Behind the Scenes at NDSC

My day ranges from troubleshooting a technical issue to helping to shape our messaging around product benefits for commercial payors and ACOs. At the end of the day, what I do is meaningful, satisfying, stimulating, and pretty difficult – what more could you want!

What is your role at NDSC and what aspects do you enjoy the most?

I am a product manager for CareSelect Lab, CareSelect Blood, and as with all of our solutions there is a strong tie to our work to automate prior authorization. My favorite aspect of the role is supporting a cross-functional team and charting the future of the product. It’s satisfying to know every nook and cranny of the products: EHR specific implementation details; interactions with our code-base; key contractual details; and specifics for the sales team.

My day ranges from troubleshooting a technical issue to helping to shape our messaging around product benefits for commercial payors and ACOs. At the end of the day, what I do is meaningful, satisfying, stimulating, and pretty difficult – what more could you want!

 

What has been your team’s greatest accomplishment at NDSC?

There are two main areas of pride for our team. The first is the speed that we developed CareSelect Lab and made it available to the market. The second is building and expanding NDSC’s relationship with Mayo Clinic to cover additional content areas.

Our engineering team has developed a platform flexible and powerful enough to create CareSelect Lab in a matter of months. The time from content hand-off to being ready for our first install was close to 90 days. That’s speed that makes you re-think how fast healthcare I.T. can move.

Regarding our expanding relationship with Mayo Clinic, as a company, we pride ourselves on the authenticity and depth of our relationships with our clinical and EHR partners. Mayo Clinic, as an organization, is a tough group to win over. There are vendors and partners that line up around the block to work with them. It’s a well-deserved honor and testament to our work together to continue expanding our relationship.

 

Can you explain the importance of NDSC’s relationship with Mayo Clinic?

Our roots are in imaging, and we have an ongoing, deep relationship with the American College of Radiology (ACR). We deliberately work with leading academic medical societies and academic medical centers to transform their clinical rules into guidelines and deliver those guidelines to providers at the point-of-order. Each clinical service line is different. We knew there was a need, but there was a lack of vetted content with the breadth and depth we saw our customers were clamoring for.

Enter Mayo Clinic and Mayo Medical Labs, a US News and World Report number one hospital, the fourth largest reference lab, and a leader in integrated care delivery. Mayo Clinic authored 1,500 best practice guidelines for ordering labs ranging from daily labs to high-cost genetic and molecular tests. In a narrow sense, no other organization could bring to the table what Mayo Clinic could for the lab space.

Zooming out, Mayo Clinic has a wealth of clinical expertise and an organizational dedication to disseminating that knowledge across healthcare. We see a natural alignment between world class clinical care with academic scholarship and our highly scalable clinical content delivery platform with deep relationships with EHRs – the future is bright.

 

What makes the collaboration between NDSC and Mayo Clinic unique?

A business relationship can look and feel a lot of different ways. On one side of the spectrum is the quid-pro-quo approach; I do something for you and then you do something for me. On the other side of the spectrum, which is where I place Mayo Clinic and NDSC, you are working together in pursuit of a shared goal that aligns with your shared values. In a matter of months, we felt like NDSC was part of the Mayo Clinic family and like Mayo Clinic was part of the NDSC family. That’s the difference that makes our partnership unique

 

Can you elaborate on the process of transforming Mayo Clinic’s advisories into actionable clinical guidance for CareSelect Lab?

It’s a difficult and complicated process. I applaud any organization with the resource commitment and wherewithal to do this in-house because it is a serious undertaking. Between both organizations, we have approximately 10 full-time informaticists, equally split, devoted to curating clinical content and transforming it into the I.T. logic deployable by the CareSelect Platform.

Mayo Clinic proposes clinical rules that are thoroughly vetted by the cross-functional Clinical Practice Committee (CPC). The CPC’s membership includes pathology and other traditionally represented clinical specialties: Internal Medicine, Emergency Medicine, and so on. What’s unique about Mayo Clinic’s process is the rigor each rule goes through and the commitment to, at minimum, yearly reviews of the recommendation.

Once a rule is approved, the logic and supporting academic literature is handed over to NDSC to build, test, and package up the logic. I like to think we have the easy part of this effort, the thousands of hours of spent researching, debating, and agreeing to the clinical logic is the larger effort.

 

Why a lab solution?

A combination of reasons. First, our customers saw what we could do with CareSelect Imaging and were asking how we can help with lab. The real question is why does lab need a CDS solution that affects ordering clinical behavior?

20-40% of lab tests are unnecessary and wasteful. The margins on reimbursement are shrinking across healthcare and acutely in lab with downward price pressure from the 2018 CMS Lab Fee Schedule. As health systems are transitioning to value-based care arrangements with their payors, quality and reimbursement are aligning around the best care for a patient. At the same time, molecular, genetic, and specialty tests are increasing in price. We see labs feeling the pressure to do more with less and the looming threat of being outsourced. Most difficult, their hands are tied when it comes to the folks that affect their bottom lines. Looking at it from that perspective, labs are some of the hungriest clinicians for CDS and care model standardization.

 

What aspect of NDSC’s CareSelect Lab do you find most valuable and why?

Our genetics and molecular content, hands down. What we hear consistently from ordering clinicians, pathologists, and payors is that staying up to date with the best practices of genetic test orders is difficult. With rapid advancement and changes in genetics testing, it’s an area that benefits everyone.

 

How has NDSC’s partnership with Mayo Clinic expanded and evolved the CareSelect Platform?

Mayo Clinic’s content and thought leadership caused us to re-think how we look at CDS and the direction of patient care.

Mayo Clinic’s integrated practice model produces a unique perspective on patient care driven by the suspected condition. We’ve always supported pathways and arranging information as a series of decision trees, but never stepped back and holistically evaluated how a team of clinicians treat a condition.

Step one in a patient’s care odyssey starts with the PCP and the underlying condition becomes less pixelated each step of the way as the patient moves towards more specialized practitioners. This perspective of organizing clinical knowledge was an eye-opener for us.

 

Looking forward, how do you see CDS evolving?

The future of medicine is the return to what we want medicine to be focused on: providers and patients making shared and informed decisions about what to do next. If we can eradicate the knowledge gap for providers such that any patient – anywhere – can receive the best care in accordance with the research, then what is left for CDS to do?

Choosing Wisely was and is barking up the right tree, the concept of shared decision making is the future of medicine. We can strip away the promising science and new, fad technologies, but what are we left with? Providers that know the best choices available and a patient that can share in determining what is best for them. It’s easy to get caught up in the “what” and “how” of the new technologies and clinical innovations. It’s harder and more important to step back and remember why these advances are important and get back to the core of enabling providers to practice high quality medicine.

 

Outside of your professional life, what do you do for fun?

I live in Madison with my wife, Katie and two cats, Remy and Bella. Outside of work, I love to travel abroad, drink wine, read books, play squash, cook, and spend time with friends and family. Also, I’m a huge healthcare policy and industry nerd. It’s funny, and not surprising to me, that my personal blurb is ten times shorter and less interesting than my musings on healthcare.

Why is it important for health systems to have Clinical Decision Support within the laboratory?

The transition from volume to value is accelerating. Appropriate lab testing can lead to fewer tests, while delivering the same level of quality patient care. Additionally, the explosion of technology and associated information around the ordering of complex testing – combined with high costs – is leading to the need for additional guidance.

 

Why is Mayo Clinic’s collaboration with NDSC unique?

Currently, there isn’t a single source of trusted, vetted laboratory guidance on appropriate test ordering. Health care providers are required to reference multiple sources, which can be a very time-consuming task. By partnering with NDSC, Mayo Clinic is able to provide a single source of test guidance, integrated into the electronic health record, available at point-of-order entry. This allows for minimal workflow disruptions, giving health care providers more time to spend with their patients.

 

Can you elaborate on the process of turning Mayo Clinic best practice guidelines into clinical advisories for CareSelect Lab?

Mayo Clinic sees more than 1 million patients every year, with conditions that range from community patients to high complexity patients. Having the opportunity to see, diagnose and treat these patients allows us to create unique integrated care models. These models represent the highest standard of care delivery with a focus on patient outcomes and efficiency. Mayo Clinic has taken these care models and converted the laboratory testing knowledge into outputs that NDSC then translates for the electronic health record. The end result is CareSelect Lab, which is then available at the provider’s fingertips. Additionally, Mayo Clinic has an internal team that is constantly reviewing and updating the care models to ensure accuracy.

 

The average 500-bed hospital performs over $750,000 worth of clinically redundant and duplicative tests annually, how does CareSelect Lab help mitigate this?

Literature has identified that 20% to 40% of laboratory orders are unnecessary. When examining a subset of CareSelect Lab guidance against a 5 million life database, it was identified that the average 500-bed hospital has $750,000 of potentially unnecessary laboratory testing.

CareSelect Lab provides healthcare organizations the ability to benchmark their laboratory test ordering against best practices. In doing so, areas for greatest opportunity are highlighted and specific guidelines can be seamlessly activated with minimal intrusion to the provider workflow.

 

How does CareSelect Lab solve current problems within health care?

The U.S. spends approximately $3.2 trillion a year on healthcare. For health care providers, reimbursement levels are declining at the same time the cost of care for patients is rising. CareSelect Lab allows providers to introduce appropriateness in order to better align cost to reimbursement and mitigate downstream costs.

 

Why was it important to expand CareSelect Lab to deliver guidance for an expanded range of difficult and uncommon clinical scenarios?

Complex condition management is what Mayo Clinic excels at – we’ve been seeing patients with complex diseases and conditions for over 150 years. Many times, these complex conditions have high-costs associated with them, and can have a large impact on the clinical diagnosis and treatment for the patient. By expanding CareSelect Lab, we’re now able to provide guidance to a variety of patients and healthcare providers – whether you’re a community hospital or a large academic medical center.

 

What impact does having clinical decision support have for patients?

Clinical Decision Support (CDS) assists healthcare providers in ordering the right test, at the right time, for the right patient. This assistance allows for numerous benefits to the patient, including:

• Fewer lab tests ordered, resulting in less expensive care and fewer blood draws
• Lower total cost of care through appropriate diagnosis and treatment
• Improved quality of life by arriving at a diagnosis quicker and allowing treatment to begin sooner
• Enhanced transparency on care delivery options and costs

 

Looking forward, what do you hope for the future of CDS with respect to laboratory testing?

CDS enables providers to leverage the full potential of laboratory testing to appropriately diagnose and treat patients. As a result, solutions like CareSelect Lab are critical to bending the unsustainable growth rate of healthcare spending. Mayo Clinic and NDSC are committed to an ongoing partnership to continually deliver existing and emerging best practices to healthcare providers and the patients they serve.

Leading the delivery of ground-breaking technology and optimization of NDSC solutions

 

Tom Conti, VP of Product and Technology

Tom has been leading the product and technology teams at NDSC since the company was established in 2012. Tom’s role ensures that the development team delivers ground-breaking technologies and that customers successfully optimize NDSC’s solutions. Prior to joining NDSC, Tom held a variety of leadership roles that included Product Lead for the Epic RIS and management of the imaging integration R&D team. Through Tom’s leadership, NDSC’s satisfied customer base continues to prosper.

“I love being able to talk to an existing customer, having them ask if our platform is able to help them improve a clinical scenario and being able to say ‘yes’.”

 

 

 

Tell us more about your role at NDSC and the aspect of your role you enjoy the most.

 

I get to have an active role in improving our current products and strategizing on what new products NDSC should build. I really enjoy being able to combine our EMR integrations capabilities, structured or unstructured clinical data, and patient care improvement opportunities to build a new product.

What would you say has been your team’s greatest accomplishment at NDSC?

 

The CareSelect™ Platform that the teams have created is the greatest accomplishment. Having a single platform that is able to seamlessly integrate into over eight major EMR systems while delivering multiple clinical content sets through each integration (Imaging, Lab, Choosing Wisely, Level of Care, etc). NDSC’s platform handles the complexity so our customers can successfully deploy CDS at their organizations.

How does your team’s work, on a day-to-day level, impact NDSC health systems using CareSelect solutions?

 

Product and Technology teams at NDSC are all about continuing to improve the delivery of the clinical content into the provider workflow. I love being able to talk to an existing customer, having them ask if our platform is able to help them improve a clinical scenario and being able to say “yes.” I was recently talking to an academic medical center where they asked if CareSelect could help them evaluate whether imaging is needed for Pulmonary Embolism using Wells pre-test probability scores. It was great to say “yes” and know that we have helped organizations do this as well.

“I love being able to talk to an existing customer, having them ask if our platform is able to help them improve a clinical scenario and being able to say ‘yes’.”

In your view, how does the technology behind the CareSelect Platform help to create impact within health systems?

 

The technology platform creates a standard methodology to extract clinical data and use that data to run complex clinical algorithms. Health systems look to NDSC to implement this system to help them achieve their clinical outcome goals. It is inspiring to hear from our customers when our analytics show both avoidance of unnecessary tests and improvement in ordering appropriateness for clinical conditions.

Tell us about how the technology behind the CareSelect Platform has helped create impact on the patient.

 

There are a lot of advantages for the patient, one being avoiding unnecessary testing. This helps prevent patients from having to take off work for that MRI and prevents angst worrying about the results of the test and the copay / out of pocket cost for the patient. NDSC customers show the average of inappropriate high-cost imaging orders at around 10% which, when projected across growing number of transactions NDSC processes, translates to over half-a-million unnecessary exams that can be avoided through our advisories and millions of dollars in unnecessary care. Furthermore, exams of questionable utility are always subject to review by insurance companies. This review process can result in denials of payment, costing the patient and their caregivers valuable time to appeal the request.

“NDSC customers show the average of inappropriate high-cost imaging orders at around 10% which, when projected across growing number of transactions NDSC processes, translates to over half-a-million unnecessary exams that can be avoided through our advisories and millions of dollars in unnecessary care.”

Looking forward, how do you see CDS technology evolving?

 

As the content sets included in CareSelect expand, the sophistication of the algorithm will grow. NDSC is exploring ways to get structured clinical information out of unstructured data. Additionally, leveraging advanced technologies like Machine Learning algorithms to train the content engine for improved accuracy on recommendations. I am attending HIMSS in March and am always interested to see how the industry is looking to leverage these technologies.

Outside of your professional life, what do you do for fun?

 

Outside of work, my three kids (William [6], Claire [4] and Charlotte [1 1/2]) keep me more than busy. I grew up playing hockey through college and still find time to both play ice hockey and coach my son’s mini-mite hockey team. Once the Wisconsin winter has thawed, I get out on the Madison lakes and water ski when I can.

Learn how Einstein Healthcare Network engaged more than 250 physicians and had a 17% increase in appropriate use studies utilizing CDS   

 

Dr. Ryan K. Lee, MD, MBA, MRMD

Clinical Associate Professor of Radiology, SKMC at Thomas Jefferson University
Magnetic Resonance Medical Director
Director of Quality
Section Chief, Neuroradiology
Department of Radiology
Einstein Healthcare Network

 

 

 

Dr. Ryan K. Lee, MD, MBA, MRMD is Clinical Associate Professor at the Sydney Kimmel College at Thomas Jefferson University. He is the Section Chief of Neuroradiology in the Einstein Healthcare Network, and serves as the Director of Quality and Magnetic Resonance Medical Director in the Department of Radiology. Areas of expertise include radiation management in imaging, radiology Clinical Decision Support, and MRI Safety. Dr. Lee is known for his work not only in CT radiation dose reduction, but also in the reduction of variance in radiation dose. An authority on quality in radiology, he serves on several quality and safety committees in the Einstein Healthcare Network. Dr. Lee has worked with National Decision Support Company (NDSC) to incrementally implement the CareSelect™ Platform across the Einstein Healthcare Network.

 

When did you start working with NDSC to implement CareSelect™ solutions at Einstein Healthcare Network?

 

We began our association with National Decision Support Company in 2015 and began our pilot program shortly thereafter.

Our initial pilot program consisted of approximately 60-70 physicians that volunteered to use Clinical Decision Support. Participants were specifically chosen to reflect a cross section of different physicians, including ER, internal medicine, family medicine, neurology, surgery, hospitalists, and oncologists.

The CareSelect™ Platform was activated either related to upgrades on the technical side or based on feedback we received from the pilot physicians. We have weekly phone conferences with our CareSelect representative, IT, PACS, and administration to make sure we stay on track with agenda items and issues.

Recently, we have entered into an expanded pilot phase, and have recruited over 250 additional physicians into the pilot. I am eager to solicit feedback from this now larger pool of physicians that are enrolled.

“Recently, we have entered into an expanded pilot phase, and have recruited over 250 additional physicians into the pilot. I am eager to solicit feedback from this now larger pool of physicians that are enrolled.”

What was the driving force behind choosing the CareSelect Platform to manage your CDS program?

 

We were acutely aware of workflow problems related to a previous vendor we had used for CDS. This service was not well received by our pilot physicians mainly due to the additional work required to order studies. When it became clear that the inherent design of that service would not allow for a smooth workflow regardless of changes, we decided to look for a new technical solution. As you can imagine, high on our priority was finding a CDS solution that had as minimal an impact on workflow as possible, one of the major complaints. This is exactly what we found with NDSC’s CareSelect. NDSC provided us with a solution that seamlessly integrated with our EMR and had minimal effect on our existing workflow.

In your experience, how has CareSelect helped improve the quality of healthcare at Einstein Healthcare Network?

 

The feedback we received from our pilot users, particularly those in primary care, was that it was a welcome tool in helping them choose the correct study. Some have told us that they feel more confident in ordering studies using the tool. Ordering the right study prevents having to reorder a script, causing inconvenience for both the patient and the facility. In addition, reducing the number of tests being ordered reduces the amount of radiation being applied to patients. CDS gives immediate test feedback during the time of order for the appropriate test. In addition to the standard CDS in CareSelect, we have also collaborated with NDSC in developing a tool to help clinicians decide if ordering head CTs in patients with minor head trauma are warranted using a well described algorithm in the literature. We believe that this is a future untapped potential in radiology CDS, which if applied in similar fashion to other clinical scenarios can have even more impact on utilization.

“Some have told us that they feel more confident in ordering studies using the tool. Ordering the right study prevents having to reorder a script, causing inconvenience for both the patient and the facility.”

What aspect of CareSelect do you think is most valuable for Einstein Healthcare Network and why?

 

The way CareSelect integrates into our EMR with minimal impact on the existing structure of our ordering process is a key component of clinician buy-in. In fact, we were able to recently recruit over 250 new clinicians into our now extended pilot program. This would not have been possible if the initial pilot physicians were not satisfied with our implementation.

What have you learned from implementing CareSelect and what impact has it had on the way Einstein orders tests today?

 

We performed retrospective evaluation of orders placed by our pilot clinicians when we first turned on CareSelect, and compared it to a time period five months after it was turned on. We found that there was a 17% increase of appropriate studies initially ordered months after it was turned on. Although this was a relatively small number of studies we evaluated, this could suggest that simply having a CDS embedded into the EMR may have an educational effect on ordering clinicians. It could be that over time as clinicians repeatedly order tests for similar indications, they learn the appropriate studies to choose.

“We found that there was a 17% increase of appropriate studies initially ordered months after it [CareSelect]  was turned on.” 

What advice would you give to other healthcare organizations looking to adopt NDSC’s CareSelect solutions?

 

Because every network has different needs, each application of CareSelect can be unique to that site. It is worth allowing sufficient lead time to work with your NDSC representative, IT department, and ordering clinicians to optimize the solution to best suit your network.

What do you envision for the future of imaging as it relates to CDS?

 

In addition to the clear utility of providing clinicians with evidence based information for the best study for each indication, I believe that using CDS to affect clinical management by applying algorithms which can help decide if studies are warranted are the next frontier.