When a surgeon mistakenly removes the wrong thing or a patient is administered 4 times the appropriate dose of chemotherapy, the error is rapidly recognized. When physicians fail to order the correct laboratory tests or incorrectly interpret the test results, even when a lethal outcome ensues, the poor outcome is rarely attributed to the doctor’s mistake involving the laboratory tests. Even as the clinical laboratory test menu has enlarged in cost and complexity, laboratory directors do not routinely provide patient-specific, expert-driven narratives of complex clinical laboratory evaluations. We would be shocked if the radiologists did not provide an interpretation of all imaging studies and if anatomic pathologists were only there to answer occasional questions that surgeons asked after they looked at the biopsies. The ordering physicians live in a world with thousands of tests, many new and highly expensive, where we call the same test by multiple different names in different laboratories. For example, there are at least 5 different names and 5 different abbreviations for von Willebrand factor activity, and there are at least a dozen tests with the word vitamin D in the title presented to physicians who simply want to know of their patient is vitamin D deficient. The consequence is that doctors order unnecessary tests and often fail to order tests which can provide an immediate and conclusive diagnosis.
How should we address this problem?
Vanderbilt University Medical Center has established teams of experts, which include laboratory directors and medical technologists, to do more than throw laboratory test results over the wall at the ordering clinician. The diagnostic management teams (DMT) at Vanderbilt allow physicians to order tests by requesting an evaluation of the abnormal screening test or a clinical sign or symptom. The DMT produces an expert-driven, patient-specific narrative not only for cases in which one is requested, but for all cases in multiple areas of laboratory medicine and anatomic pathology. The value-added activity Vanderbilt calls a DMT considers clinical information and laboratory data, meets on a regular schedule, includes their diagnostic conclusions in the medical record, and provides information not known to non-expert physicians. Vanderbilt has recognized that there are tremendous clinical and financial benefits to providing advice on test selection and result interpretations. There is no expectation that a professional fee generated by providing an interpretation of clinical laboratory data is required to cover the salary of an attending laboratory director, because laboratory directors providing interpretations generate savings that exceed the amount of their individual salaries. In addition, participation as a leader in the diagnostic management team is independent of the degree of the participant. If payment for the consult is less relevant than the savings from a quick and accurate diagnosis, all qualified individuals must be invited to help establish the correct diagnosis, independent of degree.
What diagnostic management teams are in place?
In hematopathology at Vanderbilt, there was rapid uptake of the DMT concept. The laboratory directors now order the lab tests, with an option provided to the hematologic oncologists for ordering tests. The savings from this endeavor now exceed $800,000, just in unnecessary laboratory tests, mostly the molecular ones. In microbiology, the diagnostic management team played a major role in bringing an end to the recent national fungal meningitis outbreak associated with Aspergillus contamination in prepackaged syringes of methylprednisolone. Leaders of that DMT were asked by the New England Journal of Medicine to prepare a publication to document how the diagnostic information came together. The transfusion medicine DMT actively pursues errors related to transfusion in real time and includes all of this value-added material in the patient’s chart. Vanderbilt’s coagulation DMT has taken pages of numbers that are usually incomprehensible to physicians and turned them into paragraphs that everyone caring for the patient can understand. The provision of the diagnostic report through the coagulation DMT has resulted in a shortened length of stay for patients with pulmonary embolism, and these savings are substantial to the institution. In endocrinology, Vanderbilt is currently providing patient-specific information about endocrine-associated hypertension, with plans to provide similar information on a wide variety of endocrine disorders. Neuropathology has recently begun to synthesize genetic information, radiographic information, and histopathology for patients with gliomas. Importantly, there is no additional payment for the synthesis of all the diagnostic information, but this is the most valuable report for the physician caring for the patient and leads to the large cost savings. Information scientists are also linked to the diagnostic management team so that anyone on the diagnostic management teams can receive an answer from someone who has searched more than 60,000 medical journals and provided an evidence-based answer to a question in a DMT within 12 hours.
The danger of reducing only what we can measure in the clinical laboratory
The percentage of health care spent on laboratory tests is only 3%. If the total operating budget for a hospital is $3 billion, and if 33% of all the technologists and all laboratory supplies were eliminated, this massive cut would only save one cent on the dollar and reduce the total operating budget of that hospital to $2.97 billion. If on the other hand, lab tests were used more appropriately and a rapid and accurate diagnosis was achieved more often, resulting in fewer complications and better outcomes, the total operating budget of the hospital could be markedly reduced – in this example, to a number much lower than $2.97 billion. This would result in a savings while improving clinical outcomes, something which is extremely hard to do. The bottom line is that if you or a loved one are seriously ill with an unknown diagnosis, you want an expert in the field with current knowledge directing your diagnostic evaluation in real-time and explaining it all to you. This is the diagnostic management team, and it needs to serve all those in need and not just those in institutions where DMTs exist.
Laposata M and Dighe AS. ‘‘Pre-pre’’ and ‘‘post-post’’ analytical error: high-incidence patient safety hazards involving the clinical laboratory. Clin Chem Lab Med 2007;45:712–719
Laposata ME, Laposata M, Van Cott EM, Buchner DS, Kashalo MS, Dighe AS. Physician Survey of a Laboratory Medicine Interpretive Service and Evaluation of the Influence of Interpretations on Laboratory Test Ordering. Arch Pathol Lab Med 2004; 128: 1424-1427