Informatics and Pathology’s Role in Healthcare

Dr Glenn Edwards

glenn.edwards@sjog.org.au

Disclosure

Former shareholder, CEO, Medical Director of Pacific Knowledge Systems

BNP use /1000 patients / PCT

Still extremely low use in many areas: • Excess costs • Poor patient

experience • Failure to adopt

innovation

Map from Atlas of Variation

Linking HbA1c Tests to Prescribing

Automated support for pathologist opinions • RippleDown reporting application

– Interfaced to LIS

– Incremental knowledge acquisition by pathologists/scientists

• Decision support for pathologist opinions

• Common, high volume tests (lipids, glucose, HbA1c, LFTs etc)

• Complex lower volume tests (PTH, fertility etc)

• Opinions designed to – Diagnosis and management according to guidelines or best practice

– Detect guideline or other non-compliance

– Make specific recommendations for action

• NOT canned comments – must be close match to manual task

9

Selection criteria for rule-based systems

• Capacity for end-user modification

• Manager driven (not IT driven)

• Early deployment (not protracted testing)

• Broad scope (eg: clinical pathology)

• Handles complex, time-course data

• Adapts to local norms

• Evolutionary

What happened to “Decision Support?”

Economic Benefit of Guidelines 12,635 patients with diabetes

– Medicare “5% random sample” database (USA) – 1998-9 incident diabetes – >= 67 yrs; without known retinopathy, neuropathy, renal or CV disease

Follow up period 2000-2003 – Measured Medicare expenditure in the follow-up period

Guideline measure: receiving at least 2 x HbA1c tests per year – Controlled for factors that may limit access to care

Outcome – 2 or more HbA1c levels per year decreases Medicare payments by $953

per patient-year – Projection: for uncomplicated diabetes >= 67 yrs, Medicare could have

saved $174 million Li et al. Am J Med Qual 2010;25(3):202-210

RippleDown Decision Support tool

21

How would you interpret these results?

39 year old female

Cholesterol 5.1 mmol/L

Triglyceride 3.5 mmol/L *

HDL cholesterol 0.9 mmol/L *

LDL cholesterol 2.6 mmol/L

Guidelines • Guidelines for the Assessment of Absolute Cardiovascular Risk (National

Heart Foundation of Australia, 2009)

• Position Statement on Lipid Management (National Heart Foundation of Australia and Cardiac Society of Australia and New Zealand, 2005)

• Diabetes Management in General Practice, 2009/10 (Diabetes Australia and Royal Australian College of General Practitioners)

• Chronic Kidney Disease (CKD) Management in General Practice (Kidney Health Australia, Melbourne, 2007)

• Local practice

• Local opinion

Key compliance issues - examples • identifying patients known to be at increased absolute risk for CVD

• identifying patients, not known to be at increased risk, who require risk assessment

• providing an internet URL as information to doctors

• identifying low- and high-risk individuals for CHD

• recommending LDL-cholesterol target levels relevant to risk category

• identifying non-compliance with LDL-cholesterol targets

• recommending statin therapy for patients at increased risk for CHD

• identifying patients with various hyperlipidaemias

• recommending target levels for triglycerides and HDL-cholesterol

• recommending triglyceride-lowering therapy for resistant hypetriglyceridaemia

• identifying patients at risk for Familial Hypercholesterolaemia

• identifying patients who require testing for secondary causes of hyperlipidaemia

– Hypothyroidism, Liver disease, Renal disease

• identifying patients at risk for diabetes

• recommending follow up testing for abnormal glucose tests

– On current or previous results

• identifying patients who require recurrent follow up (eg impaired glucose tolerance)

• recommending timing and selection of appropriate tests for follow up testing

• In diabetes, identifying non-compliance and recommending corrective action with:

– annual HbA1c testing for people with diabetes

– annual urine microalbumin testing for people with diabetes

– annual assessment of lipid profile in people with diabetes

– more frequent HbA1c testing in people with poor glycaemic control

– annual eGFR testing in people at increased risk for chronic kidney disease

Role of lab decision support in FH

Population relevance • FH kills young adults

• Many unrecognised until CCU or morgue

• Preventable

• Family studies

Clinical benefit • Earlier statin and other intervention.

• Referral for genotyping, scoring and Dx, family studies

Doctor visibility • Uncommon condition (cf very common CVD risk assessment task)

LIS power

• Temporal record of cholesterol results

• Record of results for secondary causes (TSH, LFTs, EUC, Uprot, etc)

• Clinical data

Impact of Pathologists’ advice on LDL cholesterol levels

Bell DA et al Clin Chim Acta 2013;422:21-25

Interpretative comment

Control Significance

Number of individuals 96 100

Repeat LDL-cholesterol Number (%)

63 (71%)

70 (70%)

NS

Mean reduction in LDL-cholesterol (mmol/L)

3.0 2.3 p<0.005

Specialist referral (whole group)

4 (4%)

1 (1%)

p=0.20

Specifically suggesting referral in interpretative comment.

3 26 individuals

(11.5%)

1 (1%)

p<0.05

UK standards for authorisation and reporting

• Comment on all reports: 5%

• 42% no policy

• 31% consider highlighting “abnormals” to constitute an interpretation of the result

Prinsloo P. & Gray T. Ann Clin Biochem 2003;40:149-55

• Gaps in best practice are well known

• In many cases, evidence of sub-optimal

practice is evident in the LIS

• What is our professional responsibility?

• Do we have a mandate to provide an opinion

with every report? If not, why not?

CLN August 2014

UK NHS National Pathology Programme DigitalFirst: Clinical Transformation through

Pathology Innovation

http://www.england.nhs.uk/2014/02/14/npp-digital-first/

“… the power of standardised information brought by the NLMC, will provide the opportunity to identify a clear link between tests, treatments and outcomes.” “Shared electronic care records will provide an end-to-end view of patients’ health care – standardised pathology terminology will enable patterns and warning signs to be detected by pathology analysts” NHS Pathology ‘DigitalFirst Report 2014’

Pathology management of care

People will manage their own health, and will have access to their records and test results through their own health portal accessed online or on personal digital devices. They will commission their own health services, and will seek support and advice from the most appropriate specialist. Pathology will be the centre of this, working directly with patients and alongside other health professionals, to support them through screening, diagnosis and monitoring of health and disease. NHS Pathology ‘DigitalFirst Report 2014’

Consumer management of care

What is our VISION for Pathology in Australia?

Pathology 2.0 Pathology 1.0 • Reactive (Transactional, commoditised)

– Responding to clinician orders – Selling lab results to payer (Govt) at the lowest price = DEAD END

Pathology 2.0 • Proactive (Evidence based, consumer centric)

– Supporting consumer-driven wellness and healthcare – Supporting evidence-based care – Collaboration in consumer and population health

– Decision support • Design, governance, evaluation, collaboration

– Remuneration • Value-based

Informatics and Pathology’s Role in Healthcare

Dr Glenn Edwards

glenn.edwards@sjog.org.au

Disclosure

Former shareholder, CEO, Medical Director of Pacific Knowledge Systems