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Press Start: Lead an Empowered Life as a Clinical Laboratorian

Why are Pharmacists Practicing Medicine?
August 30, 2015 6:31 PM by Glen McDaniel

A few days ago I was speaking to a physician, an ID specialist, who shared how frustrated he was with, as he put it,  “pharmacists telling us how to practice medicine.” He is a member of a healthcare organization which, like many today, has a fairly specific formulary. Physicians are restricted as to the medications available for routine use. All off-formulary orders must be justified to various degrees.

 

Pharmacists have done a phenomenal job in driving better medication utilization. They serve powerful roles on pharmaceutical and therapeutics (P&T) committees where they not only offer guidance, but also critique on medication use. They have procedures and protocols meant to effect more efficacious use while controlling cost.

 

In many organizations clinical pharmacists guide anticoagulation therapy and direct therapeutic drug monitoring (TDM). In states like Georgia pharmacists order and and in some cases even perform some laboratory tests. Lately pharmacists have taken to administering common vaccines as well. Again in Georgia state law has been modified to increase the scope of pharmacists who have a strong lobby (including pharmacy-legislators).

 

I understood the frustration of my physician friend who, as he explained, was recently constrained form ordering the expensive Zyvox for a patient with several gram positive organisms showing resistance to the on-formulary medications. His latest outburst was prompted by a block from ordering Synercid for another patient.

 

My thought immediately went from empathy for the ID doctor to a comparison of how far away from controlling utilization the laboratory profession is right now. We do have small utilization projects from time to time, but generally we are far from being able to dictate laboratory test selection and interpretation. I have long advocated a laboratory formulary.

 

This doctor probably had reason to be frustrated, but for the most part pharmacy expansion of scope of practice has been accepted (and even welcomed) by the medical profession and by administration.

 

Medicine is a team sport and we all have to work together. That should mean drawing on the expertise of each professional role. We have different bodies of knowledge and add value to the patient in a different way. Exerting influence should not mean overstepping your expertise, but it also should not mean a physician with little a laboratory training, overwhelmed by data dictating medical laboratory utilization.

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AACC Issues Position Statement on Personalized Medicine
August 8, 2015 10:14 PM by Glen McDaniel

The AACC recently issued a position statement on personalized medicine(PM). Much has been written about the emergence of a more individualized approach to medicine.  Patients often present with a variety of symptoms for the same disease and react differently to the same treatment.

 

The laboratory will play an increasingly important role in personalized medicine.

 

The exciting thing for Medical Laboratory Science is that there is a scientific (usually genetic or genomic) explanation for how patients react to various medications. The presence or absence of  a gene often influences  metabolism or overall sensitivity. Types and dosages of several medications are often customized for patients with diabetes, cancer, coagulopathies and the like. In other cases, a gene could indicate a predisposition for developing a certain disease and so on.

 

Since MLS plays such a pivotal role in personalized medicine, AACC put forward certain positions in its statement. For one it suggests Congress should increase funding for more research in PM tests. They also urged the FDA not to adopt policies that would, in effect, stifle test innovation.

 

Reimbursement from Medicare, Medicaid and private payers  should cover PM tests adequately under the Coverage with Evidence Development program. This is especially important since the increasing concentration on cost savings does not provide an incentive to adequately cover conditions that may affect only a relatively small subset of the patient population.

 

Another position is that laboratorians must assume the role of educating clinicians on the availability, advantages, limitations and interpretation of PM tests. Drawing from areas like clinical pharmacy the laboratory should work jointly to provide guidelines and algorithms for testing. They should consider producing reports with more interpretive guidelines.

 

As medicine advances, and as payers  increasingly concentrate on outcomes and evidence-based practice, I think we will find that laboratorians will have more opportunities. It is up to us to assume a more expanded role as these opportunities present themselves.

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Take Yourself to Summer School
August 2, 2015 7:09 PM by Glen McDaniel

I was speaking to a friend who was complaining about how busy and tired she was this summer. In addition to working full time on the evening shift she has been shuttling kids to activities and summer camp. She has a seriously packed schedule which starts early in the morning and goes all day..

 

“I can’t wait for the kids to go back to school,” she bemoaned. "The kids are out of school, but it's like I am in summer school."

 

Her schedule is such that  sometimes it’s not worth her while to go all the home between “pick ups” and “drop offs.”

 

Having had a long commute years ago where I worked 140 miles from home and only made it home on weekends, I developed ways of occupying myself during the drive. I listened to books on tape, MBA audio lectures and even studied lines for whatever community theater play I happened to be in at the time.

 

The bigger point is that down times, long commutes, or those annoying wait times can be turned into opportunities for acquiring new knowledge and skills.

 

If you have been placed on the night shift and have downtimes  when you twiddle your thumbs, that’s a great opportunity to study for an online degree or learn some new skill in another laboratory department. If you work on weekends and have odd weekdays off, those are the best days to pamper yourself, have alone time and run errands when most of the world is at work.

 

But back to my friend shuttling the kids. She found a park close to the center where her daughter does dance; so she often takes the opportunity to walk and get some exercise in. For some reason she never learned to ride a bike really well, and has now made friends with a lady who is teaching her to ride a bike, while her new friend’s teenage son is teaching her to skateboard (!) in exchange for English lessons. It’s like she is now in her own Summer school-and enjoying every minute of it. How cool is that?

 

Those are pretty simple examples. But you can always use inconvenient times to your benefit. Just look around and see how you can fill those moments not simply with with busy-work, but with something worthwhile; something that will add value to your own life.

 

Try it and see the difference it makes.

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Celebrating Differences
July 26, 2015 3:56 PM by Glen McDaniel
 

There are differences all around us: at work, in society, and even in our own family or circle of friends. We tend to focus on the differences a lot. Just look at the news and see how all of societal ills are being blamed on those who are different from us.

 

This weekend I have been catching up on my reading. I just read several Facebook posts on MLS-related pages where several posts are recounting negative interactions with nurses and doctors. As a profession we tend to make sport of the “stupid things” nurses and doctors say and highlight how they think differently from us. It’s always “us versus them.”

 

Psychologists describe how individuals develop and act on biases based on the concept of the “in group” (those like us) and the “out group” (those who are not like us). We construct in/out groups for individuals, cliques, communities, organizations, races and entire countries. Think of some countries which are like America. Now think of countries which are unlike America. Then ascribe negative and positive qualities (actions, expectations, morals, values) to each. See how we place higher values on countries which are more like ours?

 

The same thing happens in professions of course. It is especially tempting to make fun of, and demonize, professions that we think exert some imbalance of power against us.

 

I just happen to be reading a book called “Us Plus Them” written by Professor Todd Pittinsky. In fact, going back and forth between Facebook and this book is what prompted me to write this blog. Pittinsky explains in convincing, if obvious, terms why differences and diversity should be valued. We can capitalize on differences to make interactions more effective. When individuals with varying points of views, or representatives of different professions, serve on a team (in a lab, in an organization, for example) we can draw on the strengths afforded by the diversity.

 

One reviewer has this to say about Pittinsky’s book, “Us Plus Them upends the way we look at relationships. No more zero-sum games; no more clever nuancing around human differences. A key challenge of leadership is harvesting the gains that arise from the basic incongruities of our collective humanity. Pittinsky’s original perspective is destined to create healthy controversy and healthier organizations.”

 

I continue to suggest that we draw in multi-disciplinary teams whenever we can, whenever we want to get ideas or make changes. This way we build relationships, build up relationship-capital for later, get different perspectives and ultimately arrive at better outcomes. This is especially important in healthcare. where patients are the ultimate beneficiaries.

 

Each nurse-doctor/lab interaction which now forms the basis of a new joke and ridicule on Facebook can become a teachable moment. It’s a natural side benefit that we learn and become better human beings as well, whenever we teach or listen.
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Is Proficiency Testing Enough to Prove Accuracy?
July 4, 2015 6:07 PM by Glen McDaniel
 

 Proficiency Testing (PT) is just part of life for most laboratories. Laboratories are sent challenges (unknown samples) which they test like patient samples and then submit their results. An agency like CAP then grades the result against those submitted by peers using the same test system. Your lab is considered as doing a good job if your results are close to those of the peer group.

 

Statistics like standard deviation and SDI give the impression the results generated are being checked for degree of accuracy. But are they? Well not really, the mean is used as a surrogate for the correct value and the variation from that mean is then regarded as the degree of inaccuracy (bias).

 

But PT materials are not patient samples and often additional material is added to preserve and stabilize the samples. How do these additives change how samples react? To assume that closeness-to-peer indicates “correct” accurate results is to be overly optimistic-and wrong.

 

Additives - and even shipping and storage conditions-  introduce matrix  and other effects meaning the PT sample used to give you that “atta boy” is in fact not directly comparable or commutable to a fresh sample from your patient.

 

So what if we just made allowance for that knowledge, knowing PT is not perfect but it’s the best we can do right now?  However that assumption raises another issue. How can we be completely sure that our test system (say an analyzer with a certain reagent) is in fact producing accurate patient results. Calibrators and quality control material often have matrix effects as well. Then there is the additional issue of comparability among various test systems.

 

Suppose research shows that a clinical condition has certain cut points or diagnostic targets. Given the degree of uncertaintity and variation how can a clinician be confident making clinical decisions based on such results? We are already familiar with harmonization for cholesterol and with the use of INR (versus PT)  to guide warfarin anticoagulation. In both cases there is much less inter-laboratory variation than there used to be.

 

That brings us to the areas of accuracy and harmonization. Accuracy is “trueness of result” while harmonization is a system of ensuring results for an analyte are truly comparable; even performed by different methods, at different sites, on different platforms.

 

CAP has recently introduced Accuracy-Based Surveys for various analytes like lipids, Vitamin D, Creatinine, testosterone and Hemoglobin A1C.

 

Participation is a totally voluntary process and laboratories might not want to subject themselves to extra scrutiny and the possibility of “failing” even if results are within the peer group. One advantage of the Accuracy Based Program (ABP) is that manufacturers can re-evaluate their products (reagents and test system) and even revisit their calibration traceability.

 

Wouldn’t it be wonderful if your PT results indicated how you were doing in an absolute sense, and not simply compared to your peer group who may have the same bias? Wouldn’t it be great to have tests systems giving equivalent results across platforms and laboratorians and clinicians having the confidence that their “numbers” are both accurate and comparable and can be used to confidently guide patient care decisions?

 

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What’s Your Style?
June 28, 2015 4:44 PM by Glen McDaniel

Have you ever found someone very difficult to work with no matter how you try? On the other hand you find others who consistently seem to adjust, cooperate and understand even if things don’t go as planned.

 

We all have different personalities and behavioral styles so it is probably unrealistic to expect all personalities to mesh. However in our increasingly diverse workplace it is important to at least learn how to have a collegial working relationship with a wide variety of individuals-with many different personalities.

 

There are various psychological tools for determining personality styles. One very popular one that has been around for quite sometime  is the Myers Briggs Type Indicator (MBTI)  Test.  Another is the DISC Personality style test . DISC stands for Dominance, Influence, Steadiness and Conscientiousness.

 

In any communication it is important to recognize your own style:  how do you perceive the world, where do you get energy, how do you relax, what pushes your buttons, what do you consider important, what do you require from colleagues and bosses?

 

Then the next step is recognizing the personality types of others you interact with on a regular basis. Like a lock-and-key you then adjust your actions and emphasize certain behaviors while minimizing others.  In that way you can indeed work with a variety of personality types and have a harmonious, productive working relationship, even if you are not personal buddies.

 

Let’s look at the DISC personality style more closely, as an example of leveraging personality types.

 

D (Dominance) is typical of a go-getter who relishes fast-paced activities and is task oriented.

 

With that type of person you want to engage them by being more fast paced (matching their style) and direct. They might not want to chit-chat about personal events in your life. They are the “just the facts” types and like executive summaries with the bottom line clearly stated. They eagerly take on challenges. They want deadlines and respect those who set and stick to deadlines.

 

I (Influence). This is also called the Promoter type. They like a fast pace but are very people-oriented. They like working in teams and will probably preface each interaction by discussing their family or asking about yours. Relationships are important to them. They enjoy a compliment or a good joke and will react favorably to either. While deadlines are important they will understand if a family emergency impacts a project temporarily.  The Influencer employee craves recognition.

 

S (Steadiness). This type, also called the Nurturer, tends to operate at a slower, more deliberate pace and is very people oriented  This is the typical laid back, congenial individual who will seek input, try to get consensus and consider the impact of change on all stakeholders. Consistency, dependability, honesty and incremental change are important to them.

 

C (Conscientiousness) or Examiner type enjoys a slow pace and is task oriented. This person is likely to create lists and pore through data. They will analyze before they come to a well-reasoned conclusion. You impress this type most by proving competency, discussing statistics, data, trends and research. If you direct this person you might have to rein them in, because they will tend to research and re-analyze all the way up to the deadline.

 

If you work in a team (and everyone does to a degree) it can be useful to know the various personality types on that team.  Depending on the task at hand it might even be useful to select certain personality types for a particular project. The good colleague or manager plays to the type of the other individual in order to have a more effective, productive  and harmonious relationship.

 

It is important to remember that this is not about being fake or changing your natural personality. Rather it is learning a valuable skill that will pay off  handsomely both in your professional and your personal life.

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Who Inspects the Lab Inspectors?
June 13, 2015 9:02 PM by Glen McDaniel

Labs are used to being regulated. It seems they are always preparing for inspection by the state, CLIA or some accreditation agency-or two. Very often laboratories think inspectors are being too hard, or picky, or even plain wrong in the way they interpret the standards and grade the laboratories.

 

My last blog discussed a very harsh critique of the laboratory profession written by a journalist. One of her claims was that not only was it near impossible to get access to specific accreditation records, but the accreditation process itself may be flawed. In that regard some laboratorians might agree with her.

 

I have been a member of several laboratory inspection teams and I observed  several differences in approaches, thoroughness and (yes) even interpretation of the standards. One big area of difference is the subjectivity of determining whether certain documentation does indeed prove adherence to, or fulfilment, of a certain standard.

 

Part of the reason for the difference as I have also discussed previously is the fact that agencies like the Joint Commission and COLA use professional inspectors while CAP uses volunteer peer-professional inspectors. It’s logical to think the use of part-time volunteers might increase variation between visits -and even during a single accreditation visit.

 

While accreditation is voluntary, licensure and certification are mandatory. Under CLIA, CMS has granted most accreditation agencies deemed status which essentially means CMS will accept the accreditation visit/finding in lieu of conducting its own visit. State agencies will often perform the role of CLIA inspector.

 

So how can a laboratory be sure that its accreditation agency is being not just fair, but accurate as well? CMS does routine validation of a subset of inspections. CAP indicates that CMS will routinely re-inspect about 80-120 CAP-accredited labs per year. They then look for differences in findings. Such differences are called disparities or misses.

 

So how much of a difference is considered acceptable? In the last round of summary reports produced by CMS they found a variation of about 17 percent for CAP-accredited laboratories. A disparity level of 20 percent is the benchmark at which CMS takes a closer look and reconsiders its deemed status. In fact they perform a “deeming status review.”

 

So are validation visits more likely to find “something missed by CAP or another inspection agency,” or are they more likely to overturn an adverse finding? Details are hard to come by, but it appears the former is more common.

 

Are discrepancies more likely to show up in some standards than others? Yes, it seems the following 5 areas are the primary source of disparities: test validation, proficiency testing, competency, personnel records and responsibility of the medical director. Given this knowledge and the fact that a validation is more likely to mark you “down” these should be considered areas of high concentration for your lab.

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More Negative Press for the Laboratory
May 17, 2015 1:58 PM by Glen McDaniel

 A little while ago I wrote a blog in which I referred to a great, balanced, intelligent article written about the medical laboratory  and printed in The US News and World Report. That article was remarkable by its rarity. I asked my readers to respond directly to the writer, thanking her for a positive article. Many of you contacted the journalist by email and Twitter, much to her delight.

This morning, another article crossed my desk. This one is a hatchet job written by a journalist for the Journal Sentinel. It is an indictment of the laboratory written using sources who have been harmed from inaccurate results generated by laboratories. Everyone from accreditors to MLSs/MLTs are assigned blame. Reference is made to shoddy habits like the use of expired reagents and mixing up samples.

To read this article it seems like there is no standardization, there is no quality assurance, and every lab test has the potential of leaving ruined lives in its wake.

Some of the "experts" who commented for the article are laboratorians and I would like to think they were misquoted or their words were taken out  of context. It's disheartening to think fellow laboratorians would allow such a biased and unbalanced piece to see the light of day.

There is a lot of buzz on social media about this article: mostly hurt feelings and righteous indignation. But as I pointed out on Facebook, commiserating among ourselves is not going to educate the journalist or the public; and will not change anything.

I strongly suggest you read the article and weigh in here. Feel as indignant as you want to, but , more importantly, respond by contacting the journalist ( reached at egabler@journalsentinel.com or (414) 224-2071) and her editor.

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Five Tips for More Productive Meetings
May 16, 2015 4:56 PM by Glen McDaniel
 

Sometimes it seems like those of us in healthcare just love to hold meetings. We seem to even hold meetings simply to figure out how to plan more meetings. Not surprisingly, as busy professionals, always on some sort of deadline we hate attending meetings as much as some people love holding meetings.

 

One reason that meetings are so dreaded, other than the sheer volume of them, is that they are often not very productive.  Since some meetings are in fact necessary, it’s important to know a view hints that can make your meeting more productive-and less dreaded.

 

Get clear about the reason for a meeting.  This seems like a no-brainer, but too often we think about the reason to meet in vague terms or try to squeeze too many subjects into one meeting, “While I have everyone together” is a common justification. Big mistake. Some attendees will be totally disconnected and the presenter will be less focused if the agenda is too loaded.

 

 State the purpose of the meeting simply and clearly in the invitations. That way invitees can start thinking about the subject. Their contribution is likely to be more considered and thoughtful that way.

 

Set a time.  I mean set a time literally and figuratively. Yahoo’s CEO Melissa Mayer is known for holding 10 minute meetings. Some studies show that 15 minutes is the ideal time for a meeting if the goal is to be focused and productive.

 

I have found that even for a staff meeting where you might discuss several items and solicit feedback from various individuals, a 1-hour time frame is the maximum. In any event set a timer and wrap up quickly (no matter where you are on your discussion list) as soon as the timer goes off. Meetings are not the time and place to do research and in-depth thinking.

 

Assign extra detailed work to a subgroup. If discussions are running too long, schedule another meeting later on. You will get more accomplished in four15 minute meetings than you will in a rambling  1-hour session. Say goodbye permanently to long drawn out gatherings unless the goal is to leave everyone feeling numb, uncommitted and frustrated.

 

Ban phones. This seems to be a no-brainer but we all know how distracting it is when someone’s cell phone goes off, they break the mood, apologize and turn it off. Then it happens to someone else.  Some of us “live” on our smart phones so it becomes a habit for many  to constantly check their phones even during a meeting.

 

Have a basket or bucket to “check” phones that made it to the meeting. It is not enough to just ask that they be silenced. The tradeoff for a long meeting is a much more focused meeting while actually engaging all the stake-holders' undivided attention.

 

Assign A Directly Responsibility Individual.  If a task has to be followed up on, assign the responsible individual publicly in the meeting.  The DRI (another trendy term) should know exactly what to do and be given a deadline for getting it done. Don’t be vague and don’t assign to an entire group (unless it’s for the group to meet and work out details).

 

Don’t abandon tips that have worked up till now. It is still good practice to have an agenda, send out the agenda before the meeting, send out a draft of the minutes and ask for corrections before distributing the final copy of the minutes, use email rather than distributing hard copies if at all possible.  All those habits still make sense.

 

The big danger with unfocused untimed meetings is that any activity tends to expand to fill the time allotted. If there is no drop-dead time, discussion just goes on much longer than necessary. If you can make just one of the changes above in the short term, I suggest setting a time-limit and sticking to it. Over time your attendees will learn to come prepared to work and get out. Your staff will be grateful and you will surprise yourself at how much more productive your meetings are.

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New Direct Patient Access Law Ups the Ante
May 10, 2015 1:36 PM by Glen McDaniel

An ongoing debate within the medical laboratory science profession for several years now has been the idea of  patients having direct access to the laboratory.

A new law recently passed in Arizona allows patients to order their own laboratory tests legally. This law goes the farthest, that I am aware of, in terms of explicitly empowering patients to order tests cafeteria- style and get the results themselves. 

In our traditional paternalistic model where big brother knows best and doctors always know best, the conventional wisdom has always been that laboratory tests should only be ordered by providers (never patients) and the results should be sent to the doctors (never directly to patients).  Many states, in fact, have laws prohibiting direct access testing (DAT), or allowing  DAT in very limited instances.

Going back as far as the Clinton administration, continuing through the Bush administration and finally in the Obama era,  the Department of Health and Human Services (HHS) has suggested that patients should be empowered to have access to their own health information. In fact there is now a specific mandate that laboratories MUST allow patients access to results if the patient asks for them.

This new democratization of healthcare has coined phrases like The Empowered Patient and the Quantified Self Movement.  Here we have the most educated, intelligent and tech-savvy generation in our history. So why should they not be able to access medical services without an intermediary? Why should their own information be withheld from them or doled out like candy to children? Why not take advantage of the available technology to access services, receive results, track and monitor progress?

The traditional approach has its place and will continue to be the norm for a long time.  

This trend of patient empowerment, frankly, is not going away and will expand. States that currently limit DAT might find those laws challenged.

It is interesting that CLIA is silent on this issue.  CLIA authorizes the regulation of laboratories that conduct testing, not the individuals who order the tests or receive test results. However most states either prohibit or severely limit DAT. It will be interesting to see how legislators in those states weigh the medical lobby against  the inevitable consumer pressure. 

One concern I have is that MLS practitioners have had a hands off attitude when it comes to patients ( I chose this profession so I don't have to deal with patients, I'll do whatever the doctor orders, once the results are generated I'll just pass it on and patients must discuss the results with the doctor.)  The effect, intentionally or not, has been to minimize in the minds of the public and legislators the role of the MLS professional.

Labs might be looking at increased test volumes as consumers start ordering (and possibly paying for) their own tests. But lab professionals can be more valuable than ever in stating reference intervals, talking to patients about test selection, specimen collection/storage, factors that affect test results and when a result might indicate further intervention by a medical provider. 

This might well be an opportunity to position the MLS practitioner more strategically-and appropriately- on the healthcare team. This could be a win/win situation for all stakeholders. 

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When Is it OK to Mention Your Employer on Social Media?
April 17, 2015 9:11 PM by Glen McDaniel

It goes without saying that we live in the world of social media. I am not ashamed to say (maybe I should be) that this not-so-young guy spends way too much time online. Among friends of my generation, I am the go-to guru for interpretation of social media terms and recommendation for the latest technology or app. I get lots of news on social media. In fact my Twitter feed often beats the national networks to broadcasting some event of national or international significance.

 

Perhaps it is because of this wide exposure afforded by social media that many organizations now have a Social Media policy. Such a policy generally addresses not just the access of social media at work and using company computers, but also spells out what can be posted and what is prohibited.

 

No organization wants to be portrayed negatively by a current employee. That is why certain posts can result in immediate termination. However, healthcare organizations have a unique concern: that of privacy and security.

 

Some employers say posting pictures, patient-identifiable information are all prohibited. Generally healthcare organizations are very prescriptive with their policies directed at employees and even non-employee physicians. 

 

None of this comes as  news, I am sure.

 

While organizations often use social media to advertise or  post positive news about themselves, should they require employees to do the same? Should an organization  “strongly suggest” that their employees post at least one feel-good post per week  reflecting positively on the organization? What about requiring employees to “reach out to friends on social media to raise X dollars” as part of a fund-raising campaign?

 

I encountered a couple of those “requirements” recently and though the requirement odd at best. What do you think? Does your employer require or strongly encourage you to post on their behalf?

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Happy Medical Laboratory Professionals Week
April 17, 2015 8:12 PM by Glen McDaniel
It's time of year again we celebrate and acknowledge Medical Laboratory professionals (technicians, scientists, specialists, pathologists and others).

The American Society for Clinical Laboratory Science (ASCLS) website has a very concise history of this celebration which, like the profession it highlights, has experienced many changes. It was started in 1975 as National Medical Laboratory Week under the auspices of American Society for Medical Technology (ASMT) which later became ASCLS.

Over the years several other laboratory organizations signed on as co-sponsors. For example, this year there are 14 organizations cooperating in the effort  to salute the nation's estimated 300, 000 medical laboratorians.

In 2005 advocates from ASCLS spearheaded a change to rename it NMLP Week, with the "P" standing for Professionals. This was a deliberate attempt to emphasize that the celebration was for actual, real, live,  talented, educated, hard-working professionals and not simply a room (the lab).  This change was small but significant and evocative.

Traditionally each year a group of professionals selected a catchy slogan as that year's theme;  often a catch double entendre. In 2010 it was decided to brand the celebration with a permanent recurrent theme, "Laboratory Professionals Get Results."

Then in 2012, the word "national" was dropped from the name to make the title less unwieldy. So here we are many years later celebrating the latest iteration: MLPW.

Much has changed over these 40 years. We have seen regulatory changes, emergence of disruptive technology, nanotechnology and healthcare reform. But one thing has not changed: the skill, knowledge, competence and dedication of a cadre of medical laboratory professionals who work diligently, often behind the scenes, to advance the health of this nation.

To all my colleagues, I say: take a bow. You deserve it. Happy MLPW!

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CAP Q-Probe Looks at Physician Satisfaction with the Laboratory
March 29, 2015 4:49 PM by Glen McDaniel
 

A recent College of American Pathologists (CAP) Q-Probe investigated the level of physician satisfaction with what the laboratory has to offer. I always find satisfaction surveys instructive and this one was no exception.

 

This Q-Probe is certainly not the first of its kind or scope, but is the latest. The study’s authors Shannon McCall, MD and Larry Massic, MD  had a sample size of 2425  physicians from 81 institutions and asked  16 laboratory-service related questions.

 

-The overall satisfaction was 4.2 on a scale of 1 to 5 (this compares to a 2007 study in which the score was 4.1)

-Physicians  were most satisfied with quality of results, test menu and staff courtesy. They were least satisfied with turnaround time (TAT) for STATS (inpatients and outpatients), and esoteric tests.

-Interestingly, in terms of what providers considered important to them, clinical report format scored fairly high as a service category

-Only 69  percent of respondents were satisfied with the ease of use of electronic order entry. This was a surprise; as ubiquitous as that function is these days.

-95 percent of physicians said they would recommend their laboratory to another physician.

 

What are some of the takeaways?

-Physicians are confused by the increasing amounts of data they must process and find it harder to extract what’s significant and actionable.

-Physicians in smaller hospitals tend to be more satisfied with laboratory service than those in larger settings. The study authors theorize that this difference might be due to closer, more frequent interaction between providers and the laboratory staff in smaller facilities

-Overall, despite some degree of frustration on both sides, physicians are basically satisfied with the lab, but would welcome greater interaction and “help” in several areas including selecting and interpreting lab results

-Turnaround time rates low on satisfaction because it rates so high on the “importance” scale. So whatever we can do to reduce TAT is welcome and is translated in a physician’s mind to “better  service.” We could also do a  better job of educating doctors as to what is included in getting a test from order entry to result. They do not necessarily understand all the steps involved, or the differences for different tests. Again, that is where communication comes in.

 

Dr. McCall gives the following advice, “Pay more attention to order selection and entry, as well as the method and frequency of communication of results in the post analytical phase. Then maybe we will see an improvement in physician satisfaction.”

 

This is just the latest in a growing number of studies where doctors say what they need from the lab. It is not coincidental that "help" and "communication" are repetitive themes. To me, this represents a real opportunity for laboratorians to expand their scope, boost satisfaction and contribute to enhanced patient care ; all at the same time.

 

 

 

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Time for More Virtual Meetings Using AvailableTechnology
March 22, 2015 1:47 PM by Glen McDaniel
This is the time of year when the major medical laboratory organizations hold their national meetings. These gatherings are a great opportunity for laboratorians to get together with their professional colleagues from around the country and also to listen to major players in the profession and on the cutting edge of science.

 

 The advantages of national face to face meetings are undisputed: to learn new information, exchange information with each other, to network and to interact socially. Many meetings are held in interesting cities, so attendees also take advantage of what the host city has to offer; with many partying or getting much-needed rest and relaxation.  Some even take this opportunity to have a family vacation. Most meetings have a vendor exhibit or exposition (ranging from modest to gargantuan) of some sort associated with the meeting.  This offers a unique opportunity to talk to vendors, to see and touch advanced technology.

 

The thing is, it has become more and more difficult for the average bench MLS/MLT to attend national meetings. Most organizations do not offer financial sponsorship for meetings and, increasingly, laboratorians have to use their own money and often utilize vacation time or PTO. What’s a laboratorian to do?

 

While highly structured meetings are important for the reasons above, the reality is that organizations must offer alternatives for those laboratorians who cannot reasonably attend a meeting in person.  Communication technology has advanced to a great degree to offer several viable options.

 

-Webinars where an individual could pay to “attend” one or more presentations

-Live streaming of presentations and vendor exhibits

-Sale of CDs after the meeting

-Access to a password-protected website for audio and visual presentations

-Use of social media like Twitter and Facebook for some presentations where individuals can participate and ask questions in real time from wherever they are

-TED-like presentations of keynote addresses and high-interest topics

-Use of technology available on smart phones like the recently launched Meerkat application

-Offering CEUs as appropriate for participation through these virtual means

 

 

All of these options can be monetized ( I hate that term) of course. It is possible to charge so that laboratorians would pay a sort of “fee for service” cost. These charges would defray costs for the organization or, more likely, be a nice source of revenue for the presenting organizations.  Even if the cost was higher than the meeting registration fee, it would still be a cost savings because the individual would not have to pay for travel, meals away from home, hotel etc. and the other typical go-to-meeting expenses.

 

Not every organization has the wherewithal to offer all these services out of the gate, but it would be nice to see an incremental move in that direction.

 

 Vendors  have a vested interest to subsidize some of the cost, by the way.  Here is a likely scenario: Vendor A allows a virtual tour of their expo booth, ability to have a Q&A online and then allow the viewer to see one presentation for free (could be a big keynote or a scientific session).  The vendor bears all the cost. I can even see a situation where the exhibits are less gigantic, with some of the savings being used to facilitate virtual attendance and participation.

 

Face to face meetings are hard to beat and will not go away any time soon. However, the reality is that they are inconvenient and expensive to attend. Luckily technology offers many convenient, affordable alternatives. It is time to take advantage of this technology.  I know many meetings sell CDs, I know some offer some CEUs after the fact, but I am suggesting something much more comprehensive, bold and overarching. .

 

The technology is there and the laboratorians are there. It’s time to bring them together.

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The Laboratory’s Expanded Role in Managing Kidney Disease
February 22, 2015 4:30 PM by Glen McDaniel

Kidney disease is one of the most significant chronic ailments affecting Americans. Renal disease is often a sequela of one of several maladies that plague Americans: diabetes, hypertension, glomerulonephritis, autoimmune disease, polycystic kidney disease and others.

 

An estimated 20 million Americans have chronic kidney disease (CKD) some managed by diet, exercise and medication alone, while others need regular dialysis.

 

Quality of life can be adversely affected and impacted by kidney disease.

 

The laboratory plays a crucial role in the diagnosis and treatment of renal disease. One of the ongoing challenges for providers is the variation in tests performed by different laboratories on different platforms using different reagents.  There have been several attempts to create harmonization to standardize results and make it easier to interpret results from various labs and even from visit to visit.

 

In late 2012 some guidelines called the Kidney Disease Improving Global Outcomes (KDIGO) Clinical Practice Guidelines for the Evaluation and Management of CKD were introduced.

 

These guidelines were developed  through the collaboration of many international experts and build significantly on lessons learned from previous guidelines. One very important aspect of this guideline is that it contains strong recommendations for laboratory input and involvement in the process of care. It only makes sense that the experts who provide the information used in decision making should understand the recommended best practices and the rationale for such practices.

 

Not surprisingly, laboratory involvement will require a more active participation, rather than the typical passive behind the scenes “just do what the doctor orders” traditional approach.

 

Among the “Key Factors for Laboratorians” required by the 2012 KDIGO Guideline are the following

 

-Ensure good communication between laboratory professionals and relevant clinicians, such as nephrologists and primary care doctors.

-Aim for common laboratory practices in a region so patients receive the same care with comparable results from visit to visit, regardless of location where the testing is performed.

-Ensure creatinine results are aligned to an isotope dilution mass spectrometry standard (IDMS)

-Select an appropriate glomerular filtration Rate (GFR) formula for your population.

-Laboratories should use the same units, number of significant figures and clinical decision points for both serum creatinine and eGFR reporting.

-Laboratories should understand, and provide information on, their creatinine method, including any limitations and interpretation

-Laboratories should provide measurements of urine albumin and urine creatinine using traceable assays. These tests might be part of a periodic monitoring protocol in a high-risk population such as  known diabetics.

-Laboratories should provide Albumin/Creatinine ratio (ACR) and do so in a clear, consistent manner to help clinicians make correct decisions regarding declining renal function in any one patient from site to site and visit to visit.

 

All of these recommendations make good sense and offer yet another chance for the laboratory to be an active participant in patient care. This involvement should provide job enrichment as the laboratorian assumes a greater proactive and professional role. However, these are recommendations, not mandates.

 

 If laboratorians are hesitant and acquiescent then another player will step forward. Then once again, someone outside the laboratory, perhaps with limited knowledge of MLS, will direct “the lab” on what to do. It’s our choice, really.

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