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Press Start: Lead an Empowered Life as a Clinical Laboratorian

Controlling Laboratory Overutilization Through Formularies
August 2, 2014 3:03 PM by Glen McDaniel

The overutilization of laboratory tests continues to be the bane of laboratory and hospital management. Overutilization is troublesome for several reasons, of course.


-Laboratory professionals are frustrated by clear misuse of tests and sometimes needless repitition of previously performed tests e.g. daily profiles or repeat of send out tests before the original are on the chart


-Hospital management are acutely aware that overutilization increases costs. Organizations that receive a per diem rate from Medicare or a managed care policy, for example, are just eating into their profit margin with every service (including laboratory test) that they perform.


Sometimes patients are not discharged as scheduled  in order to perform additional tests or to wait for test results. Some tests are not necessary; others are important but can be performed on an outpatient basis.


-Physicians do not benefit from overutilization because they have to address any abnormal results that turn up during the process. They also are under pressure from administration to keep costs down and to discharge patients ASAP.


-Patients are inconvenienced and suffer discomfort when subjected to frequent lab draws, and they may have a heightened sense of anxiety while waiting for “yet another test result.” They do not always understand why a result will vary from day to day and worry needlessly.. One cause of idiopathic anemia is frequent blood draws while in the hospital.


So what is a laboratory to do? Since physicians drive test ordering it is important to get physician input and to co-opt physician champions to tackle the problem. If you have a strong, knowledgeable pathologist that helps. But even absent such a person, it is possible for the laboratory to gather information regarding the points raised above and also refer liberally  to independent sources describing best practices in laboratory utilization.


One method that a few laboratories have adopted successfully is the use of formularies similar to drug formularies. It is a common concept that just about every hospital pharmacy has a formulary of “acceptable and available medications.” Physicians must pick from that list. Any deviation must be approved by a committee-or at least be honored only after detailed justification and documentation.


The information technology folks play a significant role in forcing physicians to stick to formularies. If they try to order an off formulary drug-or even an off-label drug available in the formulary- they may receive a soft stop or a hard stop in the computer system.


The same concept can be used for laboratory testing. If a physician orders some tests (no longer available, inappropriate, very complex, very costly, ordered too frequently for that patient) they can receive the same hard or soft stop. Either the test is not allowed at all, or the ordering physician needs further documentation and approval in order to have that test done.


It is very likely (as happens in pharmacy with off-formulary and off-label use of medication) that some physicians will protest, be slow adopters or will call the laboratory directly for an explanation of rationale; or even to over-ride the hard stop. They will pull rank and try to be exempt from the rule. Pharmacists are very adept at fielding such calls. In order for laboratory formularies to work it is important for laboratorians to be equally knowledgeable and confident when speaking to possibly frustrated and aggressive physicians.


In today’s climate of high cost, innovative operational methods and overutilization of lab tests that this is an approach worth pursuing.

Ebola Outbreak: What Do You Tell Friends?
July 29, 2014 2:43 PM by Glen McDaniel

The most recent Ebola Virus outbreak has made the national news. This highly contagious virus of the family Filoviridae, genus Ebolavirus causes a hemorrhagic illness that approaches 90 percent mortality.


This latest episode in West Africa has claimed the lives of over 600 people, but has made the news largely because it is the worst-ever outbreak in history and two Americans have been infected.


Friends have been asking me: What is Ebola exactly? Why is it so deadly? How is it spread? Are we at risk here in the USA?

While not an expert in virology or epidemiology, I take that imposed educational role seriously. I keep up to date as a scientist, interested in disease and health. I give basic, factual information when asked and then refer friends to credible sources like the CDC website. I also vet popular news sites and endorse links that give current updates, explain Ebola, summarize aspects of epidemiology, and discuss risk in a sober yet non-alarmist way.

I am curious: what role do you think medical laboratorians should play in educating friends and family? What do you do?  Are you less interested if the “disease du jour” is affecting only unknown people from faraway places and poses little risk to the US?

Are You More Than a Passive Technician?
July 26, 2014 5:59 PM by Glen McDaniel

I recently saw a discussion on a Medical Laboratory page on a popular social networking site. Someone started off a thread detailing an encounter with a nurse in which a request was made that was so ludicrous it was funny. Others weighed in with accounts of their personal experiences: mostly questions or requests from nursing based on ignorance of laboratory procedures and interpretation of results.  This sort of story-telling is a favorite pastime of medical laboratorians as we know.


I made a brief comment indicating that we needed to project ourselves more as knowledgeable professionals and less as “passive technicians” who followed orders mindlessly and offered no opinions at all. Sadly, one person took umbrage to my use of the term "technician" and accused me of belittling the role of MLTs such as herself. This is despite the clear context and even the blatant hint that “technician” was in quotes, indicating I was quoting someone else’s words.


Nurses and others on the healthcare team often refer to medical laboratorians at any level as ”the lab” or “technicians” and suggest implicitly and, sometimes explicitly, that as members of the ancillary staff we do not have much to offer in terms of independent thought or knowledge. This is clearly not true and I am bothered when we buy into this interpretation and passively (there is that term again) stand by and let others wallow in their ignorance or persist in their misconception of who we are.


It is sad we can muster up lots of whining, sense of self-victimization, hypersensitivity and criticism of each other while we passively let others misjudge and undervalue us and the contribution we make to the patient care. More than our ego is at stake. When we are not fully utilized, patient care suffers as well.


Members of the profession at every level- phlebotomist, MLT, MLS, specialist, pathologist- are all valuable and each has a unique body of knowledge from which they can draw and enlighten those who do not know. I have many friends who are physicians and they almost unanimously appreciate when I enlighten them about the proper selection, use and interpretation of laboratory tests. They are always surprised when I speak about our education or detail processes that explain turnaround time, how reference intervals are derived, quality control and the like. Am I unique in that regard? I refuse to believe that. Clinicians need and welcome our help, but we often do not give it. Instead we roll our eyes and joke among ourselves.


If someone calls us “technicians” as a way of relegating us to a vague inferior class of button pushers we do not have to accept it. Our energy should be directed at undoing that perception and not internalizing that label. It should certainly not be squandered on attacking those who work tirelessly to advance the profession. That is misdirected energy.


Each “stupid” question or request, each term of denigration is an opportunity to teach and to demonstrate that you are more than a “technician.”


Here's to Your Independence
July 4, 2014 1:43 PM by Glen McDaniel

I do not often repeat posts, blog or articles. However I have received several requests for a repost of this blog. One kind reader from Massachusets wrote, "That is the singular most emotional call I have read in a while. Please reprint on July 4th. Do not just refer to it give a link. Please reprint it so when anyone logs on they will see it on the front page of the ADVANCE blogs."


Well, for that kind reader and others, less effusive but still requesting a reprint, here goes: 


On July 4, 1776 the United States declared independence from Britain and a vigorous new democracy was born. This year we celebrate our 236th birthday and our founding fathers are probably sputtering in wonderment, “Who knew this experiment in democracy would be so successful?”

When American patriots chose to defy King, Crown, a powerful power structure, and even history itself, the conventional wisdom was that the fledgling movement could not survive. There was little more than a deep desire to be free, a belief in the power of determination and the shared aspiration to be independent.

Independence is a scary thought.  Whether it is a country, a profession, an organization or an individual, the status quo can be safe because it represents a known quantity. One learns how to cope with the expected; it is the unexpected that presents the greatest challenges. Psychologists describe this as the “better the devil you know” phenomenon and posit that it explains why even victims of horrendous treatment will opt to remain in what might seem to everyone to be an obviously untenable situation.

 It is not that our forefathers had all the answers, or were imbued with extraordinary strength and courage; it is simply that their desire for a better life superseded their fear. As executives in healthcare, beholden to so many masters and powerbrokers, we are often tentative about moving beyond our fears.

As a profession, we obsess about how we are beholden to pathologists, the government, regulatory agencies and other healthcare professionals. How can we deny the "reality" that we are negatively impacted and held back by so many?

One consideration often overlooked is the very preoccupation with the “reality” prevents us from changing it and moving forward. What would be the result if we chose not to be subservient or subject to the whims and fancies of others? The strong likelihood is we would be closer to our dream of a vibrant, independent, proud profession. The worst case scenario is we would be where we are right now.

Personally and professionally, individually and as a profession, I wish you a Happy Independence.


8 Tips to Improve Your Conversational Effectiveness
June 28, 2014 7:07 PM by Glen McDaniel

I am sure you have all heard the lament, “He/she just does not know how to talk to people.” As team members laboratorians have to interact with each other and convey information not only to fellow laboratorians (peers and supervisors) but to their customers outside the lab as well.


Managers, especially brand new managers, just promoted from the bench, might find it challenging or awkward to have those difficult conversations where someone (possibly a former peer) has to be counseled or told unpleasant news. Supervisors also have to arbitrate conflict among co-workers. They also represent the lab to outsiders and have an extra responsibility to present a professional, conciliatory tone.


No matter the nature of the conversation, some very simple rules can help. EAP Resources, an Atlanta firm providing Employee Assistance Programs to various organizations, offers some very simple conversation tips.



1. Use the other person's name from time to time during the talking, such as, “I agree with you, Betty, and will support your proposal.” Our names are precious to us and nearly everyone has a feel-good experience when being addressed by name. “Gary, would you call me tomorrow with the quote?”


2. Instead of asking general questions such as, “How's it going?” ask specific personal questions like, “How does your son like dental school?” Being specific shows that you remember details about matters important to the other person, such as the family, special interests, and certain individual challenges. Routine and general questions usually elicit only routine responses like, “Fine thanks.”


3. Lighten up the talk with a smile. Even with serious topics, a friendly smile can be appropriate and can add a measure of good will that is helpful in advancing understanding. Being overly-serious tends to suppress feelings and makes the tone of our conversation seem flat and aloof. Relax, drop your shoulders and breathe.


4. Respect people's time for talking so that you don't hold them hostage. If you're uncertain ask, “Do you have a few minutes to talk now?” This is especially useful for telephone conversations, or even for someone in the lab who may be busy trying to complete a time-limited task. Work with their schedule.


5. Give the other party their turn to talk. You can do this by talking in paragraphs, not chapters, and then signaling it's their turn with a question like, “What are your thoughts?” Do not talk over the other person or even answer questions before the questioner has finished asking.


6. When you're with someone, give your full attention. The gift of your presence and attention is quietly powerful and strengthens relationships. Fully engaged listening is rare in our multi-tasking worlds of work and home. When you listen, just listen. Don't wander.  Even constantly averted eyes or “got to take this call” interruptions can break the mood, cause interruption in flow and be perceived as a lack of interest-or worse, disrespect.


7. End your conversation gracefully and not abruptly. When appropriate, thank or compliment the other person when you are ending. “I really enjoyed talking with you and understand the situation much better now. Thanks a lot.”


8.  If possible, recap what you heard and set a time for follow-up. “So, Bella you are suggesting working 32 hours on weekends and being off an extra day during the week? I will look at the schedule you created and get back to you by next Wednesday or Thursday. Thanks for being creative and please feel free to let me know if you have any other ideas.”


These little things add a quality of civility and care to any conversation. Ultimately, they mean a lot because your attitudes tend to be reciprocated. Some individuals just simply have a knack for easy conversation; others don’t.  If you make an effort to incorporate certain phrases and to follow some simple rules you will be rewarded with a much more harmonious and effective workplace.

What Message are You Sending?
June 21, 2014 3:33 PM by Glen McDaniel

In business school my marketing professor was fond of saying, “Marketing is everything.” It was tempting to see this view as the opinion of an overzealous marketer who was trying to convince students of the need to create complex and obtuse business/marketing plans.  But as I continued the course, and long after graduation I realized that to a degree he was right. Marketing is used in several aspects of our lives.


Look at the news: some politician with whom we disagree or who appears to be unpopular sweeps the race with a landslide victory.  Companies create a brand that we instantly recognize through a slogan or even a diagram (think of the Golden Arches or the logo of an apple with a bite taken out of it). Celebrities who do something obnoxious or spout off in a politically incorrect way often hire high-priced fixers to rehabilitate their image. That is all marketing. Marketing can be used for or against your cause and is often based on the strength of the marketing campaign rather than on any objective measure of accuracy or reality.


What does this have to do with medical laboratory science? Well, I think as a profession we too often pitch and perpetuate a negative marketing campaign against ourselves.  When an “old-timer” tells an enthusiastic new graduate or intern how horrible this profession is, that’s marketing. If someone who has been around for years states that, given a choice, they would have chosen another profession, advises the graduate to pursue another vocation and keeps up a mantra of how burnt out they are, what effect do you think that is having both on the youngster and on other’s perception of our profession?


Very often outside the lab, administrators and other members of the healthcare team refer to us in inaccurate ways. They might call us “technicians,” mischaracterize the work we do, minimize our value or even re-state some negative association. We do not have to agree with them; but if we let it slide, we are engaging in a negative marketing campaign against ourselves.


Many observers think everyone in a white coat is a “lab technician” with equal expertise and scope of practice, the lab is always losing specimens, every delay in the ED is due to waiting for lab results, and doctors send specimens to a black hole where machines automatically regurgitate results-with no input from a thinking human being. How many times have we heard this line of thinking and sat silently by while it is repeated ad nauseum?


Professionals in healthcare are called by their names: nurses, doctors, physical therapists, pharmacists. But we are generically “the lab”, a room in the basement. Until recently our week in April was called “Lab Week” with no mention of the professionals who actually practice the profession. I never use the misleading term, Lab Week, for that very reason.


When someone talks about a great hospital experience in my presence or on my Facebook page and thanks all the doctors and nurses, I jokingly say, "Thank all the medical laboratory scientists providing the information used to diagnose and treat the patient. And, thanks to the doctors, nurses and others as well.” I am only partially joking when I reframe the statement; I am practicing deliberate marketing that makes people think a little.


Sometimes my smart-alecky comment elicits dead silence, sometimes a chuckle, but very often it starts a conversation where I can educate-and yes, market, our profession. We are all marketers, broadcasting a message. Choose your message wisely.

Managing Cross-Disciplinary Teams is a Required Skill
May 31, 2014 8:43 PM by Glen McDaniel


Those of us in healthcare have worked in silos for so long it has become the norm. In fact we justify it by saying due to the complexity of our body of knowledge, others just will not understand. Physically and psychologically we are more comfortable sharing space and projects with colleagues who are like us.


Ideas are shared but usually within the group. Even high quality outcomes tend to have just the perspective of our peers as opposed to any other stakeholders on the outside. We serve on teams and committees, but that’s not fully cross-disciplinary because we tend to come together, give input, accept or reject ideas and then move apart to continue life as usual.


It is becoming popular to learn how to cope with inter-generational teams as the workplace changes. It is common to have two or three generations of workers side by side in the same department. But again, that is not inter-disciplinary.


In recent interactions with clients and colleagues I have seen the following odd bedfellows, if you will:

-A radiological technologist in charge of the laboratory (in a non-licensure state)

-Point of Care duties shared by a nurse coordinator and an MLS analyst

-A pathologist who is Director of Diagnostics (with the medical laboratory, imaging and sports medicine reporting to him)

-A pharmacist substituting for a pathologist for coagulation consults for laboratory testing


In the above situations, laboratorians are forced (“made to”  as opposed to “coerced”) to interact with nonlaboratorians in a significant and ongoing way. This is new territory.


Cross-disciplinary work teams are being increasingly created out of the necessity for leaner staffing, need for increased productivity and efficiency.


Mark Lanfear, a global practice leader at KellyServices, a company that specializes in providing workplace solutions, believes successful interdisciplinary teamwork always begins with a committed manager.


His prescription

-Managers must make the commitment and deliberate effort to start thinking in a more interdisciplinary fashion. They must consider various options and direct the team to think of a “common front.” What is the desired outcome? What do all the stakeholders have in common? What perspectives do they want to consider/include in the project?

-The manager must explicitly communicate the cross-disciplinary nature of the project and the interconnectedness of all team members. There are no winners or losers or head honchos based on the silos they previously occupied

-Make it clear that in the same way that communication and working together strengthen the outcome, failure to fully engage will hurt the outcome.


This cross-pollination might be a new, even uncomfortable method of relating. However as laboratorians we will find that this is an increasingly common, efficient and beneficial way of working.

Why License Tour Guides but not Laboratorians?
May 11, 2014 1:24 PM by Glen McDaniel

A recent article in the Economist made me chuckle. It covers in a deliberately humorous way, the story that tour guides in Washington, DC must be licensed, or face stiff fines.


The idea is that a certain body of knowledge is needed and the public can be fleeced or shortchanged if everyone and their uncle start offering tours of the city to gullible, fee-paying tourists.  If you think about it, tour guides probably need to be trained, there might even be a good reason for some standardization of facts. But how detrimental could it be if a guide does not seek the extra training required and pay the government a fee to be licensed?


The reality is that many careers (which cannot even realistically be called professions) are required to be licensed. Generally,  licensure is required to protect the public in some way. For many professions it is important that there be a demonstrated minimum level of knowledge and that service is delivered according to guidelines. Why doesn’t medical laboratory lab science fall into such an important category?


Can you think of a situation in which an untrained-or undertrained- individual could provide incorrect results that could affect patient care? What about providing blood and blood products? Why does the government not have a vested interest in protecting the public health un such areas?


The Economist article continues, “In the 1950s only one American worker in 20 needed a permit from the government; today that figure is around one in three. Some jobs, such as doctors, clearly need strict controls. But some states require licenses for florists and interior designers.”


They could have added barbers, masseuses, cosmetologists, realtors, electricians, nail technicians and a host of others. In fact, I could go on and on with that list. What is ironic is that medical laboratory science is missing from the long list. There are still, in 2014, only a small handful of states (and US possessions) that license laboratorians.


The distraction often used by opponents of personnel licensure is that of the constantly increasing cost of running government. I have suggested in the past, and still believe, that states can minimize the administrative costs of licensure by using reciprocity (as nurses, attorneys and many other professions do). If you have a “clean” license in one state you will be accepted by another state without too many hassles. Instead of developing and controlling their own exams, states can accept recent national certification in lieu of a state exam, except in those very unusual areas where the state requires some narrow body of knowledge.  Once a data base is set up, a clerk reporting to a volunteer Board of Licensure can monitor licensure as just a part of his/her job. Cost can be minimal.


Continuing education can be mandated, including issues that relate to state law or healthcare issues that the state feels are especially important.


None of us wants to pay any more fees than we have to. But what if for a nominal sum you would be licensed, ensuring job protection from unqualified competitors and protecting the public health at the same time? I fear that the protest against paying a small licensure fee has made the fight for licensure more difficult and has unwittingly increased competition for jobs and artificially depressed wages. If an employer can legally take all comers, that diminishes the value of certified professionals. Sometimes we really can be our own worst enemies.


Is it really more important to license the guy who points out the Washington monument to a group of tourists than it is to license those individuals who use critical thinking and independent judgment to provide over 70 percent of information used to make medical decisions?

In Celebration of Medical Laboratory Professionals Week
April 19, 2014 2:16 PM by Glen McDaniel

So, it’s that time of year again. This week we turn our attention to celebrating medical laboratorians.  It is the one week out of the year when we highlight the very important role played by those of us who practice in the laboratory.  Although the information we provide is so vital to healthcare, we are largely invisible. Arguably we provide the majority of the concrete data used in the diagnosis, treatment and monitoring of diseases. By the nature of our work and the technology used, we increasingly also help to rule out illnesses and advance wellness.


Each year I have written an article, a blog or two, and participated locally in the celebration of “our week.” Although some of my professional career has been spent outside of the laboratory, I always return to my roots and try to join in the celebration whenever I can.


Most of you work long hours, tirelessly, outside the attention and consciousness of the patient, day in and day out. With such little public recognition, I am all in favor of a week of celebration. In recent years, however, I have argued against turning inwards as the only means of celebrating. Mutual pats on the shoulder, wearing t-shirts, hosting baby-picture contests and attending lunches thrown by vendors are great. However, I also advocate aggressively promoting the profession so that others-doctors, nurses, other health professionals, administrators and patients-see who we are, how we think and what we do.


Teaching others starts with knowing our own history. For example, how about having a contest in your lab to see how many of your colleagues know the following facts:


-There are approximately 300,000 medical laboratory professionals in the USA

-Medical laboratory science emerged as a discrete profession around the 1920’s

-In 1975 a week of celebration, originally called National Medical Laboratory Week (NMLW), was initiated by the ASCLS, which back then was named ASMT. Over the years, other laboratory organizations have joined in cosponsoring the week

-In 2005 the organizers of the week changed the name to National Medical Laboratory Professionals Week; adding the “P” to emphasize the role of the professional, the individual. We are more than a room in the basement; after all, we are a profession.

-Each year, a different slogan was chosen to highlight the week. However, in 2010 a permanent theme was chosen: Laboratory Professionals Get Results. This is very catchy and creates a brand that we can all remember, relate to, and use all year long.

-The week is often called “Lab Week” for brevity and because the official name has changed so much. However that casual term probably perpetuates ignorance of the real name and helps to minimize the role of the professional.

-In 2012 the organizers removed the “N” (National) from the name which had been pretty unwieldy, you have to admit. So the current, correct name is Medical Laboratory Professionals Week (MLPW)


This week, celebrate, enjoy yourselves. But whenever possible, use the opportunity to introduce yourself and your profession to those who benefit from your dedication and talent, but know little about you and your skills.


Enjoy. Have Fun. Thank you for all you do, and Happy Medical Laboratory Professionals Week (MLPW) to you.


Answering Your Questions About Patients' Direct Access to Lab Results
April 5, 2014 11:48 AM by Glen McDaniel

Since 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 here.


Doesn’t this new requirement reverse HIPAA?


No, 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 regulations.


This 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.


Labs 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?


I 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.


What about those states that prohibit release of results directly to patients?


As 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?


The 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.


Physician 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.


HHS 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.


It 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 physicians.

There is a Great Need for More Useful MLS Research
March 29, 2014 5:45 PM by Glen McDaniel

I 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.


There 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.


The 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 respective professions.


A 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. 


We 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 testing done.


This 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 care.

HHS Publishes Final Rule on Patient Access to Their Lab results
March 16, 2014 1:21 AM by Glen McDaniel

Health 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.


A part of that initiative, she indicated, had to include a re-assessment of the whole idea of who owns the patient’s information. 


We 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.


This 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.


Both 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.


The Final Rule goes into effect April 5, with all covered entities mandated to comply by October 2 of this year.


The final rule is available at www.federalregister.gov


How will your lab comply with this new mandate?

Glucose or HbA1c..Who you Gonna Call?
March 1, 2014 1:28 PM by Glen McDaniel

I 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,” she said.


Her 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.


She 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.


The 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.


He 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.


This 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.


-Clinicians 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 box.

- Are pathologists, especially anatomical pathologists, really the right individuals to represent the clinical laboratory as experts on what we do?

-Some 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 determinations are.

-I 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.

-Our 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. 


Because 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.

As Long as You Don’t Call my Instrument a Machine
February 22, 2014 3:15 PM by Glen McDaniel

I 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.


Again, 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.”


A 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.


To 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.


As 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?


What 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?



Labs Need to Embrace m-Health
February 2, 2014 5:24 PM by Glen McDaniel

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.



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