Lines of communication: How laboratory ordering can go wrong

Oct. 16, 2019 / By Pam Banning

I recently listened to a laboratory medicine podcast on the need for clinician friendly terms in laboratory testing. They gave various ordering error examples where the assay values provided no clinical benefit. I was stunned by two examples from test utilization studies which intend to identify areas for clinician improvement:

1. The laboratory was following up with the clinician asking why a 1,25-dihydroxyvitamin D2 was ordered (this is not the appropriate assay for routine screening of Vitamin D levels, it is tied to parathyroid hormone activity more than patients’ D stores). The clinician was in an oncology office and asked the staff to order CA-125 to follow up on the cancer marker. He had no idea the 1,25 Vit D2 had been ordered. The staff member searched electronically for “125” and chose the first option in the drop-down menu. This is not the first time I have heard of drop-down menu selection errors.
2. A staff member working in a low-income area clinic was ordering free Prostate Specific Antigen (PSA) as the screening test for prostate cancer.  They thought “free” was a financial indicator rather than the amount of PSA that is not bound to protein. A free PSA test is typically given after, or together with, a total PSA test (which measures both the bound and unbound—i.e. free—antigens). In general, a high total PSA level together with a low free PSA level indicate a risk of prostate cancer that warrants further investigation such as a prostate biopsy. Ordering a free PSA test without having had, or together with, the total PSA test may be counterproductive.

The podcast interview was advocating for the doctors to participate in a grassroots campaign with professional societies to overhaul laboratory names of assays. I’m not convinced that “clinician friendly terms” is the solution here, or that we need to start over in this realm. There are literally millions of volunteer workgroup hours between professional organizations spanning decades, engaged in improving health care. Our team, for example, is encouraged to participate in terminology workgroups. Perhaps I’m getting worn and weathered when it comes to where I focus my work time each week. New workgroups don’t replace prior assignments; they are in addition.

Project and business management basics teach us that the sender is responsible for the receipt of a communication piece. This would put the informal communication of placing a laboratory order on the doctor’s shoulders, “informal” denoting they’re not both in front of the computer at the moment. Verbal or written, it might have been done too casually for the recipient to identify the intent. In the laboratory, quality assurance methods begin with categorizing errors by occurrence pre-analytically (before the laboratory test is run), during analysis (during the test) or post-analytically (in communicating the results). There are many remedies within the clinical-laboratory interface. Pathologists and laboratory directors are encouraged to proactively interact with the client—the clinical staff—via lunch sessions, featured staff meetings, etc. The laboratory spends an inordinate amount of time on portal development, designing screens and menu offerings to assist in correct order entry. The informal communication between the doctor and his staff BEFORE it gets to the lab is a pre-analytical situation; one may wonder how much training medical assistants, physician assistants or nurses have when interacting with the laboratory on the physician’s behalf? Maybe instead of recruiting clinicians to change lab test names, there should be inclusion of office clerks, medical assistants and nursing staff. Or perhaps there should be team building between physicians and the people they task to place their laboratory orders.

There are a variety of campaigns to reduce mistakes in reading laboratory test values and in choosing appropriate testing. Many professional societies are engaged in process improvement within the healthcare industry. The American Board of Internal Medicine (ABIM) Foundation created the “Choosing Wisely” campaign in 2010, after recognizing that 33 percent of U.S. spending on health care is estimated to be of low-value (which could indicate a waste of $750 billion annually). Participating medical societies are challenged with identifying five wasteful or low-value services that should cease. The focus supports open communication between clinicians and patients in ordering the right test on the right patient at the right time. A recently published success story featured a federal qualified health center in Norwich Connecticut called the United Community and Family Services (UCFS). Patient care is provided using a team approach including social work, dentistry and psychology. When integration of “Choosing Wisely” practices started, they realized the need to involve the entire care team, including the medical assistants. By promoting current clinical guidelines, education was spread “vertically” and “horizontally” across the staff make-up. The patients appreciated the open lines of communication (e.g. knowing why the doctor wasn’t going to order a barrage of tests). The practice became more insightful and everyone started thinking more critically.

The right test on the right patient at the right time. What could be more desirable?

Pam Banning, healthcare data analyst with 3M Health Information Systems.