Tracking Test Utilization Management Cases and Metrics for Iterative Process Improvement Gillian W. Hooker PhD, ScM, CGC
Concert Genetics
ACMG Annual Clinical Genetics MeetingMarch 8-‐12, 2016 ·∙ Tampa, Florida
• Paid Employee of Concert Genetics
Conflict of Interest
Utilization Management programs aim to provide patients with diagnostic tests that are appropriate to the patient, high-quality, and cost-effective.
ACMG Annual Clinical Genetics MeetingMarch 8 – 12, 2016 • Tampa, Florida
A Utilization Management Framework
4
PatientOutcome
Order Error Rate
Dollars SpentInstitution
Clinician
Patient
BackgroundFactors
InstitutionCulture
ClinicianAttitudes
PatientAttitudes
Test ordering decision
Sample Processing& Review
Test Resulted
Outcomes
ACMG Annual Clinical Genetics MeetingMarch 8 – 12, 2016 • Tampa, Florida
Utilization Management End Outcomes • Dollars spent/saved
-‐ Pre-‐post design-‐ Costs avoided1,2
• Errors/Errors avoided – Duplicate testing – Inappropriate testing3
• Patient outcomes-‐ Diagnostic yield 4
-‐ Actionable results
ACMG Annual Clinical Genetics MeetingMarch 8 – 12, 2016 • Tampa, Florida
A Utilization Management FrameworkIntervention Points
6
Test ordering decision
Institution
Clinician
Patient
InstitutionCulture
ClinicianAttitudes
PatientAttitudes
Sample Processing& Review
Test Resulted
PatientOutcome
Error Rate
Dollars Spent
BackgroundFactors
Decision SupportFormulariesPrivileging
Review RedirectionRestriction
Education and marketing
ACMG Annual Clinical Genetics MeetingMarch 8 – 12, 2016 • Tampa, Florida
Intervention Points & Metrics to Define Intervention Success • Attitudes– Provider satisfaction
• Decision Making – Test ordering patterns5
• Review 1,2,3
– Tests reviewed– Potential costs saved at review
7
ACMG Annual Clinical Genetics MeetingMarch 8 – 12, 2016 • Tampa, Florida
A Utilization Management Framework
8
Test ordering decision
Institution
Clinician
Patient
InstitutionCulture
ClinicianAttitudes
PatientAttitudes
Sample Processing& Review
Test Resulted
PatientOutcome
Order Error Rate
Dollars Spent
BackgroundFactors
Outcomes
ACMG Annual Clinical Genetics MeetingMarch 8 – 12, 2016 • Tampa, Florida
Tracking
ACMG Annual Clinical Genetics MeetingMarch 8 – 12, 2016 • Tampa, Florida
Challenges to Tracking Cases and Metrics:Market Dynamics
Net New Tests to the Market 2014-2015
On average, 8-10 new tests enter the market every day.
ACMG Annual Clinical Genetics MeetingMarch 8 – 12, 2016 • Tampa, Florida
Challenges to Tracking Cases and Metrics:Workflow
DxEMR
LIMS
ReferenceLaboratory
scan
SpecimenProcessing
Sendout Lab
ACMG Annual Clinical Genetics MeetingMarch 8 – 12, 2016 • Tampa, Florida
Finding and Collecting UM Data
• Where is the data? – EMR – LIMS (pending logs) – Billing – Reference Lab Reports– Other?
• What data to collect?
ACMG Annual Clinical Genetics MeetingMarch 8 – 12, 2016 • Tampa, Florida
Key UM Data Points
NSGC TUSC Committee“Establishing Genetic Test Review at Your Institution”
ACMG Annual Clinical Genetics MeetingMarch 8 – 12, 2016 • Tampa, Florida
Strategies To Continually Track Cases and Data
• Consider feasibility of questions and impact of potential outcomes
• Mechanisms to track – balancing workflow and documentation – Spreadsheets – Access databases – Integrating data collection into the platform for ordering and tracking results (GeneConnectTM)
• Establish reporting periods and intended audience
ACMG Annual Clinical Genetics MeetingMarch 8 – 12, 2016 • Tampa, Florida
Controlling Costs with Increasing Volume
3 month 9 month6 month
Test Volume
Per Test Cost
- 50% increase in volume
- 30% decrease in per test cost
- No change in overall costs
ACMG Annual Clinical Genetics MeetingMarch 8 – 12, 2016 • Tampa, Florida
Looking Ahead
• Who will do all of this work?
• Won’t utilization management work itself out of a job?
• What happens when everyone just gets their whole genome sequenced?
Utilization management may be a mechanism to scale the expertise of those trained in genetics.
Testing is changing so rapidly, utilization management must change and adapt with it.
See above.
ACMG Annual Clinical Genetics MeetingMarch 8 – 12, 2016 • Tampa, Florida
Acknowledgements
Concert Genetics Team – Cheryl Hess – Dan Kauke– Nick Tazik– Taylor Murphy– Jud Schneider
ACMG Annual Clinical Genetics MeetingMarch 8 – 12, 2016 • Tampa, Florida
References 1. Riley, J., Procop, G., Kottke-‐Marchant, K., Wyllie, R., Lacbawan, F. (2015) 'Improving
Molecular Genetic Test Utilization through Order Restriction, Test Review, and Guidance.' J Mol Diagn, vol. 17, no. 3, pp. 225-‐229.
2. Dickerson, JA, Cole, B, Conta, JH, Wellner, M, Wallace, SE, Jack, RM, Rutledge, J & Astion ML 2014, ‘Improving the value of costly genetic reference laboratory testing with active utilization management’, Arch Path Lab Med, vol. 138, pp. 110-‐113.
3. Miller, C, Krautscheid, P, Baldwin, E, Tvrdik, T, Openshaw, A, Hart, K & LaGrave, D 2014, 'Genetic Counselor Review of Genetic Test Orders in a Reference Laboratory Reduces Unnecessary Testing', Am J Med Genet, vol. 164A, pp. 1094-‐1101.
4. Shashi, V, McConkie-‐Rosell, A, Rosell, B., Schoch, K., Vellore, K., McDonald, M., Jiang, Y., Xie, P., Need, A., Goldstein, D.(2014) ‘The utility of the traditional medical genetics diagnostic evaluation in the context of next-‐generation sequencing for undiagnosed genetic disorders’ Genet Med vol. 16(2) 176-‐182.
5. Feldman, LS, Shihab, HM, Thiemann, D, Ardolino, M, Mandell, S & Brotman, DJ 2013, ‘Impact of providing fee data on laboratory test ordering: a controlled clinical trial’, JAMA Internal Medicine, vol. 173, no. 10, pp. 903-‐908.
