Controversies in Laboratory Medicine: A Series From the Institute for Quality in Laboratory Medicine

John R. Butterly, MD; Richard E. Horowitz, MD

In This Article

Dr. Horowitz's Response

This brief exercise has identified a list of problems that involve the interface between the laboratory and the clinician. It is remarkable that both groups have very similar concerns. It seems that we have "systemic problems" that require "root cause" analyses; nevertheless, some immediate fixes would be useful.

All laboratories have user guides or manuals that detail specimen and collection requirements, appropriate test utilization, result interpretation, testing algorithms, and some even indicate which tests Medicare designates as "medically necessary" and reimbursable. Wider distribution of the user manual to nursing stations and doctors' offices is clearly needed. Annual in-service training for operating room nurses, ward clerks, and for doctors' office personnel in test ordering and specimen handling can be very effective in eliminating problems.

Prompt reporting of STAT or critical values requires that the laboratory know who the ordering physician is. Most requisitions, whether manual or via computer, show only the name of the admitting physician, who may or may not be the ordering physician. All requisitions should also show the name and phone number of the ordering physician, particularly on outpatients. Also, on outpatients, the patient's phone number should be required so that the doctor receiving a STAT or critical value report can notify the patient. The inclusion of the name of the ordering physician on every requisition would also ensure that reports are sent to all of the patient's physicians.

All laboratory information systems know when specimens are QNS or have clotted or are mislabeled, but they generally don't pass that information back to the ordering clinician. Rather than just canceling the test, it would be simple, either manually or by computer, to let the doctor or his/her staff know.

All laboratory reporting systems currently report test results, reference ranges, panic alerts, and delta checks but generally do not, but should, provide sensitivity, specificity, and predictive values and charts that show equivalence values for different test methodologies. Again, this information is generally present in the laboratory's user manual, but the clinician must have the manual readily available. To print all this information on a test report would make it unwieldy. A monthly lab newsletter to clinicians, which provides such information, particularly on new tests, is a very much underused tool. The standardization of test methodologies and metrics needs to be addressed by organizations, such as the IQLM.

So these are just a few examples of the simple things that could be done now, some with little expense, to address a few of the minor irritations faced by clinicians and laboratories, but when we look a bit deeper, it becomes clear that there are at least 4 (root) causes for the occasional disquieting relationship between the laboratory and its customers.

First, medical schools are no longer teaching clinical pathology or laboratory medicine as a distinct discipline, and the rate of progress in laboratory medicine, with new tests and methodologies, makes it extremely difficult for a clinician to remain well-informed.

Second, as stated above, laboratories are not effectively teaching clinicians and their staffs how to order tests appropriately, how to ensure proper specimen collection, and how to interpret test results correctly.

Third, pathology training programs are not producing anatomic pathologists who know the needs of surgeons and oncologists and can guide them in patient diagnosis and management, and are not training disease- and patient-oriented clinical pathologists who are capable of serving as consultants to clinicians, assisting them in the proper use of the laboratory for patient management.

Finally, medicine as a whole has not yet embraced the sophisticated information systems, including the electronic medical record; online order entry, including online user manual; and computerized result reporting, including test interpretation modules and computer paging systems, that would enhance the communication that is so essential for the clinician-laboratory relationship.

Hopefully, this exercise will encourage greater use of existing manual systems and provide justification for the development and installation of upgraded computerized systems.


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