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?

Most equipment manufacturers now offer some kind of hospital information system (HIS) interface with their software but what this primarily means is that they are able to communicate using HL7, which is currently closest thing to a universal communications protocol in the medical field. Although the two systems have the potential to be able to talk to each other, it doesn’t mean that you can just plug your PFT system into an ethernet jack and walk away.

An HL7 interface is like a Swiss Army knife and is capable of transmitting many different types of information in a structured manner but there is, as yet, no standard, off-the-shelf interface that will work for all PFT Labs and all hospital information systems. For labs whose hospital’s HIS systems come from a major vendor there may well be a previously configured interface that will save planning and design time. Having said that HIS systems are often highly customized to a specific hospital and automating the report process in any way is going to make significant changes in existing work flows. The implications of these changes and in what is needed to make them work has to be planned for in advance and is most definitely not something to be coped with after the fact.

Planning for an HIS interface is going to require active participation of your hospital’s IT department and your pulmonary function equipment vendor. Much if not most of the technical negotiations will be between them. The hard reality of time, budget, policies and technical limitations will act as overall constraints to any interface but it’s important to not just sit back and let others make all the decisions. The PFT lab and the patients and physicians it serves are the primary clients in this process and determining many of the operational details of the interface is going to be important to ensure that the most efficient use will be made of it. For all these reasons the lab needs to be persistent in advocating for its own interests and needs to be aware of the consequences of planning decisions.

The most significant decision that is going to need to be made is in what form the PFT test results will be transferred in: ie, as an entire report (PDF or similar format) or as individual data elements (age, height, barometric pressure, FVC, FEV1, etc.). This may seem like a simple decision but it has very far-ranging implications for the entire report management process and so needs to be made carefully.

Using an entire report as the primary element in the HIS interface is probably the easiest way to create and maintain an interface, and for that reason it is also probably the most common approach. This only works however when all of the reports the Pulmonary Function lab creates can be made using only the one vendor’s software. If there are any tests or reports at all for which this is not true, then they will not be able to be uploaded into the hospital’s information system.

An interface using individual data elements is going to take longer to design, longer to create and will be harder to maintain but it’s advantage is that it can be tailored very closely to a pulmonary function lab with complex reporting needs.

Note: There are a number of issues driving rapid improvements in inter-hospital communication. The regulations and standards for this are evolving just as rapidly. At the present time the ability to transmit PFT results as a single report is possible and meets minimum requirements but this is likely to change. A major reason for this is that once information is enclosed in a PDF or other image file it cannot be searched and can only be read by a human. The need to perform searches on patient test results by clinicians, insurers, researchers and automated decision systems is eventually going to make interfaces composed of individual data elements mandatory, not just for PFT Labs but for all clinical departments.

Regardless of which approach is chosen, the same information that is in the final, signed version of a report must be in the hospital information system for both legal and clinical reasons.

The next most significant set of decisions is going to revolve around on-line physician signing. Electronic signing of reports is probably the area where the next biggest potential gain in efficiency can be found and this will be for both physicians and the PFT Lab. There are going to be a number of technological, procedural and policy options and limitations to electronic signing and everybody who has a stake in this process (and this definitely means the physicians) needs to be part of the decision-making.

A framework for managing the HIS interface has to be determined. Something or somebody has to decide when reports are transferred from the pulmonary lab network into the hospital information system. Automated transfer may be a built-in property of the equipment manufacturer’s interface but it may be simpler and perhaps safer to have it triggered by a human. For this reason it makes sense that the Pulmonary Function lab controls the interface and this is mainly because it is the lab that knows when it is appropriate to transfer results to the HIS.

Because there is always a time lag between the time tests are performed and the time a final, signed report is available there is much to be said for being able to upload a preliminary report that contains just the test results. This is a policy issue as much as it is a technical issue, however. Since reports in the hospital information system are part of a patient’s official medical record then if there are going to be multiple copies of a patient’s report then there will have to be an audit trail for all reports. This issue will also apply to the correction of any reporting errors. Because maintaining an audit trail and multiple copies of the same report adds a layer of complexity, this may limit the interface to only the final copy of the report.

Finally, the interface must be able detect that an error has occurred in the transfer process. Most commonly these are due to a mistake in patient identifiers. The interface should be able to log transfer errors and transfer successes. There should be a protocol for correcting errors and re-transferring reports. There will also need to be a process for cross-correlating patient visits and reports to ensure that all visits have reports and all reports have been transferred.

An HIS interface can be a major project that will take time and resources to complete but is very worthwhile. It will allow the entire report management process for your PFT Lab to be revamped and improved, leading to a number of long-term benefits.

When the costs of performing pulmonary function testing is analyzed, report management is usually an ignored component. This may be because costs are shifted to clerical staff in another cost center or because they are just considered overhead. Ignored or not, the cost in employee hours exists and the last time I checked, wages continue to rise, not fall. Any automation of the report management process will permanently reduce the number of employee hours spent managing reports.

Timeliness is just as important a benefit. There is a great deal of concern in effective patient care in all areas of the health industry. Slow reporting reduces effective clinical care and increases its long term costs. Timely pulmonary function reporting will be a factor in improving outpatient patient care and decreasing hospitalizations. Admittedly the effects of timeliness are difficult to analyze so the benefits will have to be taken on faith.

A final benefit is that it allows the pulmonary function lab to do more with either the same or fewer resources. Although trivial in the larger scheme of things, if nothing else substantially less money will be spent on paper and printer ink cartridges. Far more importantly however is that the staff time spent shepherding reports will be reduced, leaving more time for testing.  

PFT Blog by Richard Johnston is licensed under a Creative Commons Attribution-NonCommercial 4.0 International License.