Ila Singh, MD, PhD, had been troubled for several years about clinicians ordering incorrect or unnecessary tests, in large part because of confusion over test names. One of the last straws was when she heard about clinicians calling a lab to ask if they had a measles test because they couldn’t find it listed under “M,” completely forgetting to look under “R” for rubella. So Singh, chief of laboratory medicine and pathology informatics at Texas Children’s Hospital in Houston, began contacting colleagues at other institutions with the idea of forming a new nonprofit group to tackle the problem.
Thus the Test Renaming for Understanding & Utilization (TRUU)-Lab group was born. The volunteer organization aims to generate a consensus guideline for test naming, generate consensus names for existing lab tests, and promote the adoption and implementation of consensus lab test names and guidance.
Brian Jackson, MD, MS, chief medical information officer at ARUP Laboratories in Salt Lake City, heard about it while eating lunch with colleagues at a laboratory conference in Seattle a couple of years ago and jumped on board.
“The idea is simple, that laboratory test names are often confusing,” Jackson said. “When clinicians are selecting tests based just on the 20 to 40 characters that typically display in an electronic medical record, it’s hard to figure out how to describe the test accurately and unambiguously enough that they’ll always pick the right one.”
A Problem Ripe for Innovation
Singh has gathered more than 45 stakeholders from clinical pathology and reference labs; societies such as AACC and the College of American Pathologists; instrumentation firms like Siemens; electronic medical record (EMR) companies like Epic and Cerner; government agencies including the Food and Drug Administration, Centers for Disease Control and Prevention (CDC), and Centers for Medicare and Medicaid Services (CMS); and even organizations outside the U.S. to rally around her cause.
“There’s a tremendous amount of interest,” Singh said. “Every organization that I approached said, ‘Oh yes, we need this.’”
There’s a good reason. An estimated 15 billion laboratory tests are performed in the United States each year, Singh said, 10%–30% of which have been found to be either unnecessary or incorrect (PLoS One 2013;8:e78962). Unnecessary laboratory tests cost an average hospital about $1.7 million a year, according to a National Academy of Medicine (Institute of Medicine) study discussed in the academy’s 2015 publication, “Improving Diagnosis in Health Care.” A survey of 1,768 primary healthcare providers in the U.S. found that 15% of them were uncertain about which tests to order (J Am Board Fam Med 2014;27:268-74).
Beyond the costs, incorrect ordering presents a significant patient safety issue, said Gary Procop, MD, MS, medical director and former co-chair of the Cleveland Clinic’s Enterprise Laboratory Stewardship Committee. “In diagnosing influenza,” Procop said, “you would order an influenza molecular test, not an influenza antibody test. But those could be sitting right next to each other on the order form. It would be very easy to pick the wrong one.”
Ren Salerno, PhD, agreed. “Physicians often order tests defensively,” said Salerno, director of CDC’s Division of Laboratory Systems. When they’re not really sure what the right test name is, they may order a whole series of tests hoping one of them is correct. “If you’re ordering the wrong test for a particular patient, you may receive a test result that you shouldn’t. And if you get a positive test result, you may believe that’s indicative of a health condition for a patient that is not accurate, because perhaps that test is measuring an analyte that you’re not aware of. It’s been a really complex challenge that the laboratory community has been trying to address for many, many years.”
Planning for a Smaller World
The reasons for confusion among the 4,000-plus tests to choose from are multifold, Singh said. Frequently, pathology laboratories create their own names with no guidance or discussion with clinicians. In some cases, test names are based upon the disease with which they’re associated, a reagent used, or even the name of a test’s developer (J Gen Intern Med 2013;28:453-8).
Some tests have proprietary names too, Procop noted. A laboratory might list hemoglobin A1C under “H” as its full name, HgbA1C, or HbA1C; under “G” as glycosylated hemoglobin or glycated hemoglobin; or even under “A” as A1C, Singh said. And some EMR platforms only allow a maximum of 20–40 characters to list and describe tests.
TRUU-Lab’s efforts are not the first to examine laboratory test naming. CDC began gathering experts on the clinical laboratory’s role in providing quality testing to improve patient outcomes as far back as 1984, Salerno said. Then, from 2008–2016, the agency’s Clinical Laboratory Integration into Healthcare Collaborative actively worked to optimize use of laboratory services and deal with diagnostic errors caused by misordering or misinterpreting laboratory results, he said. Those efforts wrapped in 2018 after issuing several publications. Logical Observation Identifier Names and Codes, developed by the Regenstrief Institute in the 1990s, is an ongoing effort to establish common language for health measurements including laboratory tests, although its target is computing systems, not clinicians.
But TRUU-Lab members are optimistic that between the timing and the wide net of committed participants, they will slowly be able to effect change.
The world has become smaller over the past few years, said Sridevi Devaraj, PhD, DABCC, FAACC, FRSC, CCRP, medical director of clinical chemistry and point-of-care technology for Texas Children’s Hospital. “If you get a lab test done here, and then go to New York for a second opinion, and they order a test that is not equivalent, then you’re not going to get the right diagnosis,” Devaraj said. TRUU-Lab stakeholders recognize this is an everyday problem in their laboratories, she noted, and they know they have to work together to create the right standards. “That is a win for TRUU-Lab, and for laboratories in general,” she said.
The plethora of mergers and acquisitions among hospitals and laboratories presents another reason why time is of the essence, Singh added, noting that two merging hospitals may have different naming conventions for their tests. “I can’t tell you how many people have contacted me asking if we have a standard list. I would like to be able to give them a list and say, ‘Build this one,’” she said. “How do you choose between two sets of suboptimal names?”
The Roadmap to Implementation
TRUU-Lab members have already conducted surveys to learn the most common problematic test names. Some 274 responses yielded about 100 unique laboratory tests that respondents felt were confusing, and included substantial diversity between institutions. The top 10 most commonly cited tests had at least three unique names, and the top two tests (for vitamin D and anti-factor Xa) had at least 10 unique names (Am J Clin Path 2020;154:S18-9).
Now, with a grant from CDC, TRUU-Lab is working with the Brand Institute—known for its expertise in pharmaceutical naming—to tackle these top 10. Surveys of primary care providers this year will assess name preferences given short prompts. In a second phase, a simulated EMR environment will present mock clinical scenarios in which physicians will select tests. Survey results will inform TRUU-Lab’s naming guidelines (Am J Clin Path 2020;154:S1-2).
“When we finally end up with the name, it will be the right name for the right test at the right time,” she said.
Singh acknowledges the long road ahead. There are a lot of test names to go through, so the scope of the work is tremendous, she noted. Even when new names are identified and agreed upon, change is hard. It’s going to take endorsements from EMR companies and professional societies, or even guidelines from groups like CMS or CLIA, for new naming conventions to take hold. “I think we have a plan, but I’m not going to say that it’s going to be easy,” she said.
While it could take years for TRUU-Lab to slowly chip away at naming conventions, the organization has a lot going for it, according to Salerno. Some previous attempts were government-led, top-down approaches, while TRUU-Lab is “a true collaborative effort among experts who are on the front line,” he said. “They’ve put together a very impressive group with excellent leadership that represents the complexity of the problem and the diversity of the stakeholders. For those reasons, I’m extremely optimistic that it will be successful.”
Meanwhile, laboratory professionals can help by being aware of the issue, and understanding that laboratory abbreviations can be confusing to clinicians, according to Jackson. “Be very careful about how you use them, and seek feedback from clinicians on whether your test names make sense,” he said.
Monitoring utilization patterns also can alert laboratories to potential naming problems. Jackson’s laboratory created its own style guide that relies on a number of rules for test names that a human can subjectively interpret. For example, the name of the analyte is the first element in the test name. Trade names are used only in parentheses where necessary. It’s also critical for laboratory professionals to be part of hospital informatics committees or other subcommittees that build order sets, Procop said.
Karen Blum is a freelance medical and science writer who lives in Owings Mills, Maryland. +Email: [email protected]