Daniel F. I. Kurtycz, MD
George Birdsong, MD
Mohiedean Ghofrani, MD
Keith Kaplan, MD
January 2017—Complaints about laboratory information technology services are nearly universal. Rare is the person who is happy with his or her laboratory information system or with the way information services are delivered. That so few of us describe ourselves as content with multimillion dollar systems is remarkable. Here we explore reasons for the dissatisfaction in hopes of identifying issues that can be addressed and prompting discussion.
The LIS is a complex construct of hardware and software, seldom described as seamless, intuitive, and pleasant to use, save by people trying to market them. IT staff are the buffer between the laboratory professional and the complexity of the LIS, but the relationship between the IT staff and laboratory staff is often rough and at arm’s length. Laboratory professionals may wonder if the IT staff and their leader are subject to the same pressures and bear the same responsibility to the patient as the rest of the laboratory. Since the clear answer is that, yes, they are ultimately responsible to the patient, then it stands to reason that the IT service and the LIS it maintains should be subject to peer-reviewed validations and quality improvement measures like the rest of laboratory practice.
Casual conversations about the interaction between laboratory staff and IT staff generate a lot of interest and have spawned events at professional meetings, such as the roundtable discussion by cytotechnologists and pathologists at the American Society of Cytopathology annual meeting in November 2015. What contributes to the rough edges in the laboratory-IT relationship? What hinders information delivery, worker satisfaction, and patient care?
To explore a large problem, it helps to look at its components—in this case, system administration, system technology, and the people. We cannot in this space raise all of the difficulties but we can raise a few. For one, the administration of LIS services is often carried out by an institutional IT group, not laboratory administration. IT priorities are thus set by bodies other than the laboratory, and the laboratory’s needs are often in a queue of tasks. IT staff often report to people outside the laboratory, with a blurring of the chain of responsibility for patient results and accountability for laboratory function.
Who controls the budget? During the discussion at the ASC meeting, some of the participants said their laboratories were assessed for IT services as a part of overhead but that the laboratories had diminishing input in directing the activity of those services. IT costs are generally divided among various departments by the percentage that administration views as reasonable, and the departments are charged accordingly. This was reported to be in addition to charges levied against the department for consultation, projects, and help desk use. Participants said they were frustrated by charges they can’t regulate but that appear on their balance sheets.
In instances in which the laboratory administration controlled IT, discussants felt it was easier and far more useful to train a laboratorian to service the LIS than to bring an IT person into the laboratory. When a member of the IT staff reports to institutional administration rather than to the laboratory, alienation from the lab is accentuated because administration will not see the need to allot time to train the IT person in laboratory procedure and culture. Some IT staff members will feel conflicting loyalties between central information services and the laboratory department they serve.
The missions of the IT and laboratory staffs are different. The laboratory tends to be patient centric and responsive to the needs of people on the floors and in the clinics. IT specialists are buffered from interaction with physicians and nurses who need to obtain information from the laboratory. The IT specialist’s job is to maintain a stable and secure information system. His or her aim is to keep the LIS awake with all of its inputs and outputs flowing and prevent security breaches in a hostile Internet-connected environment. Any change to the LIS can disrupt function and has to be carefully weighed, no matter how much the laboratory wants it. The more complex the system, the harder it is to ensure that changes will not be disruptive.
IT specialists rarely have medical training, and certifications are distant from any American Society for Clinical Pathology or American Board of Pathology examination. They’re likely to be computer science majors who found or placed themselves in hospitals and other health care settings because an IT position was posted and they answered the ad. Fair or not, laboratory staff may see them as replaceable cogs without medical or laboratory knowledge, who could just as well support applications used in manufacturing and banking.
The reasons for the gulf between information specialists and the laboratory are not one-sided. Many laboratory staff members lack computer skills, are technophobic, or just push back in the face of progressive (some would say oppressive) computer control—and this is not always a factor of age. It can lead to situations in which the laboratorian has a problem, asks for help, and cannot even adequately describe what’s needed. We do have a subset of workers who are technology enabled and who seem to enjoy IT, but most in the lab do not fit that description. If a worker demonstrates proficiency with computer-based tasks, they’re often rewarded with more work, as administrators believe they can kick productivity up another notch.
Participants in our ASC roundtable perceived training opportunities in laboratory computing to be declining. Many were hard-pressed to recall recent offerings by professional societies or residencies with informatics programs.
They recalled many efforts in the 1980s and 1990s to encourage the development of skills in pathologists and other laboratory professionals, among them CAP conferences led by the late William R. Dito, MD, who was famous for his presentations on then state-of-the-art informatics. Such training opportunities became fewer as laboratory information systems became more complex, in the view of the roundtable participants. While there are a few fellowship programs for laboratory informatics, general training in informatics for laboratory professionals is seen to be waning. Participants could not recall any informatics-related questions on the ABP or ASCP registry exams. This may make sense if economics are considered: Salaries for pathologists are much higher than for information specialists, so an administrator or department chair is not going to want a pathologist to spend his or her valuable time involved with the computer. Information specialists get paid about a third more than medical technologists and significantly more than technicians.
Responsibility for the information system is tending to leave the lab. Long ago, the laboratory director or a designee had control and direction of the information system. Today, even the laboratory director has to submit a request ticket for any change or customization, and the request will go into the prioritized queue. Even modifying a synoptic report can become a non-trivial task in an IT system’s bureaucracy. Few laboratory directors have superuser status in the current age.
Dissatisfaction in the laboratory pales in comparison to our clinical colleagues’ dissatisfaction with electronic health records. Buying systems with government money was relatively easy; integrating them into health care has proved to be more difficult. The American Medical Association conducted a study with Rand Corp. on the major sources of physician discontent with the state of medicine, and one of the major sources of discontent centers on the quality and usability of current EHR systems. The culprits: problematic user interfaces that are time-consuming and inefficient and systems that are unable to transfer information from one application to the next. The study found frustration with template-generated notes, degradation of documentation, and the expenses associated with buying and supporting EHRs. Query any Web browser about the relationship between physicians and EHRs and you will find pages of negativity.
In the laboratory, it used to be that when you purchased a software system it was complete. It was during implementation that you modified it to some degree, but it was essentially a finished product. You consulted with other users and bought the system that had the best reputation. With some modern systems today, there’s an alternative approach. The company may not come with an established, firmly grounded system. It has general modules and a build team, and the company expects the client to create a build team of its own. The resultant quality of the system is proportional to the quality of both build teams. The software company usually comes to the institution’s door with young, bright professionals who may not have had much laboratory experience but who understand computers well. The build team the laboratory has to create takes people away from their daily work. The company wants your best people, and because the outcome depends on the quality of the teams, you had better give them your best. But the laboratory’s productivity may suffer in the interim.
These problems will have to be solved in the future and doing so is dependent on complaints and competition. The systems will not get better unless there is pressure to make them so. To administrators, the popularity of many of our current computer systems is secondary to their ability to capture every chargeable action, and one of the reasons users dislike them is that someone has to key each one of those actions. For every bean to be counted, someone has to register it. Information entry has to be improved. The companies that construct EHRs and LISs should sit at the feet of design engineers like Jonathan Ive of Apple and bend their talents toward ease of use. Perhaps some of those billions of dollars the federal government is spending could be directed to a competition between companies for the production of usable systems. A resumption of training of bench workers in the functions and nature of the LIS is unlikely unless there is economic pressure to do so. More likely is that IT specialists engaged in laboratory work could be required to take courses in clinical laboratory function. We could suggest that CAP accreditation checklists incorporate common-sense requirements on system ease of use and information transmission, but they may have to be dependent on revisions to the Affordable Care Act and meaningful use requirements. We should gather data, in part by asking people what they need and what’s missing, and generate policy changes that could improve laboratory practice.
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Dr. Kurtycz is a member of the CAP Cytopathology Committee, and Dr. Birdsong, Dr. Ghofrani, and Dr. Kaplan are former members of the committee. Dr. Kurtycz is a professor in the Department of Pathology at the University of Wisconsin and medical director of the Wisconsin State Laboratory of Hygiene; Dr. Birdsong is director of anatomic pathology, Grady Health System, and a professor of pathology and laboratory medicine, Emory University School of Medicine; Dr. Ghofrani is with PeaceHealth Laboratories, Vancouver, Wash.; and Dr. Kaplan is with Carolinas Medical Center, Charlotte, NC.