overutilization of laboratory tests continues to be the bane of laboratory and
hospital management. Overutilization is troublesome for several reasons, of
-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.
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.
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.
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.
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.
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.
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.
today’s climate of high cost, innovative operational methods and
overutilization of lab tests that this is an approach worth pursuing.
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.
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.
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?
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.
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.
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.
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.
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.
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.
“stupid” question or request, each term of denigration is an opportunity to
teach and to demonstrate that you are more than a “technician.”
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.
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.
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.
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
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.
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?”
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
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.
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.
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.
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
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.”
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.”
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.
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.
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.
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?
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.
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?
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.
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.
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
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.
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.
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.
recent interactions with clients and colleagues I have seen the following odd bedfellows, if you will:
radiological technologist in charge of the laboratory (in a non-licensure state)
of Care duties shared by a nurse coordinator and an MLS analyst
pathologist who is Director of Diagnostics (with the medical laboratory, imaging
and sports medicine reporting to him)
pharmacist substituting for a pathologist for coagulation consults for laboratory testing
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
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.
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?
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
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
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.
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
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
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?
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.
education can be mandated, including issues that relate to state law or
healthcare issues that the state feels are especially important.
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.
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
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.
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.
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.
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:
are approximately 300,000 medical laboratory professionals in the USA
laboratory science emerged as a discrete profession around the 1920’s
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
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.
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.
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.
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)
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.
Have Fun. Thank you for all you do, and Happy Medical Laboratory Professionals Week
(MLPW) to you.
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.