Narrowing Down the Focus of Your DMT
Developing clear-cut goals and objectives can help make your DMT more manageable and effective.
With a nearly unlimited list of topics, ideas and goals available to pursue, the process of building a Diagnostic Management Team (DMT) from the ground up can feel somewhat onerous and overwhelming. The ability to set clear expectations and objectives from the start, lead your team effectively and periodically evaluate its progress are the keys to a successful endeavor.
Improve stewardship by reducing waste and improving the administration of expensive pharmacy drugs
DMTs reduce hospital readmissions, increase teaching insights for residents, and improve communication between laboratorians and physicians
A topic must be chosen based on the DMT learder's experience and expertise
DMTs must be small enough to keep a narrow scope in discussions
Contributing Lab Leaders
Dr. Michael Laposata
Professor and Chairman of the Department of Pathology at the University of Texas
Medical Branch in Galveston
Dr. Heather Stevenson-Lerner
Director of the Pathology Imaging Core Lab
University of Texas Medical Branch-Galveston
What value does a DMT bring to your organization?
Across the country, DMTs aim to reduce the incidence of medical errors in the United States by assembling a multi-disciplinary group of healthcare professionals to meet on a regular basis, evaluate individual patient histories, interpret clinical data, and generate an expert-driven narrative that becomes part of the patients’ medical records.
DMTs also pave the way to optimize test selections with great potential to improve the accuracy of diagnoses.
“When a DMT is on-site, diagnostic experts can communicate directly with colleagues to indicate which tests may be unnecessary and which tests should be performed, but haven’t been ordered,” said Dr. Michael Laposata, Professor and Chairman of the Department of Pathology at the University of Texas Medical Branch in Galveston.
Another prospective benefit, on-site DMTs can improve stewardship by reducing waste and improving the administration of expensive pharmacy drugs. “A drug that costs tens of thousands of dollars for a single dose is much better directed when DMT experts are there and available to help physician colleagues understand how it should be delivered and monitored in the laboratory,” Dr. Laposata explained.
Where to start?
The first goal of any DMT is to decide what kind of topic or niche you want to examine. Because DMTs can address any subset of cases within nearly any specialty, the options are virtually endless.
While there are certainly many different clinical and anatomic areas for DMT experts to explore, most take one of two main approaches — either focusing on a group of related disorders or focusing on an individual disorder, usually zeroing in on cases with high complexity.
Dr. Laposata feels the greatest potential for DMT impact may lie in diagnostic areas that involve large numbers of patients, such as groups of patients who have experienced blood clots or bleeding episodes as related to myocardial infarction and stroke.
“There many patients as well who have disorders stemming from an adverse combination of therapeutic drugs or the use of illicit substances,” he continued. “Similarly, the number of patients with infections is extremely high. On the other end of the spectrum, disorders such as cystic fibrosis may not affect as many patients but have high diagnostic complexity with more than 2,000 known mutations in the associated gene.”
How specific does a DMT need to be?
Once you’ve chosen a topic for your DMT to concentrate on, the next decision to make is what you hope to accomplish and where the best opportunities lie. A measurable reduction in hospital readmissions, teaching insight for residents, and improved communication between laboratorians and ordering physicians are just a few objectives that might be appropriate to keep top of mind during DMT activities.
Many factors can play into determining the scope of your DMT’s focus, including the number of cases within your healthcare system, scheduling availability of the group’s participants and the amount of resources at your disposal. Ultimately, however, honing down a target goal depends on the expertise of the DMT leader.
“If the DMT leader is knowledgeable about a very narrow group of disorders, then the focus of the DMT is going to be narrow, too,” Dr. Laposata explained. “If the DMT leader has broad knowledge about a category of disorders that involves hundreds of related entities, the focus of the DMT can become quite broad.”
Dr. Heather Stevenson-Lerner, Director of the Pathology Imaging Core Lab at UTMB, leads an anatomic pathology DMT that meets for an hour every other week to discuss 5 to 8 high-complexity liver biopsies.
“For surgical pathology, you really need the pathologist to have subspecialty training, expertise or a sincere interest in the area being presented,” she said. “You cannot properly lead a DMT if you don’t have someone on board who is an expert in the diseases being discussed. The whole point is to talk about complicated cases and assist with the proper work-up, lab studies and treatment. If the person leading the DMT doesn’t know the ins and outs of the topic, the DMT will not be successful.”
For Dr. Stevenson-Lerner, the decision to focus on liver anatomic pathology was a simple one.
“It was easy for me to decide on a topic because my main focus is liver pathology and research, and my fellowship training was in liver and transplant pathology,” Dr. Stevenson-Lerner said. “It was my chairman’s idea to turn my liver pathology conference into a DMT.”
As the leader of a coagulation DMT at UTMB, Dr. Laposata kept several important points top of mind when determining the focus of the team.
“There is a tremendous need for advice on test selection in coagulation because there are so many tests in this area,” he pointed out. “And, the data for diagnostic studies involving patients with clotting or bleeding disorders emerges largely from one clinical laboratory, which was an advantage for us because it helped identify cases for discussion at the DMT meetings. Every evaluation that was larger than routine screening tests for coagulation was easily identified.”
Growth and evolution of DMTs
If the focus of a DMT is too broad, it may result in the need to reevaluate the goals of the group or facilitate the spinoff of a new DMT with a narrower scope.
“When it was originally created, the coagulation DMT largely involved tests for bleeding disorders,” Dr. Laposata said. “The large number of tests that emerged to identify patients predisposed to thrombosis greatly changed the focus of the DMT. At this point, approximately 70 percent of cases are associated with patients who have blood clots and 30 percent with patients who bleed excessively.”
In Dr. Laposata’s coagulation DMT, the emergence of multiple cases of children with bruising and bleeding also led to a focused evaluation for underlying medical disorders that would dispute misdiagnoses of suspected child abuse.
“Our child abuse DMT has reunited dozens of families thanks to the identification of bleeding disorders that explain the children’s injuries,” he noted.
Where can DMTs go from here?
After your DMT is up and running, stay open minded about the directions it may end up going. The goals of any given DMT may require periodic evaluation and fine-tuning over time as new information and trends organically emerge. Once a topic has been determined and tested using real-time cases, DMT leaders can always go back to tweak, narrow or expand the focus of the group based on the results of findings.
“We are now planning a DMT for the many patients who have premature atherosclerotic vascular disease,” Dr. Laposata mentioned as an example. “It’s likely that this will evolve into a DMT to focus on nutrition and a parallel DMT for dyslipidemias, such as familial hypercholesterolemia.”
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