my blog last month regarding to the HHS mandate that laboratories must grant patients
access to their lab results on request, my mailbox has been inundated with comments and questions.
A few questions were asked by more than one writer and so I thought I would
seek direct guidance from HHS and answer the most commonly asked questions
new requirement reverse HIPAA?
both CLIA and HIPAA regulations have been adjusted to accommodate these requirements.
HIPAA privacy rules had always sought to protect how patient information was
secured and protected, and specify under what conditions such information could be
disclosed. In the final rule published
by HHS in February, some restrictions were removed from both HIPAA privacy rules and CLIA
is a very specific requirement and does not negate, reverse or cancel HIPAA. Maintaining the security
and confidentiality of patient results are still very much in effect.
will still need to verify the patient's identity before releasing results. In cases where results are
requested by a patient’s “personal representative,” the lab must verify both
the identity and authority of the patient’s legal designee.
Is there no concern
for how much this will cost labs?
am not sure about concern from the federal government, but CMS does estimate that about 23,000 labs will be
affected. It recognizes that processes, infrastructure and equipment might all have
to change. The agency estimates that labs will receive between 175,000 and 3.5
million patient requests annually and the cost of compliance might be as high as $59 million. Labs will be permitted to charge each patient a reasonable fee for each request.
Will this apply to
all labs including reference labs?
Good question. I
suspect the reasoning for this question is that patients do not generally have
a direct relationship with reference labs. For most reference labs the client
is a referring entity like a hospital, physician etc.
CMS says the rule
should be applied uniformly and applies to all laboratories. Their goal is to make
it easier to access results, wherever tests are performed, so reference labs
will not be exempt.
those states that prohibit release of results directly to patients?
I alluded to in my earlier post, this rule supersedes state law restricting the
release of results. About 13 states have some specific restriction on releasing
results to patients directly. This rule voids that prohibition and labs must now
release results to patients regardless of previous prohibition by state law.
Doesn’t this place a
legal burden on laboratories being asked to explain test results?
requirement is to provide the result to the patient within 30 days of receiving
a request from the patient. The mandate is not to interpret the result or to
explain the clinical significance to the patient. In many cases, the patient
will have already discussed the result with their physician by the time the lab
receives a request. Sometimes the patient just needs a valid copy for their records or to seek a second opinion.
groups like the American Medical Association have opposed this rule on the
basis that patients are not prepared to interpret their result and having free
access without a doctor’s help might actually be more harmful than helpful.
responded that this is based on the philosophy that the patient owns his or her
own results, and the benefits of direct access far outweigh any theoretical
risk. HHS also points out that the rule does not diminish the role of the
provider in interpreting and explaining lab results to patients. Diagnoses and
treatment will still be based on the full picture, not just a few lab results.
is interesting to note that several studies have shown that providers fail to
notify patients of abnormal results about 7 percent of the time. Some estimates
are even higher.
Direct access to one’s own results is designed
to empower the patient, not to burden labs and not to minimize the role of
love science! I always have and I always will. So when I asked recently to be a judge
at a science fair at a local college, I immediately jumped at the request. I was really impressed with the quality of the
projects and the soundness of the research, the hypotheses proposed, and the findings.
were no MLS students, but other healthcare professions were represented. I noticed that most of the cool toys were developed by
the computer (IT), engineering and robotics students. I also took note that pre-pharmacy,
dietetics and nursing students had quite a few papers and posters
about the value of their profession to healthcare. Nursing especially had several
research projects on nursing skills, nursing practice, expanding scope of practice, value of nursing diagnoses and ideal nurse-staffing
standards. There were also several examples of joint student-faculty collaboration.
goal is to have much of the research published in print and electronic journals.
The students will receive not just academic credit but valuable exposure and the
pride of adding to the body of knowledge of their respective professions. I thought
that, given the quality of work I observed, there will be no scarcity of good data which will prove useful (and usable) for their
few years ago when I worked on a staffing taskforce for a national healthcare
company, we had a tons on research on nurse-patient ratios, patient outcomes based on
nursing skill mix and the like. But we could find nothing except old CAP workload units and generic
productivity data for the laboratory. Consequently, nursing staffing was increased based on
lobbying and the use of published data, while staffing in several other areas including the laboratory
was cut back. Instead across the company they were asked to cross train and work flex hours (including partial shifts)
to reduce labor costs. Supervisors were expected to take on more bench work.
need more MLS research. I don’t mean just academic PhD-level type studies, but
we need more useful (and usable) data on appropriate skills mix for the laboratory,
the most effective MLS ratio to patient census or MLS/test volume ratios. We should be able to even correlate some
outcomes (length of stay, discharge from ICU) to the volume and type of laboratory
will not happen overnight. However, as I look at what other professions are
doing I realize we do not have the same amount of direct, robust research available
that would bolster our requests for adequate staffing or inclusion as vital members
of the healthcare team. As a simple example: how do you measure productivity? How do you decide your benchmark? What evidence do you have that a particular benchmark is relevant?
Without specific targeted MLS-specific research we are likely to
be considered “ancillaries” and allocated staffing and other resources based not
on hard data, but on financial considerations, regardless of effect on patient
and Human Services (HHS) has issued a final rule that requires laboratories to
give patients access to their lab results. A
few years ago Health and Human Services Secretary Kathleen Sebelius reaffirmed
the Obama Administration commitment to patient-centered care.
part of that initiative, she indicated, had to include a re-assessment of the
whole idea of who owns the patient’s information.
had always believed that the patient could have access to their medical
records, but even in that context, providers maintained that certain notes
could still be withheld from the patient as not a material or essential part of the record. HIPAA (the Health Insurance Portability and
Accountability Act of 1996) laid out very specific restrictions on the
handling, storage, protection, and sharing or disclosing of patient information.
In addition many states severely restricted the release of laboratory results.
In most states, lab results can only be released to the ordering provider with very few exceptions.
new final rule by HHS says that patients own their results and have the right to receive access to their
lab results. In other words, laboratories must establish a clear process for
providing patients with their results if and when patients request such results.
CLIA’88 and HIPAA had to be amended to allow this expanded access. Patients may
still continue to receive results from their provider, of course. But under the new
mandate, laboratories must give requested results (including an electronic
copy) to the patient and/or the patient’s designated representative. Requested
results must be provided within 30 days.
Final Rule goes into effect April 5, with all covered entities mandated to
comply by October 2 of this year.
final rule is available at www.federalregister.gov
will your lab comply with this new mandate?
have the most instructive conversations with physicians and others outside of our
profession. Some day I would like to write a book of such conversations and recommend
its use as a discussion point for medical laboratory students. My friend the endocrinologist
was gushing to me about how wonderful HbA1c is. “I no longer order glucoses,”
logic was that glycosylated hemoglobin gives her a more accurate, realistic, long
term view of the patient’s glucose management. The patient does not have to be
fasting and she finds that she can “bust” patients who watch their diet meticulously
a few days before their visit, hoping she will see what she calls “a good number”
suggestive of better glucose management than really does exist.
wanted to know why “the lab” has not developed point of care HbA1c instruments for
use in clinics and medical offices. Why can’t she have that result when the patient
is in the office? I was explaining the state of the art technology available when a pathologist joined us.
endocrinologist recapped the discussion for the pathologist who immediately furrowed
his brow and declared that a glucose is still far superior to a HbA1c. Results from different
labs and even from different visits at the same laboratory are not comparable,
he said. HbA1c should ideally be used a few times per year for monitoring patient compliance with their medical regimen.
continued that glucose has ben around for ever, the technology is better and it
should always be used as the screen which then triggers a HbA1c. Besides, a physician
will only be reimbursed for ordering a HbA1c a couple times a year. I had no way
of verifying if that’s true or not, so I did not comment. But when he
launched into a discussion on the relative inaccuracy and imprecision of HbA1c compared to glucose,
and the merits of the oral glucose tolerance
test (OGTT) I sort of zoned out to protect my brain.
pathologist was an anatomical pathologist, not a clinical pathologist, which is an issue for an entirely different discussion. But the conversation and how it progressed got
me thinking about several things.
like this endocrinologist are very eager to discuss the use and relative merits of laboratory tests with the
experts-whether those are MLSs, pathologists, pharmacists or vendors pushing the newest black
Are pathologists, especially anatomical pathologists, really the right individuals to represent
the clinical laboratory as experts on what we do?
research after our talk indicated that fasting glucose variation can run around 8 percent In a single individual day over day, so
my pathologist friend was not entirely correct about how accurate/precise glucose
discovered that the American Diabetes Association (ADA) has been recommending that HbA1c be adopted
as an adjunct in the diagnosis of diabetes and prediabetes. Further, agencies
like the National Glycohemoglobin Standardization Program (NGSP) has done tremendous
work in standardization and controlling coefficient of variation among tests. Consequently, the accuracy and comparability of HbA1c have increased remarkably
in recent years.
discussions with clinicians need not be too technical. But we should remind them
when they ask about a new test or want a new point of care toy that as scientists
we need to look at aspects like ease of performance, specimen requirement, accuracy,
clinical utility, and positive or negative correlation with disease or disease risk.
-People tend to believe us if we speak with authority and have a history of not mis-speaking.
of family history and my own personal medical history I have a vested interest in how my physician uses and
interprets glucose and HbA1c, but more importantly, I want medical laboratorians
to be informed, to keep current, and to offer sound scientific guidance to clinicians. Nature abhors
a vacuum and if we are absent, all sorts of “experts” will jump in, often offering
information which is misleading at best.
had witnessed this situation many times before, but I still paid attention. "It’s an instrument, not a machine,
stupid,” the MLS yelled to the entire room in general, and no one in particular, as she hung
up the phone. angrily. When questioned she explained that a physician had called wanting to know if
the “troponin machine” was calibrated because he seemed to be getting high values
on his ED patients this evening.
I recalled how upset many laboratorians get at the equipment nomenclature. In
this case she could have decided to rerun controls, explain the issue might be
the patient population: patients presenting with chest pain in the ED, troponin requested on symptomatic patients to make a differential diagnosis . She might also have legitimately explained that of all the troponin tests done that shift only 2 had been elevated. But
instead she took umbrage at the terminology “machine.”
name is certainly important. For example, I resent being called a tech, techinician,
technologist or “the lab.” I recoil when laboratorians are mistaken for nurses, or I , as an older male, am presumed to be a doctor. I do not like being considered a person who pushes buttons
and if my “machine” is calibrated, all I have to do is read the number off the screen
or a printout. But I do not care if that big hulking piece of metal which I use to generate results is called Bob,
Mary, an instrument or a machine.
a pilot, their airplane is a machine and instruments are parts of the machine
that give information and help to fly the plane. To a surgeon, instruments are the
tools of their trade (scalpel, retractors, clamps) while machines (ventilators,
monitors) maintain patient function or provide vital information about the patient’s
status. To others in healthcare, like respiratory therapists, the terms machine and instrument are in fact interchangeable. The point is: machines can be very sophisticated contraptions that perform
some very vital functions. No other profession I can think of gets as
anal and defensive about this innocuous distinction.
a profession our career path is very compressed, there is overlap of scopes of
practice between professionals and paraprofessionals, other professions legally co-opt
the right to perform laboratory testing. We do not have professional licensure
in most states. Our scope of practice is not protected. The public we serve is
not aware of our education, value or role in healthcare. Why don’t we expend our
energy on changing these anomalies?
do we gain professionally if our tools are addressed respectfully as “instruments”?
Certainly we have bigger fish to fry that
getting all bent out of shape because someone outside the profession refers to
one of our tools as a machine?
We have all got fairly used to the concept of e-healthcare in recent years. It is the odd healthcare organization, laboratory or physician office that depends mostly on paper records anymore. From legibility to patient safety to access to patient information across the continuum of care it makes sense to use computers and the internet rather than paper.
I experienced the seamless use of e-health delivery recently when I went to see a physician who was a member of my HMO. I went to an office that was convenient to where I was attending a seminar-as opposed to going to see my regular physician. My medical record, including lab results and medication list, was immediately available and my (astute) physician was pretty conversant with my history by the time I saw him in the examination room. I needed a paper prescription and it was printed out on secure counterfeit-free paper and available to me at check out.
A subset of e-health is the area of m-health or mobile healthcare. Just about every business has an app (application) these days that can run on a smartphone operating system platform. Increasingly healthcare is joining the app revolution. A study by PricewaterhouseCoopers, LLP predict that globally m-health will be a $23 billion market by the year 2017, of which the US will account for about 28 percent.
I had the option of getting my detailed discharge instructions printed in the office or emailed to me along with a copy of the receipt for my co-pay. I chose email, instead of detailing with reams of paper with the risk of misplacing them; or having the formation end up in the wrong hands.
Providing as much vital information as it does the clinical laboratory must start looking at the adoption of m-health sooner than later. Possible uses include
Ability to email a provider directly
Receiving lab results by text or email. At a minimum, patients and providers should have the option of being advised that results are ready; and then being able to access a secure portal where the actual result is viewable
Being able to easily track, trend and graph lab results over time
Accessing results of lab tests done outside the traditional system (such as while traveling) and therefore not otherwise available to the regular provider
Storing scannable patient identification: medical record number, unique identifiers
Being able to make and confirm appointments with a provider or the outpatient laboratory through text or email
Increased health literacy by accessing information about use and/or interpretation of lab results individualized by patient
To be sure there will be issues of security and confidentiality. Systems must have inter-operability without a significant risk of leaks. Sensitive information has to be restricted and accessible only to those who have a genuine “need to know.” But these requirements can be met; in fact more confidently than with paper records and through telephone calls.
First we had voice and paper, then e-health and now m-health. For the laboratory with its masses of vital time-sensitive data, the opportunities are both positive and endless.
We seem to have lots to
complain about in this profession: low pay, lack of recognition, a flat career ladder
and encroachment on our scope of practice for starters. Next to pointing out our
ills the runner up theme is the mantra things will not improve until “they” fix
it. Who are they?
Depending on whom you
ask, the real influential people who can make a difference are professional organizations,
employers, pathologists, regulatory agencies and, possibly, the government. Maybe
if we formed a group or put together a petition, then we could influence the real powerbrokers.
Notice it is never, “What can I do?”
The proof that one person
can in fact make a difference has been driven home to us over the years. The road
of history is paved with examples of heroic individuals who made a difference.
Even if they eventually influenced a large group, they often started alone with
an idea or belief and then ventured forth while it was still unpopular. One person
can indeed make a difference.
This idea of the Power
of One was demonstrated to me recently. The two-man bobsled Jamaican team qualified
to participate in the Winter Olympic Games in Sochi, Russia.
How someone in a tiny tropical island conceived
of creating a team capable of competing against world class athletes in a
winter sport is a miracle in itself. In any event the team
found itself so strapped for cash that there was the real possibility they would
not be able to make it to the games. Then one sports fan in
Washington, DC decided to use the magic of social media and start a fundraising
campaign on the crowdfunding site Crowdtilt.
The news quickly went
viral being shared by thousands on social media and covered by major news organizations
Cash started rolling
in and within a couple of days the campaign had netted almost $130, 000. I emailed both the fan
who started the campaign and the CEO of Crowdtilt and they
both said they were blown away by the response. All
they had going in was a passion for the cause and a belief that they should do
something, rather than waiting for others.
Think for a minute; what
were the odds of success without a big corporation or government (“they”) stepping
in and helping? The existence of the bobsled team, their qualifying for the Olympics,
one individual starting a fundraiser, the creation of crowdfunding
sites like Crowdtilt; all speak to the Power of One.
Success is always great,
but it is instructive to remember that many times the most phenomenal feats have
been achieved not through a large group of others, but simply by each one of us
doing something to start the ball rolling. We all can influence, even if not totally transform, simply by harnessing the Power of One.
Director of Nursing hotly defended her staff. They had in fact performed quality
control on the point of care glucose meters per policy. They had dated and initialed the appropriate line on the sheet. What was the lab
complaining about? What did the state inspector mean by citing them?
me back up and explain. A few years ago I was associated with an organization where
nurses performed glucose and urine pregnancy point of care testing. The nurses
were trained to perform quality control and to document QC as well as
maintenance on a log sheet. However it was a constant battle to ensure compliance. One
day the state came in and found a couple instances were QC was performed, but
were out of range. There was no corrective action documented, yet patient
testing was performed.
Director of Nursing could not grasp the concept of running QC to indicate
acceptable performance of the test system. In her mind, QC and maintenance were
just tasks to be checked off a list. Over the years, I have come to realize
that many concepts we medical laboratorians consider fundamental are alien to those in other
professions, including nurses.
have also noticed that as laboratorians we also do some tasks by rote without
thinking whether they are logical or not. Some recent examples I have seen with
clients: performing 3 levels of QC daily for low volume tests that the lab
performs maybe twice weekly. Another client performed correlation on all 82 of
their (identical) glucose meters instead of using a representative sample as
recommended by CLSI. A small laboratory performs quality control on their
chemistry analyzer each of three shifts. Yet another , strapped for space) uses valuable refrigerator space storing their urine samples for a week. Why? Their policy says, "patient specimens are stored for 7 days."
much of what we do is based on ensuring quality and how much is simply checking
off a task on a list? With the increased sophistication of laboratory
instruments is it still logical to perform the sort of validation studies traditionally
required by CLIA? How often should methods be revalidated?
Another area that needs consideration is reporting results. Increasingly physicians are pleading for decision limits or cut-points instead of a "normal range." Maybe our reference intervals should provide more information than normal/abnormal, or low-normal-high.
laboratorians we are very concerned with quality, but I suggest we periodically
look at our long list of “tasks” and reconsider which ones contribute to quality
and enhance patient care, versus those which are just something on a list and no
longer serve a useful purpose.
there a task or process in your lab that has passed its prime or that you perform
without knowing exactly why you do it?
A new year starts in just a few hours and this is
traditionally the time to make resolutions.
Some people are just pressured into resolving to do better because it is
what is expected. Others sincerely pledge to make some positive change in their
The sad reality is, however, that most new
year’s resolutions fail. It doesn’t take long either: many New Year’s
resolutions go the way of the wooly mammoth within the first few weeks of the
A study conducted last year showed that a full
50 percent of folks abandon their firm resolve, before even making an effort to
A goal can be made at any time, not just at
New Year, of course. Generally I recommend that in order to be effective every goal should be SMART (specific,
measurable, achievable, realistic and time limited). So a goal to further my
education and get a higher paying job might be refined to read:
“I will complete my first year in the MHA
program at XYZ college by December 2014.”
SMART goals give specific yardsticks by which
success can be measured. In order to
achieve a SMART goal, specific, targeted actions have to be taken to ensure the goal is
achieved within the time frame. There are maps, goalposts and deadlines.
Making goals SMART is a very sound strategy. However,
if you have been unsuccessful in keeping New Year’s resolutions in the past, and
if you have only a general idea of what you want to achieve, you may use a
modified version of a resolution by creating and writing down a vision. A vision is
essentially what you want to be or do or have. It sets a direction for where you
want to go, or end up.
Organizations use vision statements as lofty
ideas of how they would like to be perceived, maybe in a few years' time. “To
be the preeminent provider of healthcare in the TriState region” is an example
of a healthcare provider's vision statement. However, although it represents a lofty goal, that statement
is almost a wish or hope and it does not have the specific and measurable
features of a SMART goal.
The good thing about a vision, other than the
facts it is less specific, less pressure-laden and less prone to failure is
that by its very existence it tends to move an individual or organization in
that direction. If an organization or individual uses their vision as a
framework or measuring stick for every action taken, they are more likely to
move in that direction. It is pretty obvious that some strategies will get you closer to your goal, while others will not.
Another interesting thing about a vision is its
psychological effect. Human beings are teleological or goal driven. Even
subconsciously they tend to move towards a goal, once the goal has been set.
Ever notice how once you become interested in a smart phone, car or appliance,
you start seeing it everywhere? You start seeing articles and commercials
featuring what you want. Your friends on Facebook start talking about it.
That’s how goal-seeking works.
Some might even say there is a conspiracy of circumstances to create your vision once you create it and turn it loose.
So this New Year I suggest that instead of yet
another doomed resolution you might want to set a vision. Where do you want to
be in 1 year’s time? In 5 years? What do you want to be, to do, to have? Write
it down. Read it often. Be open and receptive to nontraditional options. Take
actions that move you in the direction of your dream whenever opportunities
present themselves-and they will!
I would love to hear your experiences of visioning
throughout the year. I wish you much health,
happiness and success in your personal and professional lives for 2014.
You might be familiar
with the comeback, “Sounds like a personal problem to me.” That expression is
usually used to quash a complaint or an excuse not living up to expectations. That
expression came to mind recently.
The weather is
usually mild in Atlanta where I live. However we had a steady two-week cold
snap and my steep, winding driveway froze over. On my way home one evening, I was unable to
successfully navigate the slippery obstacle course and my car slid into the
bushes, teetering dangerously close to a
I called my emergency
road service company and they sent a wrecker out to “rescue” me. The driver
arrived a couple hours later and immediately complained that he was working alone on a job
that should be staffed by two people. Not only were they short-staffed, he said, but there were lots of wrecks because of the weather. He gave me a lecture on safe winter driving,
how to navigate a hazardous roadway and the wisdom of never choosing a
residence with such a steep driveway.
He then told me he was being paid only a paltry sum by his company and so this very complicated
operation was not worth it to him financially. He warned me it was very unlikely my
car would not be scratched and damaged even if he could somehow get it on the bed
of his truck. I signed the waiver, absolving the wrecker of any liability for
damages incurred during the operation. I waited with trepidation, helping to push, pull, steer-whatever he asked me to do.
After an hour of manoeuvers
and curses, my car was safely “extricated” and rested on terra firma at the
bottom of my driveway where it spent the night until my driveway could be
I kept thinking what
lousy customer service and how unconcerned I was with all the driver’s “personal
problems.” I paid for a service and
expected the company to honor their contract without whining or blaming.
How often as professionals
do we whine, blame and play victim when confronted by a deadline or
complication? Our customers (patients,
doctors, nurses) feel pretty much the way I did as a customer, “Sounds like a
personal problem to me. “ They have
certain expectations and we as professionals implicitly promise we are
competent to deliver, and capable of making good, on that promise.
Those we serve really do not
care if we are short staffed, our equipment is acting quirky, the antibody is
“hiding” or our Wright’s stain has artifacts. You say, "Those are
realities, so why shouldn't we let them know?”
I believe it’s all a
matter of perspective and approach. First recognize we all have the same goal
of quality, timely patient care. However at any one time, our priorities and perspectives may
be different. It is normal that we tend to be ego-centic in our views. The suggestion is to acknowledge the clinician’s
frustration with not receiving a result in the expected time frame. Then calmly explain why the result might be
taking longer than anticipated. If possible, give an expected timeframe for
completion. Finally, when the result is available, go the extra mile of making sure the
decision maker knows what it is, or where it’s available to be accessed.
This sounds very
simple and almost too simplistic, but the suggestion is to explain the reality in non-confrontational and non-defensive tones. This is an opportunity
to practice the Straight A’s of responding to customer complaints: Acknowledge,
Apologize and Act.
Acknowledge: I realize/ I agree/ I know that…
Apologize: I am really sorry that…
Act: This is what is happening (this is why we have an issue
making service more complex, less timely, or falling short of what’s expected).
Then immediately go on to explain what actions
you are taking to resolve the issue.
is what I am doing about it
an expected, realistic timeframe for resolution, if possible
result ASAP and inform customer
by giving a progress report if the deadline is not going to be met
In most interactions,
we do not have to deny the reality or try to obscure the facts. However, those whom
we serve, those who are depending on us to deliver, respond very differently based
on how we present the reality.
this week, the Bureau of Labor Statistics (BLS) released its report of job prospects
for the next ten years (actually between 2012 and 2022).
surprisingly, healthcare topped the list of attractive fields, projected to
grow at almost three percent, adding an estimated 5 million new workers- a
third of all new jobs. The report also
breaks down the statistics by occupational role.
Most of the overall
10.8 percent growth will occur, not surprisingly in service jobs like
healthcare as opposed to jobs that produce goods like manufacturing or
construction. The healthcare sector is further broken down by scope. It turns out that healthcare will be among the four major occupational groups that
are projected to grow more than 20 percent—nearly double the overall growth
from 2012 to 2022. But healthcare support occupations will surpass healthcare
practitioners and technical occupations (28.1 percent versus 21.5 percent. (See
Chart 2 and Table 6).
As we all already
know, in all areas of healthcare paraprofessionals will be in increasingly greater
demand and will be utilized more as the population ages and care needs
increase. Does that mean laboratory scientists will be replaced by laboratory
aides or technicians? No, that is very unlikely. That fear is as unfounded as
the perennial rumor that more instrumentation will eventually make medical lab
It does mean two
things, however. If paraprofessionals are to competently assume greater
responsibilities and represent the laboratory even more, we have to make sure
they are prepared to safely and effectively fulfil those roles. Phlebotomists might be trained as lab
assistants with expanded auxiliary roles. Customer service reps should be
taught scripting to answer common questions and trained on when to escalate
issues outside their scope. MLTs may be encouraged to become MLSs and assume
more responsibilities. Education and training should be seen as added value; as
should seeking national certification.
As roles shift across
the entire healthcare team, the needs of the laboratory's customers will also
change and we must be ready for the new challenge. Scientists should jump at the opportunity to interact
more with their peers outside the laboratory, instead of performing the more
“tasky” duties that are customary. There
can be more effective representation on decision making committees like the
Quality Council, Pharmacy, Nutrition and Therapeutics (PNT) committees and the
Long delayed projects
related to test utilization and provision of interpretive guidelines can be
pursued. Busy, overwhelmed clinicians
would welcome even the most basic phone
consultations, if they were available. There are best practices to be
established and research to provide hard data applicable to medical laboratory
science practice, much like other professions have done.
Many of us are on our
way out, possibly on the way to retirement. However it is heartening to know
that our profession will continue to grow.
matter what your job is, it’s likely you periodically encounter situations that make you
consider whether you should just look the other way or take ownership. This
might range from a customer service issue with a patient, to an interdepartmental
impasse to a human resource issue.
often we are tempted to take a pass on resolution of the problem because we already
have enough on our plate. We either ignore (or delegate) resolution of what is seen as just a nagging interruption to our already busy day.
not all challenges are created equal. As laboratorians we wag our fingers at
clinicians who constantly over-order or order inappropriately, but we say
nothing using the excuse, “He is the doctor,” or “I am just a tech.” Do we have
a responsibility to voice an opinion? I do not mean delivering a lecture, or outright refusal to perform
the test. But what about a concerted push for the development of a team looking at
utilization and developing algorithms for test ordering? Variation from of the algorithm would require some sort of justification. Pharmacists have developed drug formularies and
ordering guidelines that physicians must adhere to. You never hear, “Well, I am
just the pharmacist, I must dispense whatever the physician ordered.”
Some issues that arise are not merely policy-related or procedural, they have an ethical component as well. How
would you react to the following real-life situations?
supervisor who asks staff to “fix” QC and temperature charts before a survey in
order not to be cited.
lab manager who tweaks quality data like blood stream infection rate or
analytical error rate before the data is submitted to the organization’s Quality
A colleague who accesses the CFO’s medical record because she “heard” he was recently
diagnosed with….. (choose an illness)
MLS who modifies the rules for manual differentials or microscopic urines in
order to end his shift on time.
A colleague, Mary, who falsifies time by asking a colleague, Tom, to clock in
and out for her so she gets credited for more than her actual time worked.
-A phlebotomist who discovers she drew the wrong patient but chose not to correct the error since no one questioned the results.
are all real situations I have encountered in laboratories and the laboratorian
discovering the ethical lapse was reluctant to act. There is always the extra
wrinkle if the policy or ethics violator is a superior, but is that a valid
reason to ignore the issue?
would love to hear from readers who have you faced similar dilemmas in their workplace
and how they reacted.
2006, industry giant, Abbott Diagnostics made a major investment in medical
laboratory science by launching a campaign called Labs Are Vital. They spent
quite a bit of money and expended human resources in setting up a website and trying
to energize the medical laboratory community to help spread the message to the
wider public that labs are, well, vital.
was significant at that time is that no other vendor had made such an
investment or even, frankly, appeared to empathize with laboratory professions
who felt underappreciated, underutilized and even marginalized. Nursing had
their huge Johnson and Johnson advertisement Campaign for Nursing’s Future.
in 2001, that campaign is still going strong, offering several ads on major
cable TV stations, recruiting students to the profession, and help in the way
of scholarships and so on.
intent was always that laboratorians themselves drive the Vital campaign. I
recall a national meeting where Abbott had a booth set up with brightly colored
professional-looking posters of various laboratorians. Lab attendees at the meeting
were encouraged to have their pictures taken with the hope of being featured on
a larger than life poster with an appropriately proud and catchy phrase.
Medical laboratorians were also encouraged and given ideas on how to celebrate
and promote the laboratory not just during Medical Laboratory Professionals Week (MLPW), but all year long.
this year Abbott finally turned over Labs Are Vital to the international laboratory
community. Currently the sponsors are ASCP, IFCC, International Federation of
Biomedical Laboratory Science (IFBLS) and the World Association of Societies of
Pathology and Laboratory Medicine (WASPLM).
Abbott continues to provide financial support, but quite appropriately
the direction is intended to be set by laboratory professional organizations
and their members.
new website www.labsarevital.com is
up and running and features blogs, commentaries, articles, letters and a
schedule of upcoming events. Laboratorians have a chance to weigh in, whether
just to comment on a topical issue or to offer suggestions for a bold new
the website, browse, contribute, get educated, get new ideas, and get energized.
Yes, labs are still vital and with your participation, Labs Are Vital 2.0 has
the potential to be even more influential than it's been in the past.
I wish I
knew everything, but I don't. On second thought: it would be pretty boring to
have every fact at my finger tips and I never have to learn, to ask, research
or dig for information. In any event, has someone ever asked you a
question and you hesitated before admitting that you don't know the answer?
am the king of trivia, so I have a collection of disjointed facts in my head. I
am the kind of friend to call as your lifeline if you are stuck on "Who
wants to be a millionaire?" I am not cocky, because I honestly don't
even know how and when I stockpiled all that (largely useless) random pieces of
family knows that I am a medical laboratory scientist (not a doctor, pharmacist
or nurse) they also turn to me a lot for medical information and advice. I
happen to know a little about a lot of things, but I am certainly no substitute
for a visit to your physician.
I have long espoused
the philosophy that as medical lab scientists we have a unique body of
knowledge and are the experts on MLS. I strongly support speaking out and
provided current and credible information to physicians, nurses and patients.
But in order to provide such a service credibly, honestly and safely, we have
to make sure we are truly knowledgeable and accurate.
I was in a
medical office recently and overheard a physician explain to a medical
assistant that it doesn't matter how long urine is centrifuged for a
microscopic examination, but "Most people don't spin long enough, I like
mine spun hard for 10 minutes to make sure everything settles."
heard a diabetes educator give blatantly incorrect information to patients
about lipids and hemoglobin A1C. When I am in the presence of healthcare
professionals who do not know my background, I am amazed at not just how they
downplay and "diss" our profession, but how they mischaracterize
important aspects like specimen collection, storage, patient preparation and
interpretation of test results.
We all have
stories about the person in the laboratory who will always give an answer to a
caller, instead of referring them to an individual who is more appropriate or
knowledgeable. Are your phlebotomists and customer service reps trained to say,
"I will let you speak to a MLS about this" or "I am sorry I am
not sure, but I will find out and call you back."
There is no
shame in not knowing. We hurt our credibility and put patients at risk if we
choose to give answers because we want to appear to "know it all."
is a lot of information we can offer; we absolutely should be more aggressive
in giving advice and interpretations; we should wear the mantle of
"expert" more confidently and proudly. But part of being a true
professional who offers real value to those he serves is to know when-and not
be afraid - to say, "I don't know."
In a recent article, Dr. Diane Shannon talked very poignantly of the reason she left the practice of medicine. Shannon said she was burnt out and wanted to be another addition to the statistic that suicide is higher among female physicians than among females in the general population.
That sounds like hyperbole until you hear how much this physician described how she, and other physicians, are often constantly plagued by worry about their patients. Even while away from work, they go down mental checklists and wonder if they ordered the right tests, gave the correct dosage of medications and so on.
Shannon refers to research that indicates that physician burnout might be related to a combination of four factors:
1. Time pressure
2. Degree of control (lack of control) regarding their work
3. Pace of work or level of chaos surrounding work
4. Values alignment between physicians and administration
You will no doubt think, "Those conditions sound familiar." Not very laboratory is characterized by chaos, but the other three factors are certainly pretty typical of Everylab USA, isn't it? So we can certainly relate to all those stressors and recognize them as contributors to the burnout characteristic of our profession; especially among the older crowd.
However, this article made me think of something else. It is a theory I have long espoused. Physicians, stressed, burnt out and inundated with data, would welcome our help in making sense of the information we provide. In fact we can do much more in converting numbers, data, and text into meaningful information. We can offer up ourselves as experts to call or consult for clarification if needed.
Think of a middle aged man presenting to the ED with belly pain, hepatomegaly and is described as icteric. He denies a history of alcoholism, drug abuse and has not traveled outside the country. So the physician starts an IV, orders a hepatic profile and admits the patient.
The result comes back, and all the attending physician sees is an alphabet soup: hepatitis A, B, C; some antibodies and antigens; IgM; surface and core "stuff." It is the unusual physician who will immediately understand what all that means. Wouldn't it make a lot of sense for us to send an interpretive report? Would not the physician and patient be better served if they could immediately see what type of hepatitis the patient has and whether it is likely to be acute or chronic, for starters.
That does not constitute the practice of medicine. It is certainly within our capability and scope of practice. We'd rather roll our eyes and make snide remarks about physicians ordering the wrong tests and misinterpreting the results.
A simple act on our part -generating a legible, clear, interpretive report- would go a far way towards improving and expediting patient care. It might not be an exaggeration to say it might well contribute to saving a patient- and
possibly a physician as well.