Information Technology Series
Editor's note: This is part 2 of a 3-part series that explores the value of information technology in the clinical laboratory and healthcare. The conclusion, to appear in the July issue, will present a new concept-process management.
For more than a decade, clinical labs have been meeting the dual challenge of budget constraints and the shortage of trained personnel against a backdrop of demands for higher quality patient care. Today, despite the continuing decline in clinical diagnostics' share of healthcare expenditures, there is increased recognition of the value of the lab.1 More often, lab results are incorporated in clinical protocols. There is increasing collaboration between clinicians and labs at individual and professional association levels. And the clinical diagnostics industry is enjoying robust growth.2
In our experience, automation and information technology (IT) have been key factors in enabling clinical labs to drive quality and efficiency, reducing errors and lowering costs while getting actionable results into the clinician's hands faster. All of this has been accomplished by a significant reduction of manual tasks (with a corresponding reduction in labor costs as well as human errors) and, more recently, the reduction of human review and greater uniformity in how human judgment is applied when needed. Considering how different our labs are, geographically and culturally, it is remarkable how our two labs have accomplished the same goals and met the same challenges. We are located respectively in Finland, where 90% of healthcare is provided by the government, and the U.S.; one lab serves a predominantly inpatient population, while the other is a reference lab. Though we deployed different technology solutions, our strategic approaches are similar-to employ diagnostics IT to augment and optimize the use of our human resources.
Less is More
An important step in improving quality and efficiency is to streamline and standardize operations by consolidating testing on a smaller number of analyzers. Päijät-Häme Central Hospital standardizes on Siemens systems and undertook this effort in 2010 by moving testing from three clinical chemistry analyzers and two immunoassay analyzers to two Dimension Vista® systems. Kaiser Regional Reference Lab (Denver) did this in 2003, going from four immunoassay analyzers to two ADVIA Centaur® Immunoassay Systems, which resulted in $350,000 per year in savings, of which $200,000 is attributed to reagent savings and $150,000 from internalizing seven tests.2 The ADVIA® LabCell® Automation Solution was added in 2006. Today, the lab has three ADVIA 1800® Clinical Chemistry Systems, two ADVIA Centaur systems and one IMMULITE® Immunoassay System. The same five FTEs (reduced from eight before the consolidation in 2003) have accommodated the test volume, which has gone from 3.5-4 million at the end of 2009 to 5.4 million today.
Autoverification is Key
When Päijät-Häme Central Hospital consolidated chemistry and immunodiagnostics, the lab selected the syngo® Lab Data Manager, based primarily on its autoverification capabilities. Autoverification enables analyzer results to go through computer review based on criteria set by the laboratory and identifies only a subset of the results that require technologist review. Previously, autoverification at Päijät-Häme Central Hospital was performed in the lab information system (LIS), and only for chemistry.
Today, about 95% of chemistry and immunodiagnostics tests go through without human review, and the percentage will continue to increase as the lab gains more experience with the syngo Lab Data Manager. The lab considers autoverification a critical item because of time savings, but the reduction in errors is just as important. The latter comes not only from reducing fatigue but also from the ability to apply uniform rules and preprogrammed parameters that guide the technologists as they triage samples that require human review. In turn, this has resulted in a faster turnaround time because any additional action (e.g., dilution) can be performed immediately. The lab is also able to improve its service by offering both chemistry and immunodiagnostics on a 24/7 basis.
The ADVIA CentraLink® Data Management System is the heart of the laboratory operation at the Kaiser Regional Reference Lab in Denver. As at Päijät-Häme Central Hospital, autoverification is a key productivity tool, and 90% of test results are released without human review. The auto-repeat feature triggers the system to fetch the specimen and repeat the test when a patient result is out of the preset range, so that the technologist will have both the original result and the repeat result for comparison during review.
The availability of the delta check feature, which allows comparison of patient results over time, provides yet another level of information to pinpoint issues and guide reviews. For example, results that appear out of range but are consistent with trends for a particular patient can be accepted. This helps decrease the number of results requiring intervention, resulting in fewer unnecessary repeats and improved workflow. Alternatively, errors in specimen collection can be identified quickly; for example, disparate cholesterol readings for the same patient can be flagged, or an abnormally low calcium level can be traced to incorrect labeling of EDTA-plasma and serum specimens during blood draw.
There are many other ways in which diagnostics IT can enhance quality and improve efficiency on a day-to-day basis. For example, the Kaiser lab uses the Levy-Jennings patient moving average plots for specific chemistries and reagent lots to ensure uniform performance across analyzers. For reference labs like Kaiser's, most of the patient samples are within normal range, and patient moving averages can be used to assure that results for the same test will not vary from one analyzer to another. Thus, it is useful to think of diagnostics IT as a flexible tool that labs can customize to achieve specific objectives.
In comparing current practices at our two labs, the different levels of reliance on autoverification seem to reflect overall trends in Europe and the U.S. While European labs have embraced autoverification historically, a recent poll showed that it is currently used in only 31% of U.S. labs and, on average, only about 20% of chemistry and immunodiagnostics results are released via autoverification, although larger hospitals (those with 400 beds or more) report a higher percentage (about 45%) of autoverified results.4 These statistics are expected to change rapidly over time. The same study showed dramatic growth in adoption of autoverification over the past two years.
For labs that are getting started and evaluating the use of autoverification, it may be useful to compare human and computer review for specific tests from the perspective of whether a different action would result from using human review. This can determine if an initial human review will make a difference in the results and pinpoint where computer review can replace human review.
The next issue, then, is setting the ranges within which human review can reasonably be bypassed and gradually increasing those ranges with experience. Features such as delta check can help guide this optimization process.
While labs may differ in the approach and path to diagnostics IT deployment, few can dispute the payoff in quality and efficiency. In fact, experience shows that with proper deployment of diagnostics IT, increase in quality is concomitant with decrease in cost.9
Dr. Paattiniemi is clinical biochemist, Päijät-Häme Social and Health Care Group, Center of Medical Services, Lahti, Finland. Dr. Sheehan is technical operations manager, Kaiser Regional Reference Laboratory, Denver, CO.
To learn more about the ways Siemens is helping labs increase their effectiveness, please visit: www.siemens.com/advanceit2
The central lab at Päijät-Häme Central Hospital (Lahti, Finland) serves the 500-bed hospital and 14 healthcare centers in the surrounding area. The annual volume of 1.5 million tests per year is divided between inpatient (60%) and outpatient populations. The Kaiser Regional Reference Laboratory (Denver, CO) has an annual volume of 5.4 million tests in chemistry and immunodiagnostics, all outpatients.
1. Dubois C, Swartz V. A vision for change: The expanding role of clinical diagnostics is evident. ADVANCE Administrators of the Laboratory 2011;20(5):50-52.
2. Rollins G. The three year outlook for diagnostics. Clin Lab News 2011;37(1), 1.
3. Sheehan M. Maximizing productivity and quality. ADVANCE for Administrators of the Laboratory 2009; http://laboratory-manager.advanceweb.com/Features/Article-1/Maximizing-Productivity-and-Quality.aspx
4. Information Dynamics Market Monitor 2010 Automation and Autoverification Report.