Robert L. Michel, Editor-in-Chief of The Dark Report, was recognized with the W.A.D. Anderson award for his contributions to the profession of pathology and laboratory medicine
DATELINE—Miami Beach, Florida: What better time to be here on Florida’s trendy South Beach than February, when winter’s chilly winds blow across much of the United States. That’s one reason why a record crowd of pathologists assembled at the Fountainebleau Hotel to attend the 40th annual “Review and Recent Practical Advances in Pathology” that took place here on February 15-19.
The conference addressed such hot topics in anatomic pathology as new predictive markers and prognostic markers in surgical pathology and recent developments in the field of cytology. This meeting is produced by the Pathology Department at the University of Miami’s Leonard M. Miller School of Medicine. It is a Monday-through-Friday event, designed to allow attendees ample lecture time with some opportunities to get outdoors and enjoy the weather and the beaches.
Sessions to Help Pathologists Understand Changes to Healthcare System
Along with the lectures by expert pathologists on different topics that directly address how pathologists diagnose cancer and other diseases, there were sessions that dealt with changes caused by the American healthcare system’s transition to integrated care, population management, and personalized medicine.
For example, “Prevention of Medical Errors” was the theme of the lecture delivered by Efren Manjarrez, MD, SFHM, Assistant Professor of Clinical Medicine and Interim Chief, Division of Hospital Medicine at the University of Miami (UM).
Similarly, given the keen interest labs have in improving how physicians order lab tests, the session titled “Advances in Improved Test Utilization” drew lots of attention. This lecture was delivered by Gary W. Procop, MD, MS, Professor and Chairman, Department of Clinical Pathology Medical Director of Molecular Microbiology, Mycology and Parasitology Laboratories, at the Cleveland Clinic in Ohio.
Keynote Presentations Addressed Challenges Facing Anatomic Pathologists
Keynote speakers at the concluding session for Pathology-on-the-Beach directly tackled the challenges facing anatomic pathologists during this rapid transformation of healthcare in the United States. Innovative initiatives underway at the University of Miami’s Department of Pathology were described in the lecture delivered by Richard J. Cote, MD, FRCPath, FCAP, Professor and Joseph R. Coulter Jr. Chair, Department of Pathology.
In his address, which was titled “Moving from Volume-Based to Value-Based: New Business Models in the Clinical Laboratory Industry,” Cote emphasized the need for pathologists to recognize that the era of fee-for-service (FFS) medicine is ending. Replacing FFS will be “new payment models,” he said. “These will include outcomes-based reimbursement, bundled payments, and arrangements where providers are ‘at risk.’ Each of these has a particular danger for pathology and needs an appropriate response by pathologists.”
Cote then provided examples of how clinical laboratories can add value in three ways:
a) Helping physicians improve utilization of lab tests;
b) Supporting precision medicine; and,
c) Helping enrich the patient experience.
Providing Physicians with EBM Guidelines to Improve Lab Test Utilization
On the utilization front, one early success was to help physicians understand how evidence-based care guidelines, in tandem with improved lab test ordering, could contribute to improve patient outcomes. “The example we first chose was the workup of hematopoietic malignancies,” explained Cote. “Previously, the workup of these complicated cases was ‘ad-hoc,’ often with oncology or pathology residents and fellows ordering the tests for workup, such as flow cytometry, cytogenetics, and molecular testing. This led to substantial over- and under-utilization, and conflicting results.
“Our hematopathologists worked with the oncologists, and using evidence-based guidelines, developed about 30 protocols for workup under the variety of scenarios seen in patient presentation,” he continued. “A key part of this project was to redesign the lab test order form.
“After several revisions, the revised lab test order form has much simpler standard ordering,” noted Cote. “Clinicians will provide the clinical picture, and using the developed evidence-based algorithms, Pathology works up the case according to the agreed on protocol.”
Simplified Lab Test Order Form Contributed to 25% Reduction of Cytogenetic Tests
“How did this turn out?” asked Cote. “There was a substantial reduction in utilization of expensive tests, such as a 25% reduction in use of cytogenetics. Of equal significance is that the newly-standardized report format supports more accurate diagnosis. Along with faster turnaround time and improved physician satisfaction, this has also contributed to more specific treatment and better outcomes, which are now among the best in the nation for small cell cervical cancer (SCCC) and lymphoma/leukemia. And we have a better ability to systematically demonstrate to payers medical necessity, leading to fewer denials and better positioning for managed care contracting.”
Presentation of the W.A.D. Anderson Award for Achievement in Pathology
Next on the program was an award. Each year for the past six years, during “Pathology at the Beach,” the University of Miami Pathology Department recognizes achievement that advances the field of pathology and laboratory medicine with the W.A.D. Anderson Award. Not only was Dr. Anderson the first Chair of Pathology at the University of Miami Medical School in 1953, but he is familiar to many pathologists as the author of Synopsis of Pathology (first published in 1942) and Anderson’s Pathology (first published in 1948), important textbooks that were updated and used for decades.
Past year’s recipients have included such noted pathologists as Jonathan Epstein, MD, and Azorides Morales, MD. This year’s W.A.D. Anderson award went to Robert L. Michel, Editor-in-Chief of The Dark Report.
“We are pleased to recognize Robert Michel for his two decades of work to keep pathologists and medical laboratory professionals informed about innovations in the management and operation of anatomic pathology and clinical laboratories,” stated Dr. Cote during the presentation. “Through his publications and the lab conferences he has organized in the United States, Canada, United Kingdom, and Australia, he has been a reliable source of timely information about new developments in diagnostic technologies, as well as about marketplace changes involving reimbursement, managed care contracting, and new models of care delivery that keep pathologists at the forefront of clinical care.”
Predict a Coming “Tsunami” of Biomarkers for Clinical Laboratory Tests
Following the presentation of the W.A.D. Anderson Award, Michel was the closing keynote speaker. In a lecture titled, “Why Precision Medicine is Poised to Play Perfectly to the Strengths of Pathology and Laboratory Medicine,” he put forth evidence in support of that premise.
“What gets little recognition among healthcare policymakers is the coming tsunami of new biomarkers,” stated Michel. “These biomarkers will make it possible to diagnose disease when it is pre-symptomatic, as well as make it possible for pathologists and clinical chemists to identify the most appropriate therapies for individual patients.
“Simply said, medical laboratories are going to have a monopoly on the use of these biomarkers for clinical purposes,” he continued. “What other specialty in medicine has the knowledge, the installed base of diagnostic testing systems, and the interfaces with hospitals, physicians, and payers that can equal that of clinical laboratories and pathology groups? The fully-integrated clinical care organizations of the future are not going to pay extra to duplicate what already exists in communities throughout the United States.”
To demonstrate the remarkable number of biomarkers that will eventually be available for diagnostic and therapeutic purposes, Michel offered the following examples from different “omics” and “omes”:
• Genome: Human genome has 20,000 to 25,000 protein-coding genes.
• Proteome: Human proteome has an estimated 250,000 to 1,000,000 proteins.
• Microbiome: Human microbiome has 10,000 species of microbes that have been identified and these microbes have eight million genes.
• Transcriptome: Messenger RNA molecules in a human cell is estimated in the millions.
• Metabolome: Current number of annotated human metabolite entries is currently 40,000.
“Currently, next-generation gene sequencing technology makes it possible for medical laboratories to develop and offer useful lab tests that may incorporate thousands of genes in a single panel,” continued Michel. “So we are already in the earliest phase of ‘diagnostic complexity.’ Imagine what happens in just a few years when medical laboratories are offering test panels that incorporate DNA markers, RNA markers, and metabolomics markers, for example!”
Michel closed his presentation with examples of how pathologists at such institutions as the Cleveland Clinic, Mayo Clinic, and Seattle Children’s Hospital were collaborating with physicians and administration to deliver more value from laboratory testing services.