Health care is evolving rapidly, becoming increasingly complex by the day, and more patients with chronic medical conditions are interacting with health care at a higher frequency. These factors lead to a higher volume of investigative tests and interventions, which often produce abnormalities in hematologic parameters. Sometimes, even subtle hematologic abnormalities can trigger a consultative request, thus generating a “tsunami” of such requests for hematologists. This influx of requests has become a concern for health care delivery, delaying access for all and contributing to inferior-quality care for patients requiring more urgent evaluation. The experience can be frustrating for patients, referring clinicians, and hematology consultants, leading to increased redundancy and financial burden on the system.
Classical hematology practice covers a broad spectrum of diseases, ranging from anemia to complex hematologic issues such as bleeding and clotting disorders and hemoglobinopathies, which requires a multidisciplinary approach to ensure the safe and effective delivery of care to patients whose conditions transcend multiple medical and surgical specialities.1-3 Beyond the many advances that have improved diagnosis and treatment of classical hematologic conditions, classical hematology also serves as the gateway to malignant hematology consultation at many institutions, providing an initial, specialized investigation via laboratory and hematopathology testing. The classical hematology team frequently steers patients to the ideal malignant hematologist for their specific diagnosis in an ever-specializing health care force. While advantageous, this steering model is particularly challenging when classical hematologists are underrepresented in number but see disproportionately large volumes of patients.
Here, we share some strategies that we have implemented at Mayo Clinic in Arizona to make our classical hematology practice more efficient. These strategies have helped us to improve patient access, optimize specialty scope, and improve provider satisfaction.
Intake Decision Trees
One of the first strategies we implemented was identifying referral diagnoses that required evaluation by our team. This strategy also involved defining diagnoses that would not be evaluated by our team, such as mutation-confirmed hereditary hemochromatosis (initial referral to hepatology), anticoagulation concerns related to atrial fibrillation (referral to cardiology), eosinophilia (initial referral to allergy and immunology). In addition, with the support of institutional leadership and invested colleagues with specialization in these areas, patients with certain conditions (such as monoclonal gammopathy, lymphocytosis greater than 5 × 109/L, and Epstein-Barr virus–positivity in the context of transplant) are routed to respective disease groups.
Development of Clinical Practice Guidelines
Our practice has a robust internal process for developing clinical practice guidelines called “AskMayoExpert.” In addition to reviewing the common causes and presenting symptoms for our non-specialist team members, this resource suggests an algorithmic approach for initial workup. Electronic medical record (EMR)–based lab numbers are also intentionally embedded for the suggested lab to facilitate implementation.
Intake Triage Process
Our team has also instituted an intensive triage process in which a classical hematologist reviews all referrals to the team within 72 hours, requiring only a few hours of dedicated time each week. This workflow facilitates discussions about the need for further testing or outside records prior to scheduling the consultative visit, as well as the selection of an optimal physician expert (if indicated) and the urgency of the referral. Implementing this process has improved the quality, efficiency, and effectiveness of each consultation because more of the desired data are available at the time of consultation, allowing the team to create a succinct and more precise plan.
Intake Navigator
A new, but essential, team member in the intake process was hired to facilitate intake navigation for new consults to the classical hematology team. The navigator serves as the liaison to the referral provider, indicating if clarification to the consultative question or additional laboratory testing is necessary before the triaging process is complete. The navigator also confirms that triage-recommended tests are, in fact, ordered and drawn prior to the hematology consultation. Through this practice, we can ensure that the consultation with the classical hematologist is spent addressing the most up-to-date data results, deciding upon advanced laboratory assessments, and providing patient education. Having a navigator in this role has also helped with decreasing the need for a follow-up visit in some cases, thus improving access.
Electronic Consultative Practice
Despite the success of the efforts we outlined here, the number of referrals to our classical hematology team has exceeded our capacity to address referrals in a timely manner through face-to-face consultation. The COVID-19 pandemic prompted the innovation of technology and creation of an electronic consultation, or eConsult, platform. Our team leveraged eConsults to provide expert guidance for specific classical hematology questions, particularly mild laboratory anomalies.4 This approach facilitates answering specific hematology questions about workups or monitoring on a faster timeline.
Leveraging EMR and Creating Solutions
While certainly a pain point in many respects, we believe the EMR can be leveraged to streamline the intake process. We have created several EMR-based solutions, such as order sets with predefined diagnosis and linked labs, templates, smart texts, and smart phrases to minimize clinical practice variation.
Conclusion
Classical hematology serves multiple roles in its multidisciplinary capacity, with common laboratory abnormality evaluation, management of classical hematologic conditions, periprocedural planning with surgery teams, and helping to diagnose malignant hematologic conditions. It is an honor to work within such an exciting and expansive field, but the demand for specialized patient care frequently exceeds the supply at most institutions. Classic hematologists are somewhat of a “unicorn” in the world of hematology/oncology. This trend will only worsen over time, as only 5% of hematology/oncology fellowship trainees are pursing classic hematology as a specialty.5 Until we can expand our classical hematology workforce, we need innovations that optimize care delivery so we can avoid burnout for the practicing classical hematologist.
The approaches outlined in this article are not perfect, but they have helped us provide timely access to our patients and decrease dissatisfaction among patients, providers, and consultants. Several of these interventions have decreased the need for multiple follow-up visits, thus improving access. Implementing these strategies has been an iterative approach where we are continually making efforts to improve the processes and stay mindful about minimizing the financial burden on our patients.
Competing Interests
Drs. Padrnos and Shah indicated no relevant conflicts of interest.
