Laboratory’s role in modern healthcare
Laboratory is simultaneously the most, and the least used resource of the healthcare system.
The reason for the first is because mostly all other medical disciplines use laboratory as their factory or a mine, and the reason for the other is that laboratory staff has insufficient clinical knowledge.
Healthcare strives towards a more modern, efficient, patient-centric healthcare system.
Even though laboratory medicine is a part of that healthcare, it is neglected and less acknowledged than other medical disciplines.
LABORATORY ISN’T A SERVICE FOR DOCTORS
Laboratory experts are often perceived as a service for doctors, and in order to have a successful healthcare ecosystem, they need to have the same status as other experts in their own medical disciplines.
But, this is a big challenge for us. And it’s a challenge because laboratory experts hesitate to involve themselves more in structuring and ordering tests, and the other reason is their assumption that doctors ordered laboratory tests correctly.
This happens as a consequence of bad communication between medical departments and laboratories. Further weakening of the communication happens because initiatives to make laboratory experts act as medical consultants are being neglected.
Repeating new and correct tests as well as pathophysiological interpretation skills, put laboratory experts in the ideal position to advise their colleague doctors on how to properly order and interpret laboratory test results.
Modern healthcare systems are oriented towards developing better communication between doctors and laboratory experts. This form of communication has an enormous influence on the treatment outcomes and medical expenses in general.
HOW TO EMBED LABORATORY IN THE MODERN HEALTHCARE SYSTEM?
Many changes in the healthcare environment will have a significant impact on laboratory trends.
The patient is becoming more and more the center of the healthcare system. UK Department of Health suggested a vision for diagnostic services until 2020. The main goals are:
- improve information accessibility to the patient,
- speed-up bringing in new diagnostic EVIDENCE BASED technologies,
- redesign diagnostic paths towards an easier integrated service.
George Lundberg explains what a laboratory test is: “A laboratory test is an intervention, and an intervention of any kind (diagnostic or therapeutic) is appropriate only if it is more likely to benefit than to harm the patient and can be done at a reasonable cost and with reasonable risk”.
Laboratory tests provide information which help doctors to provide better and more effective care for their patients. It’s often cited that laboratory results are an integral part of every medical decision.
Laboratory results are component of 70% medical claims = 70% of medical decisions = 70% of medical records
Nevertheless, these changes will have a questionable influence on laboratory processes. The crucial question is to decide which way we should take to ensure a more relevant healthcare. There are two basic factors influencing the organization of a laboratory:
- significant technological advancements (full laboratory automation, molecular diagnostic technique, biochips, new generation sequencing, expanding the genome studies, POC solutions etc.)
- economic pressure limit laboratory budgets, as a part of an initiative to reduce costs causes laboratory service consolidation and regionalization.
LABORATORY ERRORS DON’T RESIDE IN THE LABS
From the patient’s perspective, every error is perceived the same, whether it is made in preanalytic, analytic or post-analytic phase. Most of the errors occur outside the laboratory due to various preanalytic factors. A large number of errors occur in post-analytic phase as well.
In recent time, errors in analytic phase got significantly reduced. Emphasize is on a significant reduction of errors related to immunology tests that seriously influence patient’s health condition.
|An inappropriate test is ordered (20% of total)|
|An appropriate test is not ordered (45% of total)|
|An appropriate test result is misapplied due to:
|An appropriate test is ordered, but a delay occurs somewhere in the total testing process|
|The result of an appropriately ordered test is inaccurate|
Table 1. Causes of laboratory diagnostic errors
This table illustrates laboratory diagnostic errors. It’s obvious that a large majority of laboratory errors occurs in pre-analytic and post-analytic phase of result interpretation.
In order to better the situation, it is essential to improve close cooperation between doctors and laboratory experts. This would enhance laboratory testing efficiency.
Experts inside laboratories should take control over those processes in which they naturally have better insight. A good example is testing periods which should be controlled by laboratory experts.
Example: Setting a rule for automatic rejection of retesting attempt based on a minimum of 48-hour interval for C-reactive protein in serum (CRP) results in performing less unnecessary retest attempts of CRP. Additionally, this decreases expenses in general.
Recommendations of UK Association for Clinical Biochemistry and Laboratory Medicine from 2015 for minimum number of (re)testing attempts in biochemistry can be very useful, table 2.
|When needed (small group of tests, electrolytes in plasma, hemoglobin, prothrombin time)|
|Once in a life time (example: genetic test for hereditary diseases)|
|Never ordered for hospital patients (example: lipoprotein as cardiovascular risk factor)|
|Never ordered after a positive result (example: treponema pallidum particle agglutination)|
|Not ordered more than once or longer (example: C-reactive protein)|
|Not ordered more than once a month (example: antibody testing for hepatitis B or C virus infection)|
|Not ordered in a 3-month interval (example: HbA1c)|
|Once a year (example: kidney function for patients with diabetic disease)|
|Never repeated (example: vitamin D for a group population-based screening)|
Table 2: Retesting frequency
REPORT AND REFERENCE INTERVAL STANDARDIZATION
Laboratory results report enhances process efficiency through a synthesis of data, knowledge and information. Whether due to lack of information, bad readability or incorrect reference intervals, an awkward structured laboratory test report can have a negative effect on laboratory tests interpretation.
In a 2015. survey, approximately 20% of doctors in US primary care still has issues with awkwardly structured laboratory result reports. This percentage affects around 13 million of patients every year, and because of that we need to raise awareness about the need for more effective structuring and efficient usage of laboratory tests.
The lack of laboratory testing terminology harmonization is still a worrisome issue.
A recent study performed by the Italian Society of Clinical Biochemistry shows that laboratory result reports for urine albumin still results with the wrong terminology in more than 40% of national laboratories.
Even though the concept of reference intervals is a part of laboratory culture, it is crucial to investigate the standardization methods to monitor reference intervals.
ISO 15189:2012 states that the biological reference interval has to be revised and confirmed every time whenever a variation in the analytic and pre-analytic phase occurs.
Prior to standardization, most of laboratories was founded on different systems. The standardization measures harmonize test performing which are interpreted inside the predefined and revised intervals framework.
Introduction of mutual reference intervals should solve the problem of reference interval deviation between different laboratories, and offer more relevant data.
As an additional tool, we can use patient specific logic LGIC, for improving interpretation of data. The influence of logic helps doctors to enhance their diagnostic accuracy in interpretation and individual comments in order to provide the best possible treatment for their patient.
There’s a need to synchronize this approach, as every laboratory has different work policies and procedures.
Laboratory experts need to play an important role in improving clinical effectiveness in modern healthcare. No medical specialty can answer every question, and in one of our previous posts we showed how the healthcare system slowly moves towards smart multidisciplinary teams. .
In each of these teams, there is a need for laboratory professionals.
An example of understanding the importance of a modern laboratory is Mayo Clinic They put a lot of effort to include laboratory experts in every segment of their work.
We know that communication between laboratories and hospital departments is sometimes poor and the integration hard to build.
Nevertheless, in order to play a more significant role in healthcare environment, laboratory experts need to change their attitude from one of being introspective and defensive to one that is outward looking and confident.
With their knowledge and skills, laboratory professionals have the unique opportunity to use their expertise, and become an even more important factor in the healthcare system.