Support Tests.

Elias Peter pheski69 at GMAIL.COM
Mon Jan 25 22:07:14 UTC 2016


This has been a fascinating thread.  

During ~ 4 decades as a practicing family doc, it has always bothered me that results are reported in ways that seem designed to maximize the risk of error. The resistance I have encountered when trying to get my local hospital to do simple things:

Put the key piece of information near the top of the form or in bold. (Why make me scroll several times to the bottom of the page to see the Pap result or the TSH?)
Include margin of error with numeric results (is a PSA of 3.2 really different from 3.6? is an A1c of 7.7 really different from one of 8.1? Can’t tell from the report.)
Separate radiologic findings from radiologic diagnosis from clinical implications in an x-ray report.

There is a great TED talk by Goetz that touches on this:

https://www.ted.com/talks/thomas_goetz_it_s_time_to_redesign_medical_data?language=en <https://www.ted.com/talks/thomas_goetz_it_s_time_to_redesign_medical_data?language=en>

Peter Elias, MD


> On 2016.01.25, at 3:57 PM, Sherri Loeb <sherriloeb at GMAIL.COM> wrote:
> 
> Thanks so all. I am not sure what your mean rob about my American Urological Association comment on my form?
> 
> Anyway, keep up the good work.
> 
> On Mon, Jan 25, 2016 at 2:53 PM, robert bell <rmsbell200 at yahoo.com <mailto:rmsbell200 at yahoo.com>> wrote:
> Thanks Sherri and Lucy. 
> 
> It would seem good to work towards greater standardization nation wide.
> 
> Sherri your American Urological Association comment on your forms may have prevented the problem that I heard about. I wonder how many lab forms have and do not have that statement?
> 
> Also, I notice that different labs use different kinds of forms to report their results. Different font sizes, different additional information, etc. Do these in any way lead to error or prevent error? Standardization here would also be good. But if that does not happen should all forms first tested with say 500 HCPs to see that there are no common errors/misunderstandings that can be easily corrected. Perhaps they are?
> 
> Is the laboratory world represented on the Post IOM diagnostic consortium group? If not that would be valuable.
> 
> Simple things first!
> 
> Rob Bell MD.
> 
>> On Jan 25, 2016, at 12:41 PM, Sherri Loeb <sherriloeb at GMAIL.COM <mailto:sherriloeb at GMAIL.COM>> wrote:
>> 
>> I find this comment particularly interesting considering my husband passed away from metastatic prostate cancer. One he was diagnosed. We noticed that occasionally his psa was ordered as psa screening to check response to chemo and hormone therapy and other times as psa diagnostic. We were told it is exactly the same. From reading this email, it is obviously not the same.
>> 
>> Thanks for the clear explanation.
>> 
>> Sherri Loeb RN, BSN
>> 
>> On Mon, Jan 25, 2016 at 1:01 PM, Knapp, Lucy <LKnapp at peacehealthlabs.org <mailto:LKnapp at peacehealthlabs.org>> wrote:
>> In a word – speaking for the laboratory world – Communicate those needs to your laboratories. As an example, here we have two tests, “PSA, Screening” which has a reference range up to 4 and “PSA, Diagnostic” which also has a reference range of up to 4 but also includes an interpretative comment: “According to the American Urological Association (AUA), serum PSA should decrease and remain at undetectable levels after radical prostatectomy. The AUA defines biochemical recurrence as an initial PSA value of greater than or equal to 0.20 ng/mL followed by a subsequent confirmatory PSA value of greater than or equal to 0.20 ng/mL.”
>> 
>>  
>> 
>> In a prior life – we had 2 tests with different reference ranges, plus a comment on the PSA, Diagnostic. Both options are easily done in an LIS (lab information system).
>> 
>>  
>> 
>> We in the laboratory would love to have better communication from physicians – we want to make your lives easier. So my advice to all the physicians out there is to build relationships with the pathologists and laboratory personnel where you practice. Let us know where improvement is needed to the LIS, you need a new test, you need better sensitivity on a current test – whatever.
>> 
>>  
>> 
>> I’m copying the to our medical director, we are trying to establish better communication with our physicians throughout our system.
>> 
>>  
>> 
>> Lucy
>> 
>>  
>> 
>> Lucy Knapp, MT(ASCP)   |  Technical Specialist, Chemistry  |  Laboratory
>> 
>> PeaceHealth <http://www.peacehealth.org/>  |  400 NE Mother Joseph Place  |  Vancouver, WA 98664
>> 
>> office 360-514-2732 <tel:360-514-2732>  |  fax 360-514-1646 <tel:360-514-1646>
>>  
>> 
>> From: robert bell [mailto:0000000296e45ec4-dmarc-request at LIST.IMPROVEDIAGNOSIS.ORG <mailto:0000000296e45ec4-dmarc-request at LIST.IMPROVEDIAGNOSIS.ORG>] 
>> Sent: Sunday, January 24, 2016 1:56 PM
>> To: IMPROVEDX at LIST.IMPROVEDIAGNOSIS.ORG <mailto:IMPROVEDX at LIST.IMPROVEDIAGNOSIS.ORG>
>> Subject: [IMPROVEDX] Support Tests.
>> 
>>  
>> 
>> I have suggested that at the same time, or even before we tackle Errors in Diagnosis, we see that all our support diagnostic tests (Lab, X-ray, etc.) are in good order so as to help make the correct diagnoses more often.
>> 
>>  
>> 
>> I have been made aware that it is easy to miss a low but rising PSA in someone who has had a past radical prostatectomy.
>> 
>>  
>> 
>> The Lab reports results as ng/mL with a reference range of (0.000 - 4.000). The range for someone with a prostate present. 
>> 
>>  
>> 
>> I asked myself with all the technology is there anything that could be done to prevent such happenings?
>> 
>>  
>> 
>> And then I thought there must be 100s of similar situations when time, disease, surgery, treatments, etc effect lab interpretations - the PSA lab reports on the ones I have seen do not mention that the ranges are for someone with a prostate. Should they?
>> 
>>  
>> 
>> Yes, good clinical skills would help but could the lab with or without technology do anything to help avoid such problems?  Could training or anything else help prevent?
>> 
>>  
>> 
>> I wondered how often this happens - and if you decided to do something about it, could you triage it - presumably not without good error data!?
>> 
>>  
>> 
>> Robert Bell
>> 
>>  
>> 
>>  
>> 
>>  
>> 
>>  
>> 
>> 
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> 
> Robert M. Bell, M.D., Ph.C.
> P.O. Box 3668
> West Sedona, AZ  86340-3668
> USA
> Tel: Fax: 928 203-4517 <tel:928%20203-4517>
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Moderator: David Meyers, Board Member, Society to Improve Diagnosis in Medicine


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