Ask any great thinker. The road to taking an innovative idea from concept to reality is often riddled with obstacles and opposition. Pushing past the resistance, generating support for your brainchild and proving its value are the keys to making progress and achieving results.
If you’re in the process of building a diagnostic management team — or DMT — in your organization, chances are you’re probably running into a few roadblocks.
A 2016 report by Johns Hopkins patient safety experts estimates that more than 250,000 annual deaths in the U.S. happen because of medical mistakes. The National Academy of Medicine has endorsed DMT consultative services as a means of reducing diagnostic errors. Healthcare organizations that have already created DMTs are quickly realizing the beneficial results that can stem from assembling a team of experts in a specific discipline to evaluate individual patient histories and lab data, and generating recommendations on diagnostic testing to improve outcomes.
“Instead of simply throwing test results over the wall to treating physicians, the DMT puts together the diagnostic puzzle and generates a diagnosis, or a short list of diagnostic options. This provides the information to the treating healthcare provider that they need because they do not know it,” explained Dr. Michael Laposata, Professor and Chairman of the Department of Pathology at the University of Texas Medical Branch in Galveston, and a leading proponent for DMT creation and use.
Here are five of the most common hurdles you’re likely to face in creating a DMT, with tips on how to overcome them.
To manage and oversee the functions of a DMT, you’ll need at least two dedicated pathology experts (one at a time usually to share leadership) in an individual service line who are committed to making themselves available for the project on a daily basis.
“There must be an attending lab expert, often a pathologist or Ph.D. laboratorian, who can review a tentative diagnostic narrative created by a person who has investigated the case and has medical knowledge,” Dr. Laposata said.
Once the leaders of the group have been established, diversifying DMT membership to broaden the expertise of the group is a key component of its success. Depending on your needs and area of focus, the team might include clinical laboratory scientists, doctors from other disciplines, project managers, IT staff, PhD fellows, and pathology residents.
“Typically in our DMT and coagulation, we have attending physicians from medicine and critical care as well as pathology, a pathology resident and a variety of visitors who come to learn how to diagnose coagulation disorders,” Dr. Laposata added.
While there’s no required number of members, you’ll benefit from different viewpoints to provide the most comprehensive recommendations. However, you want to keep the group small enough to allow everyone the chance to offer input.
The ultimate goals of a DMT are shorter time to diagnosis, increased diagnostic accuracy and greater optimization of lab tests. While these aims may sound like goals everyone in your organization should already have, getting people to join your DMT on a volunteer basis isn’t often as simple as you’d expect.
Convincing prospective members to participate comes down to overcoming individual objections and providing DMT success stories that offer reassurance of the concept’s value.
Because private insurance companies determine which activities are worthy of payment in the U.S., the provision of a patient-specific, expert-driven lab test interpretation may only be partially covered, if at all. Another factor to consider, lab experts who aren’t medical doctors can’t bill for consultative services. “If revenue is the only concern, an MD can co-sign DMTs generated by non-MDs. However, the savings from a quick and accurate diagnosis and optimization of lab test use saves far more than the very small revenue from the interpretation,” says Dr. Laposata.
“At this time, insurance companies are unfamiliar with a truly value-added, patient-specific, expert-driven narrative that involves clinical laboratory tests,” Dr. Laposata described. “I’m hopeful that as true value-added information emerges from large numbers of diagnostic management teams across the country, it will be apparent that this DMT paragraph is as valuable as the paragraph that describes a biopsy or an imaging study. At that point, I believe the insurance companies are far more likely to pay for expert advice from a DMT because it’s clear that it improves outcome and saves money.”
Establishing rapport and creating a sense of trust among DMT members sets the stage for open communication that leads to positive results. Everyone wants to feel that his or her opinion is valued and appreciated.
Dr. Joshua Kish, Anatomic and Clinical Pathologist at Greensboro Pathology Associates and Medical Director for the Aurora Research Institute, participated in a DMT during his residency at Massachusetts General Hospital.
“The trust was there already because our group was led by Dr. Laposata, and he had already established such a strong knowledge base and team of physicians across multiple disciplines,” he said.
Dr. Kish feels that working with passionate doctors who represented a broad spectrum of relevant disciplines and respected the opinions of their fellow participants was a key contributing factor to his DMT’s success.
“The commonality was that we looked forward to doing rounds and discussing these cases to get input from everyone’s experience and knowledge,” he continued. “Having that trust, we were able to come up with verbal interpretations and recommendations that people were willing to really listen to. It was an interplay between the lab and the treating clinicians, which I think is really the point of the DMT initiative.”
Every organization struggles with the Catch-22 of finding a way to decrease episodic costs and prevent readmissions while at the same time improving the overall quality of patient care.
DMTs can save your organization money by minimizing overutilization and underutilization of diagnostic tests, and by helping reach definitive diagnoses in less time with fewer studies required. However, demonstrating value to the administrative powers that be in your organization comes down to a matter of being able to quantify results.
Health economist and Executive Director of Health Affairs at the Owen Graduate School of Business at Vanderbilt University, Dr. Larry VanHorn makes a compelling argument for the use of an Interrupted Time Series control that ties DMT intervention to specific cases and time frames, examining differences in resource use and length of stays — measurements that hospital management values and understands.
“The financial challenges faced by hospital administration are growing year over year,” Dr. VanHorn said. “A demonstrated ability to reduce costs and resource consumption will be key to success. One must recognize that management is frequently confronted with the ‘make an investment today and you’ll see a return tomorrow’ story line. Through the use of small pilot/proof-of-concept initiatives, you can produce real data that will make it easier for management to support broader initiatives.”
Selecting a specific patient group or DMT area of focus, Dr. VanHorn suggests comparing financial and operating metrics pre- and post-DMT intervention, taking into account length of stays, resource use, billing and the costs of operating the DMT.
“The challenges facing the DMT team are to measure the effect of the intervention, tie it as directly as possible to the DMT initiative, and translate those changes into financially meaningful results for the facility,” he explained. “If successful, through the design of the DMT intervention, the team should be able to approximate a randomized control trial and quantify the incremental differences between the treatment and control population.”
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