Category Archives: Lab Management

LOINC, and why it matters to your HIS Interface

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The Hospital Information Systems (HIS) at different medical centers have grown up mostly in isolation from each other. Even when an HIS is installed by a national vendor, each individual hospital has tended to make its own customizations and to follow past conventions. This is changing and it is changing because there are a number of issues driving rapid improvements in inter-hospital communication. The Meaningful Use (MU) Act is major factor and one that has been helping to set the pace, but because improved communication lowers costs and improves the quality of care insurers and medical institutions have been moving in this direction for their own reasons as well.

The regulations and standards for Health Information Exchange (HIE) are evolving rapidly. The overall framework for HIE resides in the Consolidated Clinical Data Architecture (C-CDA) and HL7 messaging protocols. This has given hospitals a unified approach towards managing their communication channels between physicians, clinics, other hospitals and insurers but one problem limiting the usefulness of this has been the different nomenclature used by different institutions for the same pieces of information.

When databases are grown in isolation they tend to end up with labels for data elements that are idiosyncratic and unique to each medical center. There needs to be a way to resolve this Tower of Babel and that is what the Logical Observation Identifiers Names and Codes (LOINC) organization is doing.

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Using an HIS Interface as your report manager

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The last several decades has seen a complete transition to the use of computers in pulmonary function testing. This has improved Lab efficiency, but it is also the new baseline. Further improvements in technology may improve the reliability and accuracy of test equipment and test results, but it is unlikely to improve PFT Lab efficiency any more than it already has.

Report management, which is really information management, has started but hasn’t yet completed the same technological transition and it is here that significant improvements can still be made. These improvement will not only improve the efficiency of the pulmonary function lab, but also its clinical effectiveness for the physicians and patients that are the lab’s customers.

To one degree or another most pulmonary function labs are still dominated by traditional reporting systems which are labor intensive and slow. Managing paper reports for a patient visit usually consists of:

  • Patient reports are kept in folders and either a new folder needs to be created or the patient’s existing folders need to be pulled from file cabinets.
  • Printing the test results and then collating the reports with patient’s lab folder.
  • Delivering a stack of reports and lab folders to a reviewer who makes penciled notes on the reports.
  • The stack of reports and lab folders is transferred to a typist who types the interpretation into the lab database.
  • The final reports are printed, collated with the patient lab folders and stack of lab folders and reports are delivered to the physician who then physically signs each report.
  • Reports are photocopied and snail-mailed to the ordering physician and medical records.
  • The lab folders are re-filed.

Not every pulmonary function lab still uses all of these steps to manage reports of course, but large parts of this overall process are often still major components in report management. So why are we still moving paper around when what we really want to do is to move the information that’s on the paper around?

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Marketing your PFT Lab

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A writer posed an interesting question on the AARC Diagnostics forum several weeks ago and that was how to market their PFT Lab. I don’t think they got much of a response but I have been thinking about this since then.

I think that any good lab manager wants to see their lab succeed and grow. I’ve always felt that pulmonary function testing is an essential component of preventive care but that despite this PFT Labs are underutilized. In order to market your PFT Lab effectively you need to understand your customers and target your message accordingly. You also need to understand that you can’t get something for nothing. Marketing requires that you expend resources, whether it is just your time or includes lab budget money, in order to get any payback.

There are three target audiences for your marketing; patients, physicians and administrators. Each audience has a different question you must be able to answer. For patients the question is going to be “why do I need pulmonary function testing?”. For physicians it is going to be “why should I send my patients to your lab?” and for administrators it is “why should I devote resources to your lab?”.

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Should PFT Lab staff be credentialed?

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The issue of PFT staff licensure or certification has recently been a topic of discussion on the LinkedIn Pulmonary Function Studies group and the Diagnostics section of the AARConnect discussion board. The overwhelming majority of those posting comments have been in favor of some form of licensure or certification. CPFT (Certified Pulmonary Function Technician) and RPFT (Registered Pulmonary Function Technician) certification is discussed most often but not surprisingly on the AARConnect board most posters feel that RRT (Registered Respiratory Therapist) certification should be required as well. Continue reading →

QC and the DLCO Simulator

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I’ll start by saying that I am not associated with Hans Rudolph Incorporated in any way. I just think they make a bunch of good products, and more specifically in this case, a DLCO simulator.

For as long as I can remember I have always had intermittent problems with DLCO testing and I suspect that every PFT Lab has had them at some time. One of my current concerns has to do with how our test system’s software is calculating exhaled CO and CH4 concentrations from calibration data, but I’ve had other concerns at other times too. One way around to verify that your test system is actually performing the way it should is biological QC but a more precise way is to use a DLCO simulator.

Every PFT Lab should be performing biological QC (self-testing) regularly (and if you aren’t, why aren’t you?). This is the simplest way to check a test system but it does have limited accuracy. My personal experience for DLCO tests is that there was usually a range of about 1.5 ml/min/mmHg (roughly 5%) within the results from a single testing session and 2.5 ml/min/mmHg within session-averaged results over the course of a year. This is good enough to get a general sense of how well a test system is working but not precise enough to pinpoint specific problems. Used correctly a DLCO simulator can produce highly reproducible and accurate test results.

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Should complete PFTs always be done on a first visit?

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This is not something I have any real influence over because the tests ordered on a patient’s first visit to the PFT lab are going to be determined by the ordering patterns of the referring physician and not by what I think. It’s still a worthwhile question, however.

There are no standards for PFT ordering. There are recommendations from the ATS, ERS, ACCP and NIH regarding patient diagnosis and treatment for a variety of pulmonary diseases and buried inside of them are some guidelines for PFT tests. What I’ve seen, however, is that these guidelines are honored far more in the breach than in their observance. As an example, for asthmatics the NIH recommends spirometry during an initial visit, after asthma has been stabilized, during an exacerbation, after an exacerbation and at least every 1 to 2 years otherwise. How often do you see this guideline followed in more than spirit?

I never used to think about this too much but several years ago I had a long conversation with a Pulmonary lab manager at a tertiary care hospital in Australia. One of the things he said was that all patients newly referred to the Pulmonary division there always had a complete set of PFTs, including post-bronchodilator spirometry, MIP & MEP and an ABG before they even saw a pulmonary physician. The ABG may be a bit of overkill, but since that time I now spend a lot less time on the front lines and lot more time reviewing PFT reports. I have a more global view of patient management (or at least I like to think I do) and I have to wonder if complete PFTs on a first visit shouldn’t be a standard approach.

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Open-access on-line medical journals

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I have been researching different pulmonary function topics for quite a few years. The medical libraries I’ve frequented were, of course, originally all paper-based and to be able to find an article the library or one of the department’s physicians had to subscribe to the journal in question. In the last fifteen years we have all seen an explosion in on-line publishing and it has become much easier to research articles. I vigorously applaud the pulmonary medicine journals (Chest, American Journal of Respiratory and Critical Care Medicine, European Respiratory Journal, Journal of Applied Physiology, Thorax) for having opened part or all of their archives to anybody who wants to search and download articles.

There are a number of other journals, however, that remain entirely behind paywalls. I was reminded of this recently while looking for an article on diffusing capacity from the 1970’s only to find that it would cost me $31 to access it (and then only for 24 hours). Although strictly speaking this does not prevent anyone from accessing these articles, anybody who does has to have deep pockets and this is acting as a significant barrier to the ability of individuals and institutions to obtain and to share information.

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It’s after midnight, do you know where your reports are?

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After the tests themselves, the second most important thing that a Pulmonary Function Lab needs to do is to report results. Like a tree falling in the woods, if a report hasn’t gotten in front of the person that ordered the tests, has anything happened? A successful PFT Lab needs to manage its reports effectively.

An obstacle that many labs will need to overcome is the reporting software that comes with their testing systems. I think that for many of the PFT equipment manufacturers reports are an afterthought at best. The ability to format reports to a specific lab’s needs is often limited and is just as often is a difficult and time-consuming process.

For example my lab maintains approximately eight different report formats, each tailored to the most common mix of tests we perform. If we need to change an item in patient demographics (and we have) then that means that this change needs to be made separately in each of the eight different formats. If this change requires more space on the report and that other report elements need to be moved to accommodate this, then this has to be done on each of the report formats as well. The software has no ability to copy or share changes between report formats (which I am sorry to say is ridiculous since I remember having reporting software in the DOS era where this was possible).

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