Download Practice Transformation for Cytotechnologists: The Mayo Clinic

Practice
Transformation for
Cytotechnologists:
The Mayo Clinic
Experience.
Amy C. Clayton M.D.
Mayo Clinic
Rochester, MN
Conflict of Interest

I have no relevant conflicts of interest
in regards to the content of the
presentation.
Mayo Cytology:
A Decade of Change
Share our journey…
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Why did we change?
What new roles are
cytotechnologists taking?
Cytotechnologist Career Ladder
Financial Impact- Does it make
sense?
TRANSFORMATION = CHANGE
2006: “New Profession for
Cytotechnologists Task Force”-
Engaged Forbes Group to analyze profession

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Defined cytology profession as “unique
body of knowledge” that fills an existing
or emerging market gap
..there is economic justification...for a
more highly skilled cytology profession
Predicts clinician and pathologist
shortage...requires new systems
New Profession for
Cytotechnologists Task Force
Forbes Group:
 Health consumerism ...changing laboratory
industry....demanding more cost effective
testing
 Expanding scope of cytologists ....could
prove essential to increasing productivity
and efficiency of cytopathology
 Digital image management important- do
cytopathology labs want to be at table or
let radiology do it?
Mayo Clinic Practice Needs: A Decade
of Change (2000-2010)
Our Own Transformation:
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Pathologist Shortage in our group
Increasing workload
Innovation to improve Cytology Testing
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FISH on urine cytology specimens (UroVysion), biliary
brush, bronchial brush
Ploidy analysis
Expanded need for histologic tumor ID for
molecular genetic testing
Improved quality desired for quantitative
immunohistochemical analysis (ER/PR/HER2)
Our Response to Needs
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Created Roles for Cytotechnologists
that make sense for the individual
practice (driven by need to save
pathologist time and understanding
the unique skills of the
cytotechnologist)
Developed Cytotechnology curriculum
that supports the expanded
cytotechnology roles
It’s still about the cells!
2010
Results – CT
Responsibilities
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2000
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GYN
Non-GYN
EUS FNA
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FISH Analysis
FNA Screening
ER/PR and Her2
review
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On site adequacy
Digital Image
Analysis
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Ploidy and
Proliferation
Specimen problem
solving
Circulating Tumor
Cells
HE Tumor
Identification
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Manual interpretation
Digital image analysis
Microdissection for
Molecular testing
AFB Screens
Test Development
New Responsibilities: FISH
Testing
New Responsibilities:
FISH testing
FISH Testing:
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UroVysion- urine specimens-2000
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Cytotechs read in cytogenetics 2000
Molecular Cytology lab- 2005 (processing
and reads)
Biliary Brush specimens-2004
Bronchial Brush specimens-2006
Esophageal Brush, Barrett’s neoplasia2011
New Responsibilities
2005
 FNA
Pre-Screen for rapid assessment
 Slide review for non prescreened FNA
cases (QA) before final release
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2006
 IHC stain- manual quantitation
(preview) for ER/PR/HER 2
New Responsibilities: Circulating
Tumor Cell Analysis- 2008
Cell Search System
New Responsibilities: Automated IHC
quantitation 2009
Immunohistochemical Quantitation – HER 2
New Responsibilities
2009
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Histology review- selecting tumor
area on HE slides for microdissection
for molecular testing
•Hereditary Nonpolyposis Colon
Cancer (HNPCC)/Lynch
Syndrome
•ALK in lung cancer
•BRAF
•KRAS
•Multiple sarcoma tests
•Many more in future
Tumor Microdissection
2011 Tissue Review Volumes
480
460
440
420
Series1
400
380
360
Jan
Feb
March
April
May
June
New Responsibilities
2009
 Acid Fast Bacillus stainprescreening for pathologists
AFB Case Volume
300
250
246
236
215
200
197
158
150
165
157
160
152
218
211
223
221
212
186
163
155
162
151
143
133
197
196
190
133
100
50
0
Jun09
Jul09
Aug09
Sep09
Oct09
Nov09
Dec09
Jan10
Feb10
Mar10
Apr10
May10
Jun10
Jul10
Aug10
Sep10
Oct10
Nov10
Dec10
Jan11
For 2011: approximately 200 cases per month
Feb11
Mar11
Apr11
May11
Jun11
Test Volumes - New
Cytotechnologist Roles
Additional Roles of Cytotechnologists
35000
30000
25000
Test Volumes
Automated HER2
Implemented
FNAs
Tumor Identification
AFB
Circulating Tumor Cells
ER/PR/HER2
FISH
DIA
Tumor Identification and
AFB Screening Implemented
Circulating Tumor Cell Test
Implemented
ER/PR/HER2 CT review
Implemented
20000
15000
FISH Test Implemented
FNA Pre-Screens
Implemented
10000
5000
DIA Test
Implemented
EUS FNAs
Implemented
0
1995
1996
1997
1998
1999
2000
2001
2002
Year
2003
2004
2005
2006
2007
2008
2009
Career Ladder
Cytotechnologist
Senior Cytotechnologist
Lead
Specialist
Education/Training Focus
Pathologist Assisting Focus
Development Technologist
Assistant Supervisor
Supervisor
Quality Focus
Requirements
Cytotechnologist
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Cytology screening; exposure to ancillary testing
CT certification
Senior Cytotechnologist
(Rewards for development of
additional expertise and broader testing responsibility)
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Screening; additional ancillary testing; emphasis based
3 years experience
Required to pass SCT(ASCP) or MB(ASCP) exam
Lead
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Troubleshooting; point person for CT’s
3 years experience
Requirements
Specialist
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Education/Training Focus
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Pathologist assisting focus
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Prescreens FNA specimens; problem solves
Quality focus
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Trains new CT’s; provides education to CT’s, pathologists
and residents
Tracks quality metrics; prepares lab for inspections
3 years experience
Required to pass SCT(ASCP) or MB(ASCP) exam
Requirements
Development Technologist
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1-2 years experience
SCT(ASCP) or MB(ASCP) preferred
Cytotechnologists and Clinical Lab
Technologists
Innovation, Research Discovery
Clinical Test Validation
Work with Vendors, Biotech companies
Academic Responsibility
 Authors Abstracts, Manuscripts
From Voss, ASC Bulletin
Comparison to other laboratory
technologists
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“Cytotechnologists..unique…ability to
combine existing morphologic skills with
molecular techniques”
“understanding of neoplasia and other
diseases”
Mayo Cytology Development
Team
Expansion of CT Roles-2010
Assistant Supervisor
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Assists managing personnel
5 years experience
Supervisor
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Manages lab workflows and personnel
6 years experience
Program Director Cytology
School
Results- Positions
20
Number of Positions
Cytotechnologist
15
Lead
Senior CT
10
Specialist
Dev Tech
5
Asst Supv
Supv
0
2000
2010
Year
Career Ladder .....Maintaining
Proficiency
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Senior CT with Cytology Emphasis
 GYN and NonGYN screening
 Only 2 ancillary rotations allowed
Senior CT with Molecular Emphasis
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Does not do GYN screening
Does do NonGYN screening
 3 ancillary rotations allowed
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Financial Impact:
Cytotech Time VS Pathologist
Time
Labor Cost Per Test
Expanding the Role of Cytotechnologists:
a Cost Effective Approach
A Cost Effective Approach
(Root et al):
Test
Path Analysis
Time
Reduction
Expense
Reduction
FISH
96%
71%
Breast IHC
86%
67%
CTC
71%
41%
Cytotechnologist Responsibilities
FISH Testing
Cytotechnologist FISH
Workflow
Match Paperwork and
Slides
43
minutes
per case
FISH Analysis
Capture Images for
Permanent File
Enter FISH Interpretation
into LIS
Pathologist Responsibilities
FISH Testing
Pathologist FISH Workflow
Review Signal Patterns
2
minutes
per case
Review Representative
Images
Review Patient Clinical
Information
Verify/Release Report in
LIS
A Cost Effective Approach: FISH
With CT
analysis
CT time Pathologist
Time
(min)
(min)
43
2
Without
CT
analysis
38
Savings
N per
year
Salary
Cost*
6099 $149,904
6099 $531,127
-$375,598
*Average CT and Pathologist Salaries taken from most recent ASCP survey and
Physician Salary Survey: Modern Healthcare;2009, Vol 39, 20-26.
CT Responsibilities:IHC- ER,PR, HER 2
IHC Workflow
Match paperwork with slides
Check paperwork for fixation times
18 minutes
per case
Verify invasive versus in situ cancer
Perform IHC quantification – manual
and image analysis
Enter interpretation into LIS
Enter methodology, fixation,
and controls comments
Pathologist Responsibilities:IHC- ER,PR, HER 2
Pathologist Workflow
Review H&E Slides and Verify Tumor
3 minutes
per case
Review IHC Slides – Verify IHC Score
Verify /Release Final Report in LIS
A Cost Effective Approach: IHC- ER, PR, HER 2 Analysis
CT
time
With CT
analysis
Without
CT
analysis
(min)
18
Pathologis N
t Time
per
year
(min)
Savings
Salary Cost*
3
6000 $91,500
20
6000 $274,980
-$183,480
*Average CT and Pathologist Salaries taken from most recent ASCP survey and
Physician Salary Survey: Modern Healthcare;2009, Vol 39, 20-26.
Circulating Tumor Cell Analysis
CT time Pathologist
Time
(min)
(min)
N per
year
Salary
Cost*
With CT
analysis
31
4
700
$16,507
Without CT
analysis
17
14
700
$27,992
Savings
-$11,485
* Average CT and Pathologist Salaries taken from most recent ASCP survey and
Physician Salary Survey: Modern Healthcare;2009, Vol 39, 20-26.
What Makes Sense for Our
Practice?
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Use Cytotechnologists in Expanded
Roles
 Provide cost effective service
 Reduce burden on Pathologists
 Preserve the field of cytotechnology
in effect preserving the application of
morphologic assessment on numerous
aspects of laboratory testing
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Enhance satisfaction for
cytotechnologists
Opportunities and Challenges
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Growth in
knowledge and
skill sets
Adds interest to
jobs
Assuages
concern over
decreasing Pap
volumes
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Maintaining
competency in
multiple areas
Scheduling
Mayo Cytology Laboratories:
What have we done?
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Expanded Cytotechnologist Role?
Yes
Changed Pathologist-Cytotechnologist
Relationship?
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Still work as team
New group of pathologists to work with
Created Visibility for Cytotechnologists
in Department/Institution?
Yes
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Impact on resource allocation?
YES!
Mayo Cytology Laboratories:
What have we NOT done?
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We have not worked outside the
current regulatory environment
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No change in CPT codes/billing
Pathologist does final review
Cytotechnologist as an Independent
Practitioner
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Much bigger than our single practice can
change
Mayo Cytology Laboratories
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Trying to keep pace with changing times
Relieved that our path is in line with society and
market analysis conclusions
Positive upbeat about future of cytology and the
role that cytotechnologists will play
Use our practice needs (pathologist shortage,
economic press of practice, demand for new
improved technologies) to define education
curriculum for cytotechnologists.
Future of Cytology Summit at
ASC meeting, 2009
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Developed Strategies:
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Do Nothing (let the profession evolve)
Optimize the current scope of practice
 without additional formal education
 “on the job training”
Expand Cytotech role with novel educational tools
(Career ladder)
 Master’s degree
 Combine with CLS programs
 Combine with Pathology Asst programs
Create a new Cytotech Professional position:
“Cytopathology Assistant”
Where does Mayo Fit in the Scheme
Described by the Summit?
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Our Decade of Change (2000-2010):
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“Optimize the current scope of practice”
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without additional formal education
“on the job training”
Looking Ahead from 2010
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“Expand Cytotech role with novel educational
tools”
We Look Forward to Sharing Our Journey!
Acknowledgements:
(Team Effort!)
Lab Supervisors:
Lisa Colborn
Cytology 1998 -2005
Lab Directors:
Tom Sebo: DIA 1994-2002
Gary Keeney:
Cytology 1995 -2002
Renee Root:
Molecular cytol 2005-present
Angela Sorenson:
Cytology 2005-present
Amy Clayton:
Test Development
Ben Kipp
Jesse Voss
Emily Barr Fritcher
Shannon Brankley
Trynda Oberg
Cytology 2002-2007
Cytology School
Michael Campion
Molecular Cyt 2005-2009
Jill Caudill
Doug Minot
Michael Henry:
Cytology 2007-present
Kevin Halling:
Molecular Cyt 2009-present
Program director 1992- present
Amy Wendel
AP education supervisor 2006-2009
Kara Hansing: AP education 2010present