Is it or isn't it a DMT?
How to determine whether your advisory group meets Diagnostic Management Team criteria
It happens much more often than you might expect. A patient presents to a physician with symptoms of a serious illness and the doctor must quickly determine which lab tests to order.
The test menu is vast and confusing, and the doctor may or may not be deeply familiar with the specific disease in question. Because he doesn’t have time (or the inclination) to ask for input from a clinician or consulting expert, he fails to order the most appropriate tests for this individual patient. Or, he may not fully understand what the results of the tests he did order actually indicate. Either way, the patient suffers the consequences.
Most of the diagnostic info doctors receive from lab tests is presented not by a clinical expert with context and direction, but simply as a number or a basic report. This communication vacuum creates prime opportunity for medical errors to occur.
The good news is that most doctors who sincerely want to provide the best possible level of care for their patients are open to receiving advice and support from clinicians in this capacity. Diagnostic Management Teams (DMTs) have the potential to serve as an effective vehicle that can help curtail medical errors in today’s healthcare industry by offering an innovative approach to consultation.
Discussion of the four defining characteristics of a DMT .
Similarities and differences between a DMT and a tumor board or case conference.
Addressing the culture shift toward more consultative roles for laboratorians.
Determining cases and areas of focus for DMTs.
Contributing Lab Leaders
Dr. Michael Laposata
Professor and Chairman of the Department of Pathology
University of Texas Medical Branch in Galveston
Dr. Eric Walser
University of Texas Medical Branch in Galveston
What is a DMT?
By definition, a DMT is a group of medical experts across different specialties that meets on a regular basis to evaluate specific current cases and provide an easy-to-interpret written report that becomes part of the patient’s medical record.
Groups must meet all four of these defining criteria to be designated a DMT:
- The team must meet frequently and regularly and provide patient-specific reports with no request required for an interpretation.
- A report must be delivered before or during the time when treatment decisions are made.
- The report must consider the clinical context in which diagnostic tests are ordered and attempt to synthesize all relevant diagnostic test results.
- The DMT narrative report must be entered into the patient’s medical record.
These criteria were established after intensive review of more than 50,000 diagnostic management team interpretations to determine exactly what distinguishes the DMT report from more general patient chart results.
“Our focus over recent decades has been the optimization of the DMT in the medical environment,” said Dr. Michael Laposata, Professor and Chairman of the Department of Pathology at the University of Texas Medical Branch in Galveston and a leading proponent of the initiative. “We’ve focused on questions that have allowed us to identify the most important information to include in the report, and how to present it in a way so it can be used by everyone to improve patient care.”
DMT vs. tumor board vs. case conference
Medical experts may already think they’re following the principles of a DMT by participating on tumor boards or in case conferences, but these groups often do not adhere to the four defining criteria.
“There are many similarities between a tumor board and a DMT; both involve a review of diagnostic information and a discussion of the treatment plan with multiple diagnostic and clinical experts in the room,” Dr. Laposata explained. “For cases that don’t involve tumors, however, the DMT provides interpretive information while clinical decisions are being made. This also differs from a case conference in which decisions have already been made and discussion of the case is occurring after the fact.”
Another important difference to note — DMT interpretations appear in the patient’s chart for reference, whereas case conference notes generally do not, even if new insights and recommendations are generated during the discussion.
The ability to conduct a DMT meeting in real-time as soon as diagnostic information becomes available is a benefit to all parties involved. Online meeting formats also allow patients to participate, saving them time and money while expediting care.
“My prostate cancer practice is worldwide; I do DMTs in order to see and follow-up with my patients,” said Dr. Eric Walser, Radiology Chairman at the University of Texas Medical Branch in Galveston. “Allowing patients to be part of the meeting means that they consent to the release of their protected health information (PHI), eliminating HIPPA concerns. Additionally, you can add schedulers and insurance authorization contacts so that decisions from the DMT are directly acted on and patients can immediately be scheduled for surgery, biopsy, imaging tests or any other procedures they might need.”
Shifting to the DMT mindset
Lab leaders who have traditionally focused mainly on specimen management may find the idea of a paradigm shift toward a more interactive, consultative role intimidating. Clinicians are now being encouraged to step outside the walls of the lab — and often, their own comfort zones — to collaborate with colleagues for the purpose of finding ways to reduce errors and improve patient outcomes.
“It’s certainly challenging to adapt to a new, highly visible role,” Dr. Laposata said. “Laboratory directors are expected to know current literature, deal with new information about procedures that has recently become available, and much more. However, the advantages of having a diagnostic expert on staff with in-depth knowledge about a specific group of disorders are quite obvious for the institution, the treating doctors and the patients.”
Even though many agree with the DMT idea in theory, it’s going to take time and support to win over the this-is-how-we’ve-always-done-it types and take the concept mainstream.
“From a cultural perspective, making the shift can be very difficult,” Dr. Walser said. “When I bring the actual patient into a tumor board, older physicians are noticeably uncomfortable. What they need to realize is that DMTs make medical care more transparent to the patient and encourage their participation, which will actually bring more patients into their practices.”
Where to start?
There can be great variability among diagnostic management team groups and the subjects they choose to focus on. Deciding which patients and cases are most appropriate for DMT intervention depends on the needs and opportunities within your institution.
Learning from variations on the format at Massachusetts General Hospital and Vanderbilt University Hospital, Dr. Laposata was able to pull together the best parts of previous coagulation DMTs he’s participated in to develop the group he currently oversees at UTMB. Now, every coag evaluation that includes any test beyond routine screenings goes directly to his DMT for an interpretive expert-driven report.
“Another example, every case of leukemia and lymphoma in a well-established DMT can be included, because the studies performed for these patients are all highly complex,” he added. “Or, for infectious disease patients, a predetermined list of situations would identify cases appropriate for the DMT.”
In the latter instance, all patients who aren’t improving with treatment using what would appear to be the correct antibiotics could be brought to a DMT for evaluation.
Where do DMTs go from here?
The DMT concept continues to evolve and grow as more medical experts become familiar with the format and seek ways to improve the delivery of care.
“We need partners who can help us with expertise in the areas of informatics, visual connectivity between institutions and providers, obtaining payment for services provided, and even coaching new DMT leaders to transition into this new primary role,” Dr. Laposata said. “When all these things fall into place, we expect nationwide adoption. If the barriers that are preventing DMTs from becoming a required part of medical practice are removed, a quantum leap in patient care can happen.”
The LabLeaders DMT series continues... Get More Here
The What and Why of Diagnostic Management Teams
Commentary from DMT proponent Dr. Michael Laposata about the value of diagnostic management teams and how they can reduce the incidence of diagnostic errors.
A Key Thing Doctors Can Do to Reduce Hospital Errors
by Steve Reinberg
Organizations have the potential to reduce medical errors by changing the ways doctors convey patient information during shift changes.
What is a Tumor Board? An Expert Q&A
by Carey August
Two medical experts weigh in on what a tumor board is and the role it plays in treatment and overall care for cancer patients.