Dr. Kahn What are some of the more innovative things that you have done in the clinical lab (in terms of a new test that you have brought up in the lab or a new technology that you have used)?
Over the years, many innovative tests and technologies that our lab implemented come to mind. Certain tests (e.g., we were early users of troponin I) happened because we were and continue to remain active in applied clinical or translational research. This allows our lab to maintain solid R & D relationships with colleagues in in vitro diagnostics and has given us 'early' looks at new tests and technologies (allowing us to determine what might fit best in our lab). In recent years, the obvious response would be formation of a core laboratory and being an 'early adopter' in the use of automation. Automation has really worked for our lab. It has helped us to standardize work processes, make better use of our precious staff resources and improve service quality while taking on a very increased workload.
In what specific areas do you see POCT really growing? Is POCT used mainly in the ER setting or is it also used at the bedside. Can you give examples of how it can be used?
At my institution, POCT grows overall at more than a 15% annual growth rate. The two fastest growing areas have been bedside glucose testing (throughout the health system) and coagulation testing (in selected critical care settings). In the past year, our bedside glucose testing has increased by more than 25% as our institution (very proactive in implementing standardized clinical protocols) has put several 'tight glycemic control' protocols into use. The evidence favoring the use of these protocols is very compelling and our clinicians (and I) feel it is robust evidence-based medicine. Due to very good TAT's from the central lab, we have not had to implement more than the usual routine waived POCT in the ER setting up to this point. But we reassess this at least a couple of times each year with our clinician and nursing colleagues in the ED and on the Chest Pain Committee. So most of our POCT has been bedside which has been greatly enhanced by the use of a connectivity system to funnel POCT results via our lab computer into the electronic medical record. Currently, we are far along in implementing computerized physician order entry in our institution and are working to improve the menu of getting non-instrumented POCT results (e.g., occult blood testing, dipstick urinalysis) into the electronic medical record.
Do you see a role for molecular cardiac markers in the clinical lab?
Yes, but not yet. Taking your question to mean completely 'molecular' in technology and design, it is still a little early for us to see the applications of molecular cardiac markers as 'routine' tests in the clinical lab, I absolutely think it will happen as more studies underscore the role of certain markers, the clinical evidence mounts and manufacturers develop the technology to make these tests available in the clinical lab. We will see technology, possibly using microarrays, used for cardiovascular risk assessment, identification and/or modulation of protein factors involved in CV disease progression and in relevant areas of critical care medicine (e.g., determining whether a patient has had a recent stroke). It is also not hard for me to envision that we will see pharmacogenomic applications for selected molecular markers that will tell us about an individual's risk of cardiovascular disease, which patients should be managed more aggressively and a patient's potential response to certain drugs.
Dr. Kahn, you are extremely accomplished, both professionally and personally; your incredible insight and vision have been key assets. The clinical lab has gone through phases of seggregation into distinct areas and consolidation. These trends can be attributed, in part, to technoligal breakthroughs, such as novel technologies, and diagnostic platforms that bridge distinct technologies. Other contributing factors to these trends are operational and business considerations. How do you envision medium and large hospital laboratories to be configured 10 years from now? Will they be more or less segregated? For example, will microbiology, BB and pathology labs always be more or less separate units?
More than ten years ago, several of my colleagues and I were absolutely convinced that some day we would see labs solely segregated by specimen type - whole blood, serum, etc.. I guess I'd have to rethink that idea now, but one never knows. Considering our experience with continuing consolidation, formation of a core lab and implementation of automation (not just in core lab, but in blood bank, in anatomic pathology, etc.), I believe that the medium to large hospital laboratories 10 years from now will be less segregated, more consolidated and automated. But I don't know that this means that all separate disciplines will no longer be visible (e.g., blood bank or even microbiology). Its also likely that there will be fewer labs. In many health care markets, we've seen successful formation of regional networks or integrated delivery systems which may further consolidate laboratory testing across many hospitals. Over the past decade and I think continuing on into the next, I see our own lab being pushed to the two extremes of being a consolidated, automated central laboratory while increasing our support in the growth of bedside or POC testing when it is simply the best thing to do clinically. While not pessimistic about it, I also see the continued drain on resources, mainly staffing and financial. Those will be the drivers for the changes mentioned above.