Many clinical decisions are based on laboratory test results. The rapidly expanding number and complexity of these tests present physicians with many challenges in accurately and efficiently ordering and interpreting diagnostic tests. Diagnostic errors affect 5% of US adults who seek outpatient care each year, and contribute to approximately 10% of patient deaths and 6 to 17% of hospital adverse events. The 2015 Institute of Medicine report, Improving Diagnosis in Health Care, highlighted diagnostic errors cause patient harm and that improvement in the diagnostic process requires collaboration among physicians and laboratory professionals. We investigated the interactions between physicians and laboratory professionals to understand why physicians might not collaborate with laboratory professionals when facing diagnostic challenges and to identify opportunities for laboratory professionals to become a more integral part of the clinical care team. Our report identifies pathology laboratory professionals, which includes pathologists, board-certified doctoral-level directors, and other laboratory professionals in technical and management positions, as critical to diagnosis but insufficiently engaged as full members of the diagnostic team. These US medical laboratory professionals possess a wealth of knowledge that would be valuable in consultation with physicians to improve diagnosis.
To assess how laboratory professionals could be better integrated into the clinical care team, the Centers for Disease Control and Prevention’s (CDC) Clinical Laboratory Integration into Healthcare Collaborative (CLIHC™) surveyed family medicine and general internal medicine physicians. The survey was designed to gain insights into their uncertainty and challenges in ordering clinical laboratory tests and interpreting results and identifying solutions for improvements. The survey revealed physicians are uncertain in ordering diagnostic tests in 14.7% of patient encounters and in interpreting test results in 8.3% of encounters. With millions of visits to primary care physicians each year, this amount of uncertainty raises serious concerns about the efficacy of laboratory testing resources and supports the magnitude of diagnostic errors. The survey also revealed only 6% of physicians contact laboratory professionals at least once a week, primarily for technical questions, such as status of missing results, preliminary test information, and assistance regarding sample collection. Even though laboratory professionals possess the most knowledge about laboratory tests and their use, consulting with them was the least used tactic to address uncertainty in ordering and interpreting laboratory tests. These findings suggest that laboratory professionals have some work to do in order to improve their image since physicians ranked them almost the least useful source of information about new laboratory tests. Only laboratory sales representatives were ranked lower.
Why don’t the majority of physicians contact laboratory professionals when facing diagnostic questions? It’s not because they would obtain unreliable information, but because of the challenges in the ordering process. Physicians considered it too difficult and time consuming to order tests and often did not know whom to contact. Only 20% of them have found an effective way to access laboratory professionals. They rarely ask laboratory professionals about medical significance of results or what to do for follow-up testing.
Physicians in our survey provided some insight into what laboratory professionals can do to help them when facing challenges in clinical laboratory test ordering. Physicians reported using both electronic and paper-based references for helpful information. While a majority of physicians surveyed had a computerized physician order entry (CPOE) available to them, only 11% of the CPOEs had electronic suggestions for appropriate ordering. Laboratory professionals in collaboration with information technology specialists can develop mobile applications and electronic health record (EHR) systems that have clinical decision support guides for appropriate laboratory test ordering. Diagnostic management teams that include laboratory professionals are collaborative teams that can guide physicians in test selection and result interpretation for individual patient cases. Multidisciplinary rounds are also other ways to improve the collaborative process. Physicians who reported having professional relationships with laboratory professionals noted these relationships to be a valuable resource when they needed help with appropriate test selection, result interpretation, and complicated diagnoses. Physicians noted that laboratory updates would be helpful and appreciate learning about new tests through training programs.
Healthcare professionals should work together to change the opinion that everyone will have a diagnostic error in their lifetime. We have a better chance to reduce diagnostic errors and improve patient care if the diagnostic process becomes more collaborative with laboratory professionals engaged as full members of the clinical care team.
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