| Web: | mayocliniclabs.com |
|---|---|
| Email: | mcl@mayo.edu |
| Telephone: | 800-533-1710 |
| International: | +1 855-379-3115 |
| Values are valid only on day of printing | |
| Web: | mayocliniclabs.com |
|---|---|
| Email: | mcl@mayo.edu |
| Telephone: | 800-533-1710 |
| International: | +1 855-379-3115 |
| Values are valid only on day of printing | |
Promoting laboratory stewardship through clinical decision support
Case Study
An order-entry, clinical decision support tool developed by physicians and scientists at Froedtert and the Medical College of Wisconsin (MCW) for clinicians within the healthcare system who order autoimmune and paraneoplastic antibody panels has significantly improved test utilization, resulting in a 28% reduction in monthly test volumes of impacted tests.
Confusion and lack of knowledge about the appropriateness of specific antibody panels for patients suspected of immune-mediated neurological illness is a ubiquitous problem. At Froedtert & MCW, this issue has resulted in improper antibody test ordering and wasted expense and laboratory resources.
The problem isn’t new for clinical labs and is one Robert Nerenz, Ph.D., associate professor of pathology and laboratory medicine at MCW, has been mulling for most of his career.
“I’m sort of tongue-in-cheek saying I’ve been thinking about it since month three of fellowship, but that is not entirely wrong,” Dr. Nerenz says. During his fellowship, Dr. Nerenz was on the front lines of confronting a lack of education about testing appropriateness.
“The way a lot of institutions handle their lab stewardship is to have chemistry fellows and pathology residents do this retrospective review after the test has been ordered and the sample collected,” Dr. Nerenz says. “We look at the indications for testing, at how the test works, what was it ordered for, what is the clinical question trying to be answered, and is this the appropriate test for that. And if the answer is anything other than yes, then you get in touch with the provider, which sometimes can be a contentious discussion.”
The disconnect usually stems from an underlying unfamiliarity with the antibody associations of certain immune-mediated disorders.
“There is some guidance in the literature, but when we, as practicing clinicians, are seeing the patient and ordering testing, sometimes you forget or don’t have the time to go and check what they are,” says Ahmed Obeidat, M.D., Ph.D., associate professor of neurology at MCW.
Autoimmune and paraneoplastic antibody evaluations ordered by MCW physicians are sent to Mayo Clinic Laboratories for processing.
“There is a big value for these panels,” Dr. Obeidat says. “We are diagnosing more autoimmune cases than ever before in neurology thanks to the lab tests developed worldwide, including those at the Mayo Clinic Laboratories, where tests with good sensitivity and high specificity antibodies have been developed.”
But in order for the value of these tests to be fully realized, they have to be used properly. At MCW, it was noted by both Dr. Nerenz and Dr. Obeidat that autoimmune antibody panels were ordered suboptimally.
“People were ordering the same test multiple times, and patients were being resulted three or four times for the same test, surprisingly,” Dr. Obeidat says. “We also noticed clinicians were ordering some of the panels that have overlapping antibodies together, meaning they would order an autoimmune encephalopathy panel and then an autoimmune dysautonomia panel and then an autoimmune epilepsy panel without realizing that they have a lot of overlap.”
When Dr. Nerenz joined MCW as co-director of the Chemistry and Toxicology Laboratory in July 2022, he made improving testing utilization a priority. Joining forces with Dr. Obeidat and neurologist Sam Hooshmand, D.O., the team set out to develop a clinical decision support test ordering tool.
“From day one there was this built-in clinical partnership where it was not only a lab initiative, but a neurology initiative,” Dr. Nerenz says. “If you don’t have clinical buy-in, it’s not going anywhere. We were both very much on the same page that this is something we needed to address, and we started on it right away.”
“The team’s initial discussions resulted in the development of an algorithm,” Dr. Obeidat says. “We actually first did everything on paper.”
The algorithm had dual purposes, Dr. Obeidat says. “The clinical decision tool is going to be both educational and help us be more efficient by increasing the yield of testing and decreasing cost, which is a big thing for us as an institution and also for the patient, too.”
Gaining support from the clinical practice was essential, and a movement disorders specialist and neuromuscular specialist from MCW were recruited to help.
“If we sit in the lab and come up with a grand idea that we think is going to solve all of our problems and roll it out without talking to clinicians who are going to be using it, maybe you’ll get lucky and it will work,” Dr. Nerenz says. “More likely the users will take one look and say, ‘I hate this, can you put it back the way it was please.’”
Next, the team gained buy-in and technical support from Froedtert & MCW’s IT experts, who were integral in making the team’s vision a reality.
The IT specialists translated the algorithm to a digital format that resided within the structure of Froedtert & MCW’s electronic medical record. Following an iterative design process, a demo model of the ordering tool was created and sent to the movement disorders specialist and neuromuscular specialist for trial. A few suggestions for improvement were given, and after implementing those changes, the tool was ready to go live.
“Building the solution collaboratively with the end users in neurology made implementation pretty seamless because they had designed a tool they knew would work for them,” Dr. Nerenz says.
Before going live, Drs. Nerenz and Obeidat scheduled an informational session with the neurology residents, who place the bulk of test orders.
“I still remember standing in that room, describing what we were going to do and what the solution was going to look like, and sort of universally their eyes lit up and they said, ‘This is great, it is going to make our lives so much easier,’” Dr. Nerenz says.
Now, when any clinician who belongs to Froedtert & MCW’s healthcare network requests an autoimmune neurology test through a patient’s medical record, the clinical decision support tool pops up, prompting users to answer questions that lead them to the right test for their patients.
“If there is any suspicion of an autoimmune illness, you have to go through the panel,” Dr. Obeidat says. “You can’t order any other test without it, so it’s really well done.”
The ability to provide test ordering guidance to clinicians in real-time is vastly more efficient than the onerous retrospective review process previously employed in the lab to ensure testing appropriateness, says Dr. Nerenz. “It is a really unique aspect of the solution we put in place.”
An important aspect of the educational goal of the clinical decision support tool was documenting and publishing the results after implementation.
“This is a challenge for lots of different medical centers, and we wanted to describe what our solution was so people could read it and say, ‘This is appropriate for our institution,’ and then adopt it wholesale or as a starting point that can be adjusted as needed,” Dr. Nerenz says.
Since the results were reported, Dr. Nerenz and his co-authors have been contacted by outside laboratory professionals interested in replicating the tool in their own institutions.
“Interdisciplinary teams can work together to achieve something like this,” Dr. Obeidat says.
“Academic centers with multiple departments can adopt this easily, they can modify it to work in their own institutions, and they really will see significant improvements similar to what we saw and what we are still seeing. This is something that will help with the diagnostic accuracy but also help cut down costs.”
