Clinical decision support in pathology: service efficiencies, cost savings and improved patient outcomes

MedCurrent CDS puts best practice guidelines in front of clinicians as they place orders in Clinisys ICE. The platform is already avoiding costs and cutting waits in radiology. Now, it has huge potential to improve patient care and deliver hard cost savings in pathology, argue founder Steve Herman and VP, account management Martin Kepa.

Steve is a radiologist by background, and many years ago he found himself wondering if all the routine, follow-up chest CT scans he was reporting were useful. He found a colleague to work on a comparative study of two groups of patients: one of which received scans, and one of which didn’t.

The study found the scans were not helping patients to live longer. Yet they were taking up capacity that could be put to better use. Steve went on to found MedCurrent, a health tech company that puts real-time, evidence-based guidelines in front of clinicians via the systems they use to order tests every day.

In the UK, this often means Clinisys ICE, an order communications and results reporting system that is used by 120 trusts and more than 75% of general practices. MedCurrent has been a Clinisys partner for eight years, and during that time it has established the value of clinical decision support (CDS) in radiology.

Now, the question is: does CDS have a role in pathology? A pilot with a hospital on the outskirts of London suggests that it does. In fact, it suggests the benefits for patients and the savings for services could be even greater than in radiology.

Clinical decision support in radiology

Our involvement in CDS for radiology in the UK started back in 2017. Two hospitals in London felt they might have an issue with clinicians ordering the wrong tests, or over-ordering tests. They worked with us on a pilot, using the iRefer guidelines from the Royal College of Radiologists, which was the genesis of MedCurrent iReferCDS.

The iRefer guidelines are not new: they were first published in 1989. However, they tend to be held on paper or on a website. Busy doctors just don’t have time to find and read them as they are placing requests. The process needed to be digital and tightly integrated into clinician workflow.  

MedCurrent has an authoring studio where guidelines can be uploaded and any local customisations made, and then it puts the relevant information in front of clinicians as part of their normal workflow. For example, a clinician may have a patient with a headache and want to order an MRI scan.

The system will ask them what kind of headache, and depending on the answer, may encourage them to order a different kind of scan, or no scan at all. And the clinician can instantly execute that decision in ICE.

The results of the initial pilots were so positive that NHS England decided to fund a national roll-out through the Digital Diagnostics Capability Programme. To date, over 60 trusts have signed up for the MedCurrent CDS platform, 35 of which are now live.

We are finding that GPs are cancelling around 5% of tests and changing another 6%. For specialists, the figures are a little bit lower, but the average trust is still avoiding around £330,000 per year as a result of radiology CDS.

Exploring the potential in pathology

One of the trusts that rolled-out MedCurrent iReferCDS wondered if the platform could have a similar impact in pathology; not least because it was worried about unnecessary or excessive phlebotomy procedures for patients.  

So, we set up another pilot, using guidelines from the Royal College of Pathologists that set out how often repeat tests should be conducted. We wanted to keep the scope manageable, so we worked with a biochemist to identify seven tests as a starting point.

Across all seven tests, the trust saved £47,000 over the five months of the pilot – the equivalent of £120,000 a year. When you consider that the hospital runs 350 tests in biochemistry alone, it is clear the potential savings are huge.

We found that the impact varied by test. For PSA tests, which are used as a screening tool for prostate cancer, there was not much change. But for Ceruloplasmin tests, which are used to help diagnose conditions that involve too much or too little copper in the body, there was a reduction of almost 50%.

That represents a significant reduction in the number of often elderly, often frail patients who no longer have to go to the lab or have blood drawn for no reason. We noted that these are hard cost savings. In radiology, we talk about cost avoidance, because demand for scans is so high, and waiting lists are so long, that any slot that becomes available will soon be filled.

In pathology, if a patient doesn’t have their blood drawn, then the cost of doing that – employing the phlebotomist, buying the consumables – will not be incurred. Plus, of course, the laboratory will not incur the costs associated with running the test.

In fact, because many trusts are outsourcing their pathology testing and do so on a pay-per-test basis, any reduction in number of tests requested leads to direct financial savings.

And we must not forget patient care in all this. As we have already seen in our pilot trust, removing any unnecessary testing will avoid any negative impact and discomfort involved in taking the specimen.

A development that aligns with national priorities

The NHS is still dealing with the huge waits that built up during the Covid-19 pandemic and rising demand from an aging population. At the same time, there is pressure on its facilities and shortages of staff in key occupations – including pathology.

The only way forward is to improve efficiency and productivity without impacting quality. The NHS England Getting It Right First Time (GIRFT) team has produced a report on pathology that describes a series of elements that need to be in place to deliver the most effective service.

The Clean Framework starts with ‘clean-in’ or ensuring the tests being ordered are appropriate and optimised. Clinical decision support has an important role to play in this, both at the point of care and when reviewing services.

Our system comes with an analytics package that enables trusts to run reports on which individual clinicians are ordering which tests and why: and that can be a powerful tool for revising local guidelines or changing individual practice.

From analogue to digital: without the drawbacks of AI

The UK Government is now developing a 10 Year Health Plan for the NHS. It has already stated that it wants to see a shift from ‘analogue to digital’ as part of the plan, and most pundits expect this to include a big role for AI.

MedCurrent’s CDS system is a great example of how moving from analogue to digital can unlock efficiencies: but it is not an AI system or large language model, like ChatGPT. The guidelines that we leverage have been created by Royal Colleges or local experts. They are not being generated by an LLM trawling the internet.

There is no danger of hallucinations. The decision tree that sits behind the information presented to a clinician is transparent and based on consensus from experts. And, importantly, our CDS is not making a decision on behalf of a clinician but instead guiding them to make the most appropriate one based on the evidence.

We believe that the introduction of CDS to pathology is a game changer and the kind of innovation that will directly support the NHS 10 Year Health Plan. We have already demonstrated that CDS can avoid costs and help to reduce waiting times and lists in radiology, and pathology is the logical next frontier.

In pathology, it has the potential to reduce painful bleeding and intrusive testing for patients, support better-evidenced care decisions, and deliver hard savings for trusts and pathology services. We will be at Digital Health Rewired, March 18-19 in Birmingham NEC – come and see how you can adopt an idea whose time has come.