No Longer Just the Doctor’s Doctor

When attempting to dispel the myth of the pathologist locked in a basement – friend only to the microscope and the tissue section – many of us turn to examples of patient interactions. It’s certainly true that there is a place for us in face-to-face conversations with patients, just as there is a place for us in medical education, and in community outreach. But these interpersonal interactions aren’t the only place outside the laboratory where our skills have value – and one oft-overlooked arena is, in my opinion, among the most important places where we can make a contribution; I see us as curators of health – not only for individual patients, but for entire populations.

The population’s doctor

In healthcare today, there are two somewhat parallel tracks, each focused on the same elements of the value equation – improving quality, access to care, and patient safety, while simultaneously reducing costs. On the one hand, increasingly personalized care narrows the focus down to the individual patient; this “precision medicine” uses genetic tools to tailor treatment protocols to improve the chances of a successful outcome and reduce unnecessary side effects. On the other hand, “population health” aims to manage and improve quality healthcare outcomes – not for specific individuals, but for groups in a community or a region. Population health also makes increasingly frequent use of genetic tools, such as genomic registries, to accomplish its healthcare goals.

Population health management offers us, as pathologists, a wonderful opportunity to use not only our diagnostic abilities, but also the teaching, administrative, and leadership skills that we have honed during our medical practice. It allows us to extend our sphere of influence well beyond our traditional “institutionalized” domains (in the hospital or private laboratory setting) into regional communities of care. It is an excellent opportunity to work collaboratively with other healthcare providers to ensure that at-risk populations are properly and regularly screened for diseases such as diabetes, cervical cancer and heart disease. As healthcare administrators and government decision-makers increasingly shift resources out of traditional acute care hospitals and into ambulatory care organizations (such as standalone surgi-centers, endoscopic clinics, or mother–child wellbeing centers), how can pathologists avoid becoming marginalized – both in terms of their remuneration and their interactions with other medical colleagues?

The answer: by stepping up to the plate – demonstrating our value to our healthcare ecosystem and by helping to lead the way through the digital transformation of our healthcare enterprise. As resources for healthcare continue to shrink and demand continues to soar, pathologists can show how targeted test utilization management (using sophisticated “big data” analytics) and clinical decision support tools, along with emerging artificial intelligence technologies, can save money and improve care for patients across the board.

A new kind of patient care

The beauty of population health management is that the need for direct contact with patients is even less of a barrier than it might be for pathologists involved in caring for individual patients. All physicians – whether they specialize in laboratory medicine, nuclear medicine, or emergency medicine – can contribute meaningfully in their respective disciplines to the bigger picture of health across populations. Indeed, the skill set required of such physicians is less focused on diagnostic abilities and more focused on a strategic mindset and organizational skills related to the transformation and integration of health systems. There are far more diverse ways to help our patients through the lens of population health than one-on-one conversations (though, of course, those remain valuable). Instead, or in addition, pathologists can tackle issues such as improving access to care, and maintaining the continuity of care as patients move – either vertically through the spectrum from primary to tertiary care, or horizontally amongst family physicians, nurse practitioners, and midwives in their community. After all, who is better placed than a pathologist to continually track a patient through the system using only their lab test results and medical records?

Pathologists, especially those with more generalist training in both anatomic and clinical pathology, are well poised to use their knowledge and skills in laboratory information systems (LIS) to guide the interoperability of hospital information systems (HIS) at the regional level. After all, it is often said that greater than 70 percent of clinical decision-making is based on patients’ laboratory information! Where better to start in population health management than in data mining the LIS and linking it meaningfully with other clinical data repositories? Not only will this help track patients and ensure continuity of care, but this kind of data analysis can also lead to new insights into improving patient care pathways in the community.

There is no shortage of potential tasks to take on in population health, but there is often a serious shortage of skilled managers, directors, and leaders to engage in important projects. By raising our hands and offering to lend our expertise, we as pathologists can quickly demonstrate our value. But be warned – many such forays into population health may not have fee codes for professional reimbursement. In the early stages, we may have to accept that it is simply the right thing to do for other reasons, although it may be a “loss leader” in terms of income (unless you are lucky enough to be recognized specifically for your efforts, perhaps through an administrative stipend or other type of sessional remuneration). If you are willing to take on such a task on behalf of your patients without requiring payment, it may offer a pleasant part-time diversion from “pushing glass” all day long… Get out there and mix with other healthcare providers; let your creative juices flow through a cross-fertilization of ideas and, together, you may be surprised by the unparalleled joy of making a difference to your community!

Bridging care gaps

The most obvious unmet need that we can tackle is in laboratory test utilization management, especially in primary care. Many family physicians and general practitioners are simply overwhelmed by the avalanche of new information that crosses their desks every month. And yet, most laboratory tests are ordered by primary care providers, not specialists. These doctors are often the gatekeepers to a patient’s health, and it is our job to help assure patient safety and prevent harm by avoiding unnecessary laboratory tests – and the potential deleterious downstream consequences of chasing abnormal, yet ultimately unimportant, results.

Improving and integrating healthcare across multiple providers is another opportunity for pathologists interested in population health. For example, optimal diabetes care may require that certain tests (such as HbA1c) are not over-utilized, whereas others (such as eGFR to monitor renal function) are used often enough. Similarly, through the horizontal continuum of care, patients discharged from hospital without laboratory test results are at risk of being lost to follow-up, if they can’t be recalled for treatment of any abnormalities discovered after their departure. Pathologists can even help track the screening and monitoring of high-risk populations. Screening for cervical cancer using human papillomavirus testing is an example; whereas previously we might not have known which patients or populations were receiving adequate testing, nowadays, sophisticated data analytics can link patient demographics with test-ordering patterns and results.

Pathology as a linchpin

Pathologists have a key role to play in almost every aspect of population health. Take, for instance, the integration of laboratory information across the continuum of care. We can participate in multidisciplinary forums, join committees, or even lead task forces whenever the interoperability of health information is being considered, or when a new HIS is being purchased. We can engage in innovation and technology initiatives in our local regions – in fact, many of us already do so by virtue of telepathology and digital imaging. In my region, for example, we are looking at implementing relatively simple digital cameras attached to microscopes in rural community hospital laboratories. The goal? To capture abnormal blood smears and Gram stains for rapid diagnosis by specialists at an academic health sciences center 100 kilometers away. In general, I think that patients in small, rural, underserved communities stand to benefit the most through this type of population health initiative. It means that their access to care stays close to home, but diagnosis –thanks to advances in technology – may take place hundreds of kilometers away.

Advances in digital imaging, and its much lower associated costs, are revolutionizing pathology in uncountable ways. It might be through remote (yet faster) diagnosis. It might be through sophisticated medical data analytics for test utilization management and clinical decision support. It might be through collaborating with clinical colleagues to improve patient outcomes – for instance, continuously monitoring patients with heart failure by electronically integrating lab results from point-of-care devices in their homes with their physiological data to prevent the need for readmission to the hospital. Regardless of how your particular region chooses to implement technological advances, there is likely to be a role for you in the patient care pathway.

Pathologists can also demonstrate their value to disease management by guiding clinicians in monitoring treatment compliance in the ambulatory care setting. Examples that come to mind include chronic kidney disease (ensuring that patients do not end up on dialysis or suffer from other complications), and heart failure. In my region, pathologists work closely with anesthesiologists to identify (through brain natriuretic peptide testing) patients in the community who are at high risk of postoperative cardiac complications of elective major surgery.  Hepatitis disease management is another example where pathologists can play an important role by alerting clinicians in the community to high-risk patients. Ideally, we would implement a system of automated alerts on providers’ ordering behavior – something along the lines of, “Your patient has not had ALT testing performed in last six months; please consider testing at this time.” A pathologist would certainly be a useful source of information on appropriate testing during the development of such an alert system.

Growing alongside technology

Point-of-care testing, the increasing simplicity and robustness of genomic testing tools, and the miniaturization of technologies are just a few examples of how innovation will change the face of healthcare. There is a growing paradox in that the location of diagnostic testing will grow closer and closer to the point of care with smaller and smaller samples (such as saliva or blood for liquid biopsy) – yet the information generated from such test results is increasingly nuanced and challenging to interpret. Much of it will require specialized expert opinions from well-trained molecular pathologists, meaning that the need for pathologists “in the field” may be far greater than ever before. Gone will be the days of large, factory-like private laboratories where the pathologist has little contact with the practicing clinician. In a virtual age, our value may be best delivered through cyberspace, offering opinions in real time to patients and healthcare providers.

Here, too, our contributions to utilization management can make a difference. Many laboratory tests sound very similar to one another, but are very different indeed – take, for instance, Factor V Leiden versus Factor V. Most of these tests are ordered in the community, so there are opportunities for pathologists at a macro level to follow trends of test utilization and bring anomalies to the attention of regional health authorities. The extent of test duplication, retesting at another facility, and discordant test results are all worthy of scrutiny. Consider expensive genetic testing, where our contributions toward the development of registries (such as those available for hemochromatosis, Factor V Leiden, or HLA-B57) can be very helpful. We can also contribute to the development of automated, electronic health record-based notifications to hospitals in our regions to intervene and cancel unnecessary genetic tests.

We can assess the reliability of one test assay over another, especially for the new tests introduced onto the market, by reviewing data at the regional level. If we do this in a timely fashion, we can make the necessary changes before it’s too late. Of course, there is always a risk of overcorrection when making procedural changes; however, a properly designed and resourced system, with checks and balances that include regular monitoring of metrics and multidisciplinary forums for communication with stakeholders, can negate any potential issues.

Population health is a massive, multifaceted science, and pathologists are only beginning to scratch the surface of our role in its evolution. We tend to think of ourselves as caretakers of individual patients – or even of individual subspecialties and sample types. And so it is not easy to recalibrate our thoughts to consider ourselves as large-scale medical practitioners; many pathologists may not realize how much population health work they are already doing, or how much they are capable of doing within the parameters of their current practices. Of one thing, I am certain: we have a unique and valuable contribution to make to population health, and it is up to us to ensure we are ready and willing to make it.

Sandip SenGupta is a Professor at Queen’s University, Kingston, Canada.