Opinion Article by Martin Wilkinson, Director of Product Introduction, Strategy and User Adoption at InterSystems.Laboratories across the world still work largely in isolation to clinical providers. Even today, in the digital age of sharing information, a large majority of laboratory professionals are not given the full clinical perspective on the very patients they are carrying out tests for, something that must change with urgency.
Diagnostic functions working within and alongside our health services need to be given clinical context and access to wider sets of information, so that laboratory professionals, like pathologists, can make active and effective decisions on testing and not just rely on inadequate and even sketchy requests from clinical colleagues in different care settings.
It is time to move the laboratory out of the back office, to become a core element of clinical delivery.
Why laboratories do not have the full clinical picture
Laboratories today still often look at their data in isolation. One reason behind this is that information systems have traditionally been niche market solutions specific to the laboratory, meaning that they have become silos of information, locked away from the frontline of healthcare.
Professionals working in diagnostics can only act on information they have, which is often limited and sometimes even flawed. One major contributing factor to this problem can be found in examination requests themselves, which are too often populated with handwritten notes that need to be interpreted and then transcribed into the system.
Hindrance too is caused by order systems which present limited information onscreen. A professional might see that the patient they are testing for is anaemic, or that they are bleeding from a wound, but they are often not aware of the full clinical picture. So by being able to provide information on previous testing, along with the patient's clinical symptoms as well as their current drug therapy, this can influence the interpretation of the laboratory results without delays having to be incurred by conducting further investigative processes.
Inappropriate testing and delays in care we cannot afford
For as long as the clinical picture is absent from the laboratory, there is the potential for the most relevant testing to be missed within an initial request.
Take a scenario: The clinician on the ward, or in the clinic, receives the report they requested and realises that they needed to request an additional test to that which was ordered. A new test is then subsequently ordered. The patient may then need to have another sample taken, which is sent again to the laboratory for retesting. A new report is written and sent to the doctor to make a decision.
This extended process can result in unnecessary increased lengths of stay, delays in clinical decisions, and inappropriate repeat tests and samples being taken from patients. At a time when healthcare budgets are under pressure, it is expensive to keep people in beds, it is costly to repeat tests and there is additional burden placed on precious resource that we cannot afford to waste. Arguably, and most importantly, there is the risk of delay in the diagnosis of the patient.
Doctors can also choose to request a battery of different tests in an attempt to cover everything - leading to further increased cost of care and unnecessary pressure on scarce laboratory resources.
The objective must be to achieve availability of relevant clinical information at the point of analysis and decision making as quickly as possible.
The right clinical indicators for the right tests
Given the right information, professionals in the laboratory have the expertise to know when tests are needed and when they are not. In a clinical investigation for deep vein thrombosis, the Wells score can be used as a guide to the clinician to assess the clinical risk of such a clinical condition and provide direction on whether additional testing is needed. However, there may be a lack of visibility of the Wells score for professionals in the laboratory.
If they had access to the score, laboratory professionals would be able to make the decision as to whether or not to make those additional tests, at the point the initial sample was received. Instead, they can all too often only perform the tests that have been requested by the clinician, which can result in the cumbersome re-testing process described earlier.
All of this can be eliminated if that clinical indicator is available to the laboratory at the initial point of testing.
Demand systems and a lack of prompts and guidance for appropriate testing at the point of care can cause similar problems. In the case of a cardiac arrest, for example, there is a need to measure Troponin, and for this and other conditions it is important to use clinical best practice guidelines available as to the indicators for retesting.
However, if the clinician does not have access to guidelines and demand management tools at the point of order, the patient will often have their sample taken multiple times, which the laboratory is then obliged to test. This means that this process is often completed regardless of the potential inappropriate nature of the test, increasing the cost of the clinical laboratory services and use of time and human resources.
We need to build rules into the ordering process, assist clinicians, but most importantly, we need to empower the diagnostic professionals within the laboratory in order to overcome such challenges.
Taking the laboratory out of the back office to the frontline of clinical care
The urgency for change is critical, particularly now with the increasing demand on our healthcare services. To achieve this we must take laboratory systems away from being islands, a back office function and a support for clinicians, to a more clinical, front of house, engaged clinical service. And by creating this change, pathologists can be provided with the information they require, along with clinical indicators, to make decisions as to when appropriate tests are required for patients.
This is about communication between the various points of care, and recognising the diagnostic function as a key clinical contributor. By empowering laboratory professionals with clinical information, we can change who plays a clinical role. This will not only save time, but make the clinical process at the patient point of care more effective.
Evolving sources of information need to be considered too in this changing role of the modern laboratory, as also taking place is a rapid evolution of a point of care testing. The next generation of laboratory systems must integrate with new care devices and wearable technologies. Wearables can be used to measure a growing range of variables in the human body. If a wearable can be used to measure blood glucose levels, there is no reason why that valuable information should not feed into a diabetic patient's clinical record, for example.
There is finite capacity in the laboratory. If we can stop patients being unnecessarily re-tested, then the laboratory will have more capacity to focus on core tasks. The consequence is a less stretched environment where both the quality and relevance of the output improves.
Benefits for the patient
Patients too can benefit from placing the laboratory at the centre of care, and not just from the perspective of avoiding unnecessary blood tests. Convenience does play a part, and unnecessary repeat tests can be a hindrance to busy lives. But more importantly, effective intervention often means timely intervention. We want to produce the best outcomes we can for our patients.
Equally, avoiding any unnecessary distress for patients should be a consideration for any healthcare service. If a patient has a blood test and is called back for another, they can fear the worst in terms of their own health.
Ending the diagnostic disconnect
At a time when healthcare services are striving to save billions of pounds, improve patient safety and deliver the best outcomes for patients, speedy, efficient and effective laboratory testing is essential. Achieving the highly sought new models of care outlined in many national strategies, means empowering the right people to make the best decisions for patients at every point of care.
To do this, laboratory professionals must be given access to the right clinical information with urgency in order to transform diagnostics, so that laboratory professionals can take decisive action for patients at the earliest possible opportunity. The current disconnect between clinical settings and our laboratories must come to an end, and this is achievable through the application of new systems and process that are now available.