'Systems-based' hematologist is new way to provide hematology expertise

In the report, "The Role of Hematologists in a Changing United States Health-Care System," senior author and 2013 ASH President Janis L. Abkowitz, MD, and colleagues note that while demand for hematology expertise remains high nationwide, ASH and its members are concerned that changes to academic training will hinder both the recruitment of new talent to the field and the retention of seasoned experts. To address this issue, ASH partnered with health-care consulting firm The Lewin Group to identify emerging career opportunities for health system- and hospital-based hematologists and to provide guidance on pursuing those initiatives. At the core of this concept is the projected need for easily accessible hematology expertise and leadership.

In the report the authors express concern that, despite rapidly advancing research in the area of non-malignant blood disorders, today's hematology trainees are unlikely to receive the same non-malignant training as many "classic" hematologists trained in prior decades. Dr. Abkowitz and colleagues add that training shortfalls are further compounded by the fact that primary care physicians do not have the expertise to manage common blood disorders, increasing referrals to hematologists. This combination of factors results in higher demand for a smaller pool of hematologists entering the field with adequate training to effectively and efficiently manage non-malignant disorders.

"Given the rapid evolution and complexity of the field, the time is appropriate to identify career pathways that attract and enable physicians to practice non-malignant hematology in a sustainable manner," said Dr. Abkowitz, chief of the hematology division at the University of Washington in Seattle.

The report notes that, in response to these challenges, U.S. hematologists are defining new paths and assuming more centralized positions in large and small health-care systems. These roles, termed "systems-based hematologists," involve specialty-trained physicians, employed by a hospital, medical center, or health system, that optimize individual patient care as well as the overall system of health-care delivery for patients with blood disorders. For example, a systems-based hematologist could work closely with surgeons to minimize perioperative bleeding and could manage care pathways for patients with chronic blood diseases.

The report offers four examples where the involvement of a systems-based hematologist would lead to cost-effective decision-making. These were based upon interviews with 14 early adoptors of the systems-based approach to hematology:

• Heparin-induced thrombocytopenia (HIT): A systems-based hematologist implements care pathways that focus on HIT, a dangerous reaction some patients develop to the anticoagulant heparin, by working to reduce unnecessary heparin exposure, optimize laboratory testing for suspected HIT, and reduce unnecessary procedures in patients.
• Thrombotic thrombocytopenic purpura (TTP): A systems-based hematologist optimizes testing for TTP, an illness of blood plasma that can be deadly if not diagnosed and treated early. This may reduce system-wide plasma utilization.
• Medical director for hemostasis and thrombosis: A systems-based hematologist fosters appropriate and safe practices, including implementation and adherence to preventive care for blood clots and optimal use of the novel and costly anticoagulant medications.
• Non-malignant hematology consultation in an Accountable Care Organization (ACO) environment: While the formation of ACOs has enabled more patients to be served by a health system, there are fewer incentives for physicians to manage common hematology-related issues. A funded systems-based hematologist in a health system ensures that patients have more timely access to hematology consultations.

"A systems-based hematologist position presents a unique opportunity for hematologists to design new models for care delivery and demonstrate their ability to improve clinical outcomes while maintaining or reducing costs," said Dr. Abkowitz. "Just as blood must flow throughout the body, the expertise of hematology must flow throughout the health-care system."

As a next step, the Society is inviting its members to share practice models they have developed and examples of how they have collaborated with others to improve health-care outcomes, reduce complications, and eliminate unnecessary spending. In addition to the systems-based hematologist project, ASH is committed to supporting recruitment and retention in hematology through robust education, training, and award programs.