Management and Compliance in Large and Academic Pathology Practices. Introduction. Process Improvement. Process Improvement.

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1 Management and Compliance in Large and Academic Pathology Practices USCAP Short Course #36 8:00 AM, Friday, February 17, 2006 Introduction W. Stephen Black-Schaffer, M.D. Associate Chief of Pathology Massachusetts General Hospital, Boston, MA Rebecca L. Johnson, M.D. Chief of Pathology Berkshire Medical Center, Pittsfield, MA 1 Organizational Models and Compliance Practices for Anatomic Pathology Course Contents 2 Theory / practice => complete subspecialty AP Applicability => large practices Particularly => academic practices Nuts & bolts => correct coding Established Emerging / controversial Legal / regulatory framework => compliance Compliance planning Why & how 3 Process Improvement Organizational Opportunities for Process Improvement in Anatomic Pathology Pathology Practice Leadership - Issues MANAGEMENT Pathology practice organization / operation => complex Academic / clinical responsibilities => balanced Health care regulation / financing => stringent How can leadership enhance compliance => while operating more efficiently? ORGANIZATION COMPLIANCE 4 EFFICIENCY

2 Efficiency in Pathology Process Variability - Two Types 5 Clinical laboratory - classic industrial model => low incremental cost & high fixed cost => marginal cost < average cost => high volume key to efficiency (doing better by doing more) Anatomic pathology - professional service model =>high incremental cost & low fixed cost => marginal cost ~ average cost => low process variability key to efficiency (doing better through working smarter) 6 Common cause process variability - results from causes intrinsic to process - variability shows an apparently random distribution - present in every occurrence of process Special cause process variability - can be assigned to extrinsic events - variability outside range intrinsic to process - can be controlled, reduced, or eliminated Subspecialization - Concept, Goals, Opportunities, and Costs Concept => diagnostic process with reduced variability Goal => increased diagnostic quality and consistency Opportunity => increased process throughput and efficiency Cost => decreased staffing flexibility => increased operational overhead Benefits of AP Subspecialization => increase productivity => decrease turn around time => enhance teaching of trainees => increase accuracy in diagnosis => promote clinical communication => facilitate faculty research involvement => align diagnostic work with academic interest => promote compliance in ordering and coding 7 8 Subspecialization - Synergies Size of Pathology Groups Subspecialization Align diagnostic work with subspecialty expertise => conducive to understanding diagnostic issues => similarly conducive to understanding coding and regulatory issues for subspecialized: diagnostic entities; specimen types; special studies. 30% 25% 20% 15% 10% 5% % >20 No Answer

3 Philosophically - is Surgical Pathology Itself a Subspecialty? Maybe yes => surgical pathology => clearly defined subset of anatomic pathology => well established clinical utility Maybe no => surgical pathology => already most of what most pathologists do Mean Percent of Time 60% 50% 40% 30% 20% 10% 0% Type of Pathology Service AP-Surg. Path. AP-Cytopath. CP-Lab. Management CP-Interp. & Consult. Teaching & Research Other AP-Autopsy Partial / Complete AP Subspecialization Large / academic practices => at least partially subspecialized Partial subspecialization => mixed mode of practice => complications Why choose => complexities of complete subspecialization instead? Then "General" Pathology Becomes Whatever cases are "left over" And "complete" subspecialization is not the addition of more subspecialties But the elimination of "general" signout 12 Critical fraction of "general" cases => had to be shown to subspecialist (sooner or later) Small Large Frozen Cytopath Autopsy 1990 Autopsy 1 Small side 2 Large side 1 OR consults 1 CYT 3 Derm 1 Neuro 1 FNA 1 B/ST 1 Small Large ENT GYN Dermpath Frozen Cytopath Autopsy Breast 1 Cardiac 1 ENT 1 GU 1 GYN 2 Pulmonary 1 Heme 1 OB 1 Renal 1 7/1/1995 Subspecialty Credit Staff Autopsy Path Frozen Sect Lab Cytopath Dermatopath Neuropath FNA Clinic Bone & Soft Tiss Breast Path Cardiac Path ENT Path GI Path GU Path GYN Path Pulmonary Path Hematopath OB Path Renal Path MGH - 7/1/95 - Complete Subspecialization 44 It is not => particular mix or combination => organ and disease oriented diagnostic services. It is => system where each specimen => directly to a pathologist with particular interest and expertise in the organ or disease the specimen represents; that is, => a system with no "general" diagnostic service.

4 MGH - 7/1/95 - Defined Subspecialties MGH - 7/1/95 - Assigned Staff to Services 45 Developed list of diagnostic subspecialties usefully covering all our specimens, as follows: Autopsy Bone & Soft Tissue Breast Cardiovascular Cytopathology (FNA) Cytopathology (GYN) Cytopathology (NON-GYN) Dermatopathology Electron Microscopy ENT Eye Frozen Section GI GU GYN Hematopathology Neuropathology Obstetric/Perinatal Pulmonary Renal 46 Each pathologist => chose five subspecialties and ranked them in order of preference. Each subspecialty => assigned at least two pathologists. Each pathologist => assigned at most three subspecialties. Work credit per week => assigned to each subspecialty according to the volume and complexity of a large sample of cases. Subspecialization - Organizational Change Subspecialization's Biggest Obstacle is: 14 Organizational change => leverage size to achieve efficiency by subspecialization in AP Basic business management, but How does it work in practice: What are the obstacles? What are the benefits? Any other outcomes? 15 MEASURING PATHOLOGIST WORK Equitable responsibilities among pathologists => consistent with practice mission WORKLOAD EQUITY In a general diagnostic practice, if you work by weeks, this can be hard enough when a week is a week is a week (because sometimes it's not) But when it becomes an issue not just of time on service, but of how much time on which service How to measure / assign this work equitably? 16 Measuring Histopathologist Work - Both Volume and Complexity Specimens Number Type (group) CPT 4 (total) Blocks / slides H&Es Special stains Immunohistochemical stains Reports Number of diagnoses Amount (items or units) of information reported Lines of diagnoses, templates, notes, gross and/or microscopic descriptions 17 Measuring Cytopathologist Work - Both Volume and Complexity GYN Cases Source Nature of screened population Diagnostic threshold for cytopathologist review Non-GYN Cases Type (group) Abnormality rate Special procedures Cytopathologist performance of FNAs

5 Subspecialization - Operational Considerations Services => very different in size Differences => vary greatly over time Quantification => ongoing Overhead => minimized Utilize data from existing processes => RVUs Utilize this process for other purposes Including monitoring compliance Annualized RVUs 24,000 20,000 16,000 12,000 8,000 4,000 All Services 05# EM FNA OB CV RP FS PP GYS NP GYL GIL BST ANCA GU ENT BR HP DP GIS CYTO 24,000 Annualized RVUs by Subspecialty Service Subspecialization - Empirical Efficiency at MGH from 1995 to 2005 RVUs (annualized) 20,000 16,000 12,000 8,000 4,000 95#2 96#1 96#2 97#1 97#2 98#1 98#2 99#1 99#2 00#1 00#2 01#1 01#2 02#1 02#2 03#1 03#2 04#1 04#2 05#1 AP work (in physician RVUs) increased 99% AP staffing (in service FTEs) increased 18% As we worked out how to measure/assign work, we realized substantial increases in productivity. Average assigned service work weeks per FTE stable: 31.0 in 1995 => 30.6 in 2005 Average service RVUs per FTE increased 47%: from 4,194 in 1995 => 6,176 in ANCA BR BST CV CYTO DP EM ENT FNA FS GIL GIS GU Subspecialty Service GYL GYS HP NP OB PP RP RVUs and Staffing after Subspecialization 95#2 96#1 96#2 97#1 97#2 98#1 98#2 99#1 99#2 00#1 00#2 01#1 01#2 02#1 02#2 03#1 03#2 04#1 04#2 05#1 RVUs (10,000s) Staff FTEs Work Weeks/FTE Work FTEs RVUs/Work FTE (1,000s) Alternative Work FTEs Alternative Staff FTEs 22 Subspecialization - Empirical Efficiency Staff Work* Work* RVUs/ FY1/2 RVUs FTEs Weeks FTEs Wrk FTE 95#2 75, ,018 96#1 80, ,048 96#2 87, ,283 97#1 111, ,216 97#2 99, ,572 98#1 105, ,782 98#2 111, ,766 99#1 114, ,741 99#2 122, ,896 00#1 128, ,170 00#2 127, ,368 01#1 135, ,898 01#2 139, ,646 02#1 142, ,870 02#2 144, ,755 03#1 146, ,032 03#2 147, ,713 04#1 150, ,188 04#2 151, ,046 05#1 149, ,176 Change 99% 18% 9% 29% 54% *Nominal FTE work weeks for a theoretical average service.

6 Work Week Efficiency 2005 => nominal 1 FTE service pathologist => 35.0 average (1.00 credit) service work weeks But Services >1.00 credit => <35.0 service work weeks Services <1.00 credit => combined with others => <35.0 service work weeks And 35.0 nominal work weeks per 1 FTE service => 30.6 actual assigned work weeks 48 Service Duration and Work Intensity Intensity of service work => measured in RVUs per week => >8:1 ratio service work credit highest credit service : lowest credit service 2.44 : Renal 0.30) Staff signing out subspecialties with high weekly credit => fewer weeks on service Staff on low weekly credit services => acknowledged lower intensity of work => perceived less time for academic pursuits Duration and Intensity Both Factors Conclusion => weight both service duration and intensity => equitable work distribution Credited work => to be blended between => simple duration of assigned coverage (credit per staff person => too similar for equity) => and mere intensity of work (credit per staff person => too different for equity) Duration and Intensity Weighted Blend Weighting => intensity (RVUs per week) at 70% => duration (weeks of coverage) at 30% => 4:1 maximum service work credit ratio between services MGH AP Subspecialty Service Credit and Staffing => 100% RVUs Subspecialty Credit Staff Subspecialty Autopsy Path Breast Path Bone & Soft Tiss Cardiac Path Non-GYN Cyto GYN Cyto Dermatopath Electron Micro 0.13 * ENT Path FNA Clinic Frozen Sect Lab Credit Staff GI Large Path GI Small Path GU Path GYN Path Hematopath Neuropath OB Path Pulm Path Renal Path All Path *Electron microscopy staffed as addon service. MGH AP Subspecialty Service Credit and Staffing => 70% RVUs 30% Weeks Subspecialty Credit Staff Subspecialty Autopsy Path Breast Path Bone & Soft Tiss Cardiac Path Non-GYN Cyto GYN Cyto Dermatopath Electron Micro 0.13 * ENT Path FNA Clinic Frozen Sect Lab Credit Staff GI Large Path GI Small Path GU Path GYN Path Hematopath Neuropath OB Path Pulm Path Renal Path All Path *Electron microscopy staffed as addon service.

7 25 Quantitative Considerations - CMS RVU Advantages: Specific physician work component => very convenient Most prevalent single basis of payment => service work credited and allocated on RVU basis has a close relationship between work done and payment received => simultaneous tracking of physician work for service credit and of physician billing for compliance 24 Quantitative Considerations - CMS RVU Limitations: Absence of Established values for autopsy services; Measures for either the work contribution, or the supervisory requirements, of trainees; Measures for the differential effect of subspecialization on: special study services, routine diagnostic services, and procedural / intraoperative services; Miscellaneous subspecialty specific factors. Quantitative Considerations - CMS RVU Autopsy MGH staff on both the autopsy and surgical services => relative values for staff activities on autopsy services => multiples of (Level VI) surgical specimen: Service Description CPT RVUs 88309s Necropsy; with brain Necropsy; without brain Necropsy; stillborn/newborn Necropsy; brain only Quantitative Considerations - CMS RUV Surgical Grossing Grossing surgical pathology specimens => included in CMS physician component RVUs => performed by trainees under staff supervision. Equity with cytopathology services => actually performed entirely by staff => 50% increment in cytopathology credit Quantitative Considerations - Routine diagnostic surgical pathology services CPT Narrative RVU Blood smear interpretation Bone marrow interpretation Surgical path, gross Tissue exam by pathologist Tissue exam by pathologist Tissue exam by pathologist Tissue exam by pathologist Tissue exam by pathologist Microslide consultation Microslide consultation Comprehensive review of data Quantitative Considerations - Routine diagnostic cytopathology services CPT Narrative RVU Cytopathology, fluids Cytopathology, fluids Cytopathology, fluids Cytopath, concentrate tech Cytopath, cell enhance tech Forensic cytopathology Cytopath, c/v, interpret Cytopath smear, other source Cytopath smear, other source Cytopath smear, other source Cytopath eval, fna, report 1.39

8 Quantitative Considerations - CMS RVU Special Studies Greatest increase in subspecialization efficiency => special studies: which special studies to order; how to evaluate, interpret, and report on the results; how to code and bill for these services. Decrement special study RVUs by 40%. Prevalence of special studies varies greatly among subspecialties. MGH subspecialty services by size (RVUs) with % special studies % Special Studies 120% 100% 80% 60% 40% 20% 0% BST*CV BR CYTO* DP EM GIL GIS ENT* GUGYL GYS HP NP* PP OB/PERI RP 30-20% Quantitative Considerations-Special studies 31 CPT Narrative RVU Cell marker study Flowcytometry/read, Flowcytometry/read, Flowcytometry/read, 16 & > Cyto/molecular report Decalcify tissue Special stains Special stains Histochemical stain Chemical histochemistry Enzyme histochemistry Immunohistochemistry Immunofluorescent study 0.86 Quantitative Considerations-Special studies 32 CPT Narrative RVU Immunofluorescent study Electron microscopy Scanning electron microscopy Analysis, skeletal muscle Analysis, nerve Analysis, tumor Tumor immunohistochem/manual Immunohistochemistry, tumor Nerve teasing preparations Tissue hybridization Insitu hybridization, auto Insitu hybridization, manual 1.40 Quantitative Considerations - CMS RVU Intraoperative and Procedural Services Least increase in subspecialization efficiency => intraoperative and procedural services: => because this variability is least well controlled by subspecialization (because it's least subspecialized). Increment intraoperative and procedural service RVUs by 40%. Prevalence of these services also varies greatly among subspecialties. % Special Studies 40% 35% 30% 25% 20% 15% 10% 5% 0% -5% MGH subspecialty services with % special studies and % intraoperative or procedural services. 3% CYTO 17% BST 19% ENT 27% NP 56% FNA 100% FS 33-10% -10% 0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100% 110% % Intraoperative or Procedural Services

9 Quantitative Considerations - Intraoperative and procedural services CPT Narrative RVU Fna w/o image Fna w/image Cytopathology eval of fna Path consult intraop Path consult intraop, 1 bloc Path consult intraop, add l Intraop cyto path consult, Intraop cyto path consult, Quantitative Considerations - Service Impact of Systematic Adjustments Subspecialties very differently affected by => adjustments for special studies and/or => intraoperative & procedural services. Credit adjustments for services most affected => renal and hematopathology (down) and => FNA and FS (up) Quantitative Considerations - Miscellaneous Factors Call coverage (transplant, neuropathology, &c.), Interdepartmental subspecialty clinics and conferences (breast multidisciplinary conferences, &c.), Changes from practice prevailing when RVUs were established (synoptic reporting generally, particularly for excisional breast biopsies; outside case consultations with the new NCCI edits, &c.), and Uniquely specialized services (OB path flotation of specimens with dissecting micro examination for identification of villi). 39 Other Measurement Systems - Kim Units and RVUs Compared Kim Units (KUs) roughly parallel RVU physician work component at 1 KU = 1.8 RVUs However, using this as a conversion factor: Specimen Type KUs 1.8 RVUs Difference NON-GYN Cytology = KU = RVUs* GYN Cytology = KU >> RVUs* *KUs > than RVU values by factor of 2.6 Autopsy Pathology = KU << MGH* *KUs < than MGH values by factor of GYN CYTO Surgical and Cytopathology KUs vs RVUs (scaled) NON-GYN CYTO Specimen Types Surgical and cytopathology specimens (except for kidney and liver, excluded to allow for special studies), with physician work RVUs scaled (X1.8) to KUs. KU RVU Other Measurement Systems - Royal College of Pathologists, 1992 & 1999 RCP (London, England) workload guidelines => annual case load per FTE direct clinical care pathologist In a district general hospital: 4,000 surgical cases, 6,000 cytology cases, or 600 autopsy cases In a teaching hospital department: 2,000 surgical cases, 3,000 cytology cases, or 300 autopsy cases

10 RCP Special Advisory Committee on Histopathology Reconsidered prior guidelines => substantial revisions required => to address cumulative effects of: increasing subspecialization, increasing use of detailed minimum data sets on cancer cases, increasing participation in multidisciplinary team meetings, and general increase in requirements for clinical governance, continuing professional development, and appraisal. RCP - Revised System, 2003 & Structure Microscopy Low 1 Intermediate 3 High 5 Very High 10 Low 1 Intermediate 3 Macroscopy (Grossing) High 5 Very High The sum of the Macroscopy and Microscopy scores from the matrix above is considered to be the relative work of the service RCP - Revised System, 2003 & Diagnostic Service Work Expected rate of pathologist work => 10 units / hour => Macroscopic and Microscopic where pathologist does both => Microscopic only where resident / technician does gross under supervision Typical FTE direct clinical care pathologist => ~ 40 weeks per year diagnostic service => ~24 hours per week diagnostic service => ~9,600 units of diagnostic service work RCP - Revised System, 2003 & Other Clinical / Professional Activities Other direct clinical care activities typically => preparation for and participation in multidisciplinary team meetings, case reviews, and second opinions Other supporting professional activities => teaching, continuing professional development, clinical governance, and research RCP - Revised System, 2003 & General Surgical Work vs CMS RVUs Service description Single small bx no level stain immuno Single small bx 1-4 levels stains immunos Single small bx >4 levels stains immunos Needle core bx no immuno Needle core bx with immuno Frozen section (any indication) RCP workload units macro+micro=score CPT code CMS professional component RVUs 1+1= =4 1+5= to * to >4* to *0.85 = 0.75 to to 0.75+>4*0.85 = 0.75 to >5 1+3= = >1* >0.85 = > = or or 0.59 RCP - Revised System, 2003 & Specific Surgical Work vs CMS RVUs Service description RCP workload units macro+micro=score CPT code CMS professional component RVUs BCC / SCC skin biopsy 1+3= Melanoma skin biopsy 1+5= Liver biopsy 1+5= Nephrectomy for tumor 5+5= Radical prostatectomy 10+10= Cervical cytology Non-gyn cyto (1-3 slides) Non-gyn cyto (4-8 slides) Non-gyn cyto (>8 slides / complex case)

11 RCP - Revised System, 2003 & Autopsy Service Work vs CMS RVUs Service description Autopsy, low input Autopsy, intermed input Autopsy, high input RCP workload units macro+micro=score 1½ hours = 15 units 3 hours = 30 units 6 hours = 60 units CPT code CMS professional component RVUs Other Measurement Systems - Canadian Experience (2005) Comparison survey => 27 Canadian pathology services (11.3% response rate): current / projected optimal pathologist FTEs, annual number anatomic pathology specimens autopsy pathology=> cytopathology => categorized for weighting, surgical pathology => number blocks & slides, and patient population served by practice Anatomic pathology consultative procedures (professional services) => categorized & weighted relative to level IV surgical (~88305) Canadian Experience (2005) - Surgical Level Weighting vs CMS PC RVUs CPT code - Individual Consultative CMS professional Relative Weighting Procedures component RVU - % of Level I - Gross only 14% % examination Level II Confirmation of normality by gross and 32% % microscopic examination of small specimens Level III Confirmation of common degenerative, 49% % inflammatory and common benign conditions Level IV Small specimens for diagnosis, including all endoscopic biopsy 100% % specimens and small organs removed for benign conditions Level V Complex biopsy specimens or small whole organs, including specimens 172% % from specialized biopsies and excisions Level VI Large complex organs, requiring extensive 253% % gross dissection and microscopic assessment Canadian Experience (2005) - Other Service Weighting vs CMS PC RVUs Individual Consultative Procedures Relative Weighting Screening cytology (sputum and urine cytology, pathologist review of marked Pap smears) Diagnostic cytology (FNA, 100% fluids) Intraoperative consultations (with and without frozen 150% sections) Autopsy (full, uncomplicated) 800% Intradepartmental 25% of level of consultation specimen reviewed Consultation, review (e.g., cancer clinic reviews, for studies) Consultation, complicated (for difficult cases, external) Other procedures (e.g., FNA, bone marrow biopsy with or without aspiration) CPT code - CMS professional component RVU - % of % % 66% of level of specimen reviewed 150% of level of specimen reviewed As per other specialties or 100% of level IV % % % % % % % % % Other Measurement Systems - Canadian Experience (2005) Best correlation with surveyed optimal FTEs => weighted level IV equivalents => mean 3,600 level IV equivalents per optimal FTE Canadian Experience (2005) 3,600 Practices Surveyed Level IV Equivalents / Optimal FTE 43 Quantitative Considerations - Major Drawbacks of Alternative Systems 1) No explicit special study / procedure credit => fails to recognize large part of much subspecialty work; 2) information not already collected => requires additional administrative procedures; 3) not directly related to billing => less readily linked to compliance. So, => despite some attractive features of alternative systems, => MGH uses CMS RVUs adjusted as described.

12 MT:AER,W- M :LRZ,U:FGC,W- F:ARA MUF:BAD,W:GRL,R:MRM MU:RHY,WR:MJL,F MGH - 7/1/95 to Present - Track Specimens by Service 49 Each specimen primarily accessioned => to appropriate subspecialty service with memo (non-billing) fee code as flag to computer system. Number and characteristics of cases on each service => automatically tracked from subspecialty flagged accessioning and billing data. Different colored tissue cassettes => track blocks and slides from each subspecialty through histology and special study laboratories. MGH - 7/1/95 to Present - Ongoing Service Measurement 49 CPT billing data aggregated twice every FY CPTs sorted to subspecialty by case Unique services redistributed by CPT (e.g., surface marker flow to heme; frozen sections (except from BST, ENT, NP) to FS service) Autopsies added at MGH values Systematic adjustments applied Miscellaneous adjustments applied Service credits developed and reviewed Staff work weeks assigned and published Path Scheduled Adjusted Service Service Assoc Other FTEs FTEs FTEs FTEs Name BAD Badizadegan DAB Bell AKB Bhan WSB Black-Schaffer KMB Braaten EFB Brachtel RBC Colvin LDC Cornell VDE Deshpande LMD Duncan JHE Eichhorn WCF Faquin JAF Ferry TJF Flotte MPF Frosch CFG Garcia JPG Grabbe FGC Graeme-Cook NLH Harris RPH Hasserjian ETHW Hedley-Whyte HOU Houser FCK Koerner RLK Kradin GRL Lauwers DCW Wilbur LEE Wu RHY Young ZBZ Zembowicz LRZ Zukerberg Name AUT BR BST CV CYT CYTG DP EM ENT FNAG FS GIL GIS GU GYN HP NP OB PP RP Weeks / FTE = Badizadegan 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 25% 75% 0% 0% 0% 0% 0% 0% 0% Bell 0% 0% 0% 0% 65% 20% 0% 0% 0% 0% 0% 0% 0% 0% 15% 0% 0% 0% 0% 0% Bhan 100% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% Black-Schaffer 0% 0% 0% 0% 75% 10% 0% 0% 0% 0% 0% 0% 0% 0% 15% 0% 0% 0% 0% 0% Braaten 0% 40% 0% 0% 0% 0% 0% 0% 30% 0% 10% 0% 0% 20% 0% 0% 0% 0% 0% 0% Brachtel 0% 15% 0% 0% 60% 10% 0% 0% 0% 15% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% Colvin 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 100% Cornell 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 100% Deshpande 0% 0% 15% 0% 55% 10% 0% 0% 0% 15% 0% 5% 0% 0% 0% 0% 0% 0% 0% 0% Duncan 0% 0% 0% 0% 0% 0% 100% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% Eichhorn 0% 15% 0% 0% 50% 20% 0% 0% 0% 0% 0% 0% 0% 0% 15% 0% 0% 0% 0% 0% Faquin 0% 0% 0% 0% 55% 5% 0% 0% 25% 15% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% Ferry 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 10% 0% 0% 0% 0% 90% 0% 0% 0% 0% Flotte 0% 0% 0% 0% 0% 0% 100% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% Frosch 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 100% 0% 0% 0% Garcia 0% 40% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 60% 0% 0% 0% 0% 0% Grabbe 0% 0% 0% 0% 100% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% Graeme-Cook 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 100% Harris 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 100% 0% 0% 0% 0% Hasserjian 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 15% 30% 0% 0% 55% 0% 0% 0% 0% Hedley-Whyte 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 100% 0% 0% 0% Houser 35% 0% 0% 65% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% Koerner 0% 80% 0% 0% 0% 10% 0% 0% 0% 0% 10% 0% 0% 0% 0% 0% 0% 0% 0% 0% Kradin 30% 0% 0% 20% 0% 0% 0% 0% 0% 0% 10% 0% 0% 0% 0% 0% 0% 0% 40% 0% Lauwers 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 10% 25% 65% 0% 0% 0% 0% 0% 0% 0% Wilbur 0% 0% 0% 0% 75% 10% 0% 0% 0% 0% 0% 0% 0% 0% 15% 0% 0% 0% 0% 0% Wu 0% 0% 0% 0% 0% 0% 0% 0% 50% 0% 10% 0% 0% 40% 0% 0% 0% 0% 0% 0% Young 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 10% 0% 0% 20% 70% 0% 0% 0% 0% 0% Zembowicz 0% 0% 0% 0% 0% 0% 100% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% Zukerberg 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 10% 10% 30% 0% 0% 50% 0% 0% 0% 0% Number of staff p Number of signou Number of weeks FROZEN SECTIONS BR CYT DPA GI GYN MON TUE WED THU FRI WEEK AUT BR1 BR2 BST CA CB CC CD CV DPA DPB EM ENT GIL GIS WEEK GU GYL GYS HP NP OB PP RP FSM FSU FSW FSR FSF Badizadegan Bell BAD DAB 01/01/02 HOU KMB MJL AER MBP DCW FCK RHT JST LMD AZ GUN LEE ASV GRL 01/01/02 GUN SER JHE JAF DNL DRU RLK LDC/RBC HOLIDAY GUN FCK AER EJM P gs 01/08/02 RLK FCK JHE GUN JPG DAB RHT EFB JST MCM LMD GUN BZP VDE ASV 01/08/02 KMB MJL CFG LRZ MPF DRU RLK LDC/RBC RHY EJM MJL JAF GUN U CB 01/15/02 JST MJL FCK VDE EFB JHE WSB JOE EJM AZ AZ GUN LEE ARA/RPLRZ 01/15/02 BZP CFG SER NLH MPF DRU EJM LDC/RBC HOLIDAY KMB JAF KMB EJM U U 01/22/02 EJM MJL EFB AER DCW MBP FCK WCF EJM AZ AZ GUN BZP MRM JOE 01/22/02 LEE OLI CFG JAF ETHW DRU EJM LDC/RBC OLI AER MRM FCK RHY V 01/29/02 RLK JHE MJL AER DAB WSB RHT VDE JST LMD TJF GUN KMB ARA/G MBP 01/29/02 LEE DRU RHY LRZ ETHW SER RLK REX LEE BZP GRL BZP MRM U CA 02/05/02 RLK KMB SGR AER JHE VDE DAB JOE HOU MCM LMD GUN WCF LRZ GRL 02/05/02 RHY RHT DAB NLH DNL DRU RLK REX MJL JAF LRZ MRM BZP U GYS CC 02/12/02 REX CFG FCK F:VDE RHT JPG RHT MBP REX TJF TJF GUN KMB 02/12/02 M:RHY,UW:LEE,R :BZP,F:GUN :DCW DRU M -R:LRZ,F:NLH ASR DRU REX REX LRZ AER EJM EJM BZP X UR GIS X MU 02/19/02 RLK MJL CFG GUN WCF EFB DAB VDE EJM TJF TJF GUN BZP JOE MRM 02/19/02 OLI DAB RHT RPH ASR RHT EJM REX HOLIDAY KMB RHY OLI KMB U GYL CC 02/26/02 REX SGR MJL AER JOE WSB DCW MBP JST LMD AZ GUN LEE ASV ARA/GRL 02/26/02 BZP RHY CFG JAF MPF DRU RLK EES KMB LRZ EJM AER FCK U 03/05/02 AKB FCK EFB AER RAO JOE DAB RHT RLK AZ LMD GUN KMB RPH MRM 03/05/02 LEE DAB RHY JAF ETHW DRU RLK EES MJL LEE BZP RHY LEE U CC GYL 03/12/02 RLK KMB FCK GUN DCW VDE JHE JOE JST LMD AZ GUN BZP MBP ARA/GRL 03/12/02 OLI MJL JHE NLH ETHW DRU EJM EES GUN OLI MJL EJM OLI U 03/19/02 HOU CFG MJL GUN RHT JHE FCK RHT HOU MCM MCM GUN LEE ASV VDE 03/19/02 BZP DRU OLI RPH DNL OLI EJM EES KMB FCK GRL JAF GUN U X 03/26/02 AKB FCK CFG VDE EFB JOE JHE MBP HOU AZ AZ GUN WCF MRM BAD 03/26/02 LEE OLI RHY JAF ETHW DRU RLK EES LEE EJM MRM LEE OLI P gs GIS V 04/02/02 HOU MJL KMB AER JOE RAO RHT EFB HOU TJF MCM GUN LEE GRL ASV 04/02/02 OLI RHY WSB LRZ ASR DRU REX EES JAF BZP GRL JAF BZP U 04/09/02 AKB MJL FCK GUN EFB DAB DCW MBP EJM LMD AZ GUN WCF GRL VDE 04/09/02 KMB CFG OLI RPH ETHW SER EJM EES OLI LEE GRL GUN JAF U CB 04/16/02 EJM FCK SGR AER RHT JHE EFB WCF RLK MCM LMD GUN KMB VDE MRM 04/16/02 GUN CFG MJL JAF ETHW RHT RLK EES BZP RHY GUN RHY MJL U 04/23/02 JST EFB KMB VDE JOE WCF FCK MBP RLK AZ LMD GUN BZP MRM ASV 04/23/02 LEE OLI SER LRZ ASR OLI RLK EES MRM FCK OLI FCK LEE U 04/30/02 AKB JHE SGR GUN VDE RHT DAB WCF EJM AZ MCM GUN LEE LRZ MBP 04/30/02 RHY SER DAB RPH MPF DRU EJM REX FCK MRM LRZ MRM JAF U GYS CC 05/07/02 RLK SGR MJL AER MBP WCF RHT EFB EJM TJF LMD GUN BZP GRL MRM 05/07/02 KMB JHE WSB JAF MPF DRU EJM REX LRZ LRZ GRL AER FCK U 05/14/02 EJM MJL FCK AER DAB EFB RHT VDE EJM AZ LMD GUN BZP ASV GRL 05/14/02 RHY RHT DRU LRZ ETHW DRU EJM REX JHE JAF KMB AER JHE U CA 05/21/02 RLK FCK MJL AER VDE MBP WSB JOE JST LMD AZ GUN KMB BAD RPH 05/21/02 GUN OLI DCW NLH DNL OLI RLK REX LRZ LRZ OLI AER LRZ P GIL U course 05/28/02 JST EFB KMB GUN WCF RAO FCK RHT EJM MCM MCM GUN LEE MRM LRZ 05/28/02 OLI RHY SER JAF ETHW DRU EJM EES HOLIDAY JHE MRM OLI GUN P 06/04/02 AKB KMB SGR GUN MBP DCW DAB WCF RLK LMD TJF GUN BZP ASV BAD 06/04/02 LEE DRU OLI RPH ETHW SER RLK EES LEE GUN LEE MRM GUN GIS CC 06/11/02 HOU FCK SGR VDE WSB DAB JHE EFB REX AZ LMD GUN LEE ASV MRM 06/11/02 GUN RHY DCW RPH ASR DRU EJM EES EJM EJM GRL BZP GRL CB 06/18/02 JST FCK JHE GUN JPG WCF EFB VDE RLK MCM MCM GUN BZP BAD JOE 06/18/02 RHY DCW SER JAF ETHW DRU RLK EES MRM GRL MJL GRL MJL P GIL 06/25/02 RLK SGR FCK AER DCW EFB JHE RHT JST AZ AZ GUN WCF BAD RPH 06/25/02 OLI WSB MJL LRZ ETHW OLI RLK EES AER LEE BZP AER JHE P GIL V Staff after "/" are backup for other staff on signout or supervisory for fellows on signout of all cases at full service credit Staff after "/" are backup for other staff on signout or supervisory for fellows on signout of all cases at full service credit.

13 WEEK Bhan Black-Schaffer Braaten Brachtel Colvin Cornell, Lynn Deshpande Duncan Eichhorn Faquin Ferry Flotte AKB WSB KMB EFB RBC LDC VDE LMD JHE WCF JAF TJF U X M BR1 RP/LDC RP/RBC DPA P GYS HP 01/01/02 01/08/02 GU RP/LDC RP/RBC DPB P BR2 U W CD GIL V FSR 01/15/02 U fr ok CA RP/LDC RP/RBC BST CB X FSW CC FSUR MU 01/22/02 X F V BR2 RP/LDC RP/RBC CD HP 01/29/02 CB ENT U CD DPA BR1 DPB 02/05/02 X F BR1 U CB DPB CA U ENT FSU 02/12/02 X X ENT X U flexible X U-F X M-R X DPAB 02/19/02 X FSUF CB CD CA DPAB 02/26/02 CB FSM DPA V HP 03/05/02 AUT ENT BR2 DPB HP 03/12/02 U BR1 U CB DPA GYS X RF U M, CC X RF 03/19/02 U U fr ok U GIS CB X M-W XM FSR FSM 03/26/02 X V CA BST CC ENT HP AUT M 04/02/02 GYS CD BR2 X F FSMR DPA 04/09/02 CA ENT FSF AUT GU GIS DPA 04/16/02 X MRF ENT CC GIL DPB CB CD HP 04/23/02 BR2 BR1 BST DPB CB X RF 04/30/02 AUT X F X CA BR1 CD FSF 05/07/02 GYS GU GYL CB HP CD DPB DPA 05/14/02 FSW CB DPB FSMF FSU X CD 05/21/02 X ENT U CA DPA MU CC U X F 05/28/02 X V BR2 BR1 U FSU CA HP 06/04/02 AUT V MUW V can U DPA V CD X RF be +/- BR1 DPB 06/11/02 CA U CD DPB CC X BST 06/18/02 U CC CD BR2 CB HP 06/25/02 BR1 CB X P CC ENT GYL FSF Staff after "/" are backup for other staff on signout or supervisory for fellows on signout of all cases at full service credit. MGH Completely Subspecialized Diagnostic Pathology - Scheduled Residents 50 Residents' work reassigned => all services covered by same total number of residents but => services (as for staff) more heterogeneous so => PAs reassigned from general coverage to assistance on the heavy grossing services (Bone and Soft Tissue, Breast, ENT, GI Large, and GYN Large services). Resident 2-Jan 9-Jan 16-Jan 23-Jan 30-Jan 6-Feb 13-Feb 20-Feb 27-Feb AP Auluck PKA S BO A GIL EL (A) EL (A) V (A) EL (A) EL (A) AP/CP Belsley NAB FZ ENT GYS/OB EL (A) EL (A) EL (A) EL (A) EL (A) EL (A) AP Davis TLD EL (A) EL (A) FZ H H EL (A) EL (A) EL (A) EL (A) AP/CP Dionigi AAD ME ME BR GYS/OB GIS BO GIL FZ GYL AP/CP Hull MJH N N GIS V (A) GYL CY CY CY CY AP/CP Hysell CKH GU GYL ME ME V (A) A BR S GIS AP/CP Kish JBK CY A GIL A FZ V (A) CY CY BO AP/CP Knoepp SMK EL (A) EL (A) CY CY CY CV CY A ENT AP/CP Koreishi AFK GYS/OB BR GU BR S V (A) GYL CV A AP/CP Lamb CAL BR S ENT GIS GIL GYS/OB V (A) GYL CV AP Lawlor MIL A FZ R R ENT GYL GU BR S AP/CP Louissaint ABL GIL GYS/OB V (A) GYL CV GU MP MP CY AP/CP Mandal RVM CV CY CY CY CY CY N N CY AP/CP Murphy EEM CY CY CY CY CY CY S BO GU AP Oble DAO GYL GU CV V (A) A FZ GYS/OB GIL GYS/OB AP Post MPO FL FL EL (A) EL (A) EL (A) V (A) A ENT H AP/CP Rao REA CY CY S BO GU BR H H V (A) AP/CP Roehrl MHR ENT GIS V (A) V (A) R R BO GU BR AP/CP Sepehr ASP V (A) EL (A) EL (A) FZ BO GIL FZ V (A) EL (A) AP/CP Shaikh SAL H H BO GU BR S ENT GIS GIL AP/CP Staats PNS GIS GIL GYL CV N N V (A) V (A) FZ AP/CP Turbiner JLT BO EL (A) EL (A) EL (A) EL (A) GIS MP MP N AP Vasilyev AKV V (A) CV FL FL ME ME H H EL (A) 2-Jan 9-Jan 16-Jan 23-Jan 30-Jan 6-Feb 13-Feb 20-Feb 27-Feb Chief Resident LDC LDC LDC LDC LDC LDC LDC LDC LDC Autopsy MIL JBK PKA JBK DAO CKH MPO SMK AFK Bone / Soft Tissue JLT PKA SAL REA ASP AAD MHR EEM JBK Breast CAL AFK AAD AFK SAL REA CKH MIL MHR Cardiac / Pulmonary RVM AKV DAO PNS ABL SMK Uncovered AFK CAL Dermatopathology PKA CAL REA Uncovered AFK SAL EEM CKH MIL Ear, Nose, and Throat MHR NAB CAL Uncovered MIL NOR SAL MPO SMK Flow Cytometry MPO MPO AKV AKV Forensic Pathology (ME) AAD AAD CKH CKH AKV AKV Frozen Section NAB MIL TLD ASP JBK DAO ASP AAD PNS Gastrointestinal Large ABL PNS JBK PKA CAL ASP AAD DAO SAL Gastrointestinal Small PNS MHR MJH CAL AAD JLT NOR SAL CKH Genito-Urinary CKH DAO AFK SAL REA ABL MIL MHR EEM Gynecological Large DAO CKH PNS ABL MJH MIL AFK CAL AAD Gynecological Small AFK ABL NAB AAD JAN CAL DAO NOR DAO Hematopathology - Anatomic SAL SAL Uncovered TLD TLD Uncovered AKV AKV MPO Hematopathology - Anatomic REA REA Molecular Pathology ABL ABL Molecular Pathology JLT JLT Neuropathology MJH MJH Uncovered Uncovered PNS PNS RVM RVM JLT Renal Pathology Uncovered Uncovered MIL MIL MHR MHR Uncovered Uncovered Uncovered Cytology EEM EEM EEM EEM CJN EEM JBK JBK ABL Cytology JBK REA RVM RVM EEM MJH MJH MJH MJH Cytology REA RVM SMK SMK RVM RVM SMK RVM Cytology SMK Elective JAN ASP ASP JAN JLT NAB NAB NAB AKV Elective SMK JAN JAN JLT MPO PKA TLD PKA ASP Elective TLD JLT JLT MPO NAB TLD TLD NAB Elective SMK MPO NAB PKA PKA Elective TLD TLD Vacation ASP AKV ABL DAO CKH AFK CAL ASP NOR Vacation MHR MHR JBK PKA PNS REA Vacation MJH MPO PNS Rationale for Subspecialization - Expertise Patients => referral facilities to consult subspecialized clinicians => expectation specimens => diagnosed by pathologists with similar expertise Increasing clinical / pathology sophistication => difficult for individual maintain literature familiarity / diagnostic competence in all of pathology Pre-Subspecialization - Expertise Issues Pathologists on general services => encouraged to show cases to subspecialists Significant diagnostic errors rare but => requests to amend reports for data / terminology required by clinician increasing 52 53

14 Post-Subspecialty Change in Surgical Pathology Corrected Diagnosis Rate % Change Surg Path Case 45,208 71, % All Revised Rep % 0.76% -24% Corrected Final % 0.04% -66%* *p<0.001 Chi 2 Rationale for Subspecialization - Turn Around Time Frequency of intradepartmental consultations increasing => decreasing both staff and resident efficiency. For some specimen types => increasing turn around time due to frequent need for subspecialized second opinion Service ALL BR1 BR2 BST CPC CV DP ENT EYE GIL GIS GU GYL GYS HP NP OB PP RP 11/05 MGH TAT Days Resident Slide Preview Tech (Small) Gross Resident/PA (Large) 56 Turn Around Times to 2003 to 2005 Surgical Pathology Turn Around Time Days Absolute Adjusted* *Adjustment allows 1 resident preview day, not changed with subspecialization (BR1-BR2=0.98) Differential between PA / resident grossed (large) and tech grossed (small) specimens from 0.46 (GYL-GYS) to 0.87 (GIL-GIS) days Clinical Communication Academic Collaboration pathologists on general diagnostic services => hard to build relationships => facilitate mutual understanding in difficult cases. Better communication among much smaller numbers of correspondingly subspecialized clinicians and pathologists. Subspecialized clinicians working with subspecialized pathologists => regard pathology subspecialists as members of subspecialty patient care "team". 58 Similar interests => foster close relationships and academic collaboration. Pathologists with academic careers => well served by concentrating on specimens in areas of interest. Ease of preparation and quality of teaching and of conferences => improve with subspecialization.

15 Post-Subspecialization Peer Reviewed Publication Record Publications Year Staff Publications (Year) per Staff Post-Subspecialization Grant Support >10% Grant >10% Grant Service Total Total Support Support Rotations (1996) (2002) 3.61 Includes publications cited in PubMed Does not include CPCs or book chapters Multiple authored publications counted once 60 Subspecialty General Total (28%) (39%) Educational Benefit of Subspecialization for Junior Residents 61 Appreciate focused nature of signout Learn effectively when exposed repeatedly to a defined panel of specimens over the course of a rotation Junior resident concern: Sustaining ongoing exposure to all areas of diagnostic pathology => MGH daily "Outs" conference: rotating subspecialties every MTWF; systemic pathology lectures alternating with current cases of all kinds every Thursday. SURGICAL PATHOLOGY "OUTS" CONFERENCE SCHEDULE For the weeks of January 2 to July 7, 2006 Week of Monday (1 hr) Tuesday (1 hr) Wednesday (1 hr) Thursday (1 hr) Friday (1 1/2 hrs) 1-2 Holiday GI DP/RP Lecture GU/AUT 1-9 GYN/CV BR DP/OB General outs ENT/AUT 1-16 Holiday BST DP/Immuno Lecture GU/AUT 1-23 GYN/PP GI DP/RP General outs ENT/AUT 1-30 GYN/CV HP DP/CP Lecture GU/AUT 2-6 GYN/NP BR DP/OB General outs ENT/AUT 2-13 USCAP USCAP USCAP USCAP USCAP 2-20 Holiday BST DP/CP General outs GU/AUT 2-27 GYN/CV GI DP/OB Lecture ENT/AUT 3-6 GYN/NP HP DP/Immuno General outs GU/AUT 3-13 GYN/PP BR DP/EM Lecture ENT/AUT 3-20 GYN/CV BST DP/CP General outs GU/AUT 3-27 GYN/NP HP DP/OB Lecture ENT/AUT 4-3 GYN/PP GI DP/RP General outs GU/AUT 4-10 GYN/CV BR DP/Immuno Lecture ENT/AUT 4-17 GYN/NP BST DP/CP General outs GU/AUT 4-24 GYN/PP GI DP/OB Lecture ENT/AUT 5-1 GYN/CV HP DP/EM General outs GU/AUT 5-8 GYN/NP BR DP/RP Lecture ENT/AUT 5-15 GYN/PP BST DP/CP General outs GU/AUT 5-22 GYN COURSE GYN COURSE GYN COURSE GYN COURSE ENT/AUT 5-29 Holiday GI DP/OB General outs GU/AUT 6-5 GYN/PP HP DP/Immuno Lecture ENT/AUT 6-12 GYN/CV BR DP/RP General outs GU/AUT 6-19 GYN/NP BST DP/CP Lecture ENT/AUT 6-26 GYN/PP HP DP/OB General outs GU/AUT 7-3 GYN/CV Holiday DP/EM Lecture ENT/AUT Educational Benefit of Subspecialization for Senior Residents 62 Appreciate opportunities => focus on interests in various subspecialties Appreciate availability => surgical pathology subspecialty rotations in each area => as senior resident electives or => for actual post-residency fellowships Staff Concerns Junior staff => not seeing material from all diagnostic areas => to stay in diagnostic academic pathology need to subspecialize to develop career Senior staff => increased responsibility for training and supervising junior staff => offset by increased efficiency of senior staff signout 63

16 64 MGH Pathology Survey 10/03 From your perspective, do you prefer the current MGH system of AP subspecialization to that of general signout? Responding Yes No Undecided Residents % 0% 0% Staff 34 97% 3% 0% MGH Model for Subspecialization - Requirements 65 Practice size => match useful range of specimen types / diagnostic entities with subspecialized services / pathologists; Commitment to specialized mode of practice => exchange broad general competence for narrower but deeper subspecialty expertise; Organizational support => administrative demands of subspecialized practice much greater than the baseline requirements of pathology practice. MGH Model of Subspecialization - Applicability? Subspecialization works at MGH, both academically and economically. In the development of pathology, is this an aberration or evolution?