are only going to get lower. But we do have some advantages we can bring. We have some values we can add, and we can make the laboratory important. . . . We must not be a commodity, and we have to deliver values outside what we’ve traditionally perceived as the value proposition in pathology. We have to reassess what laboratory services are and how we provide them.”

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