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Rogers KJ, Blau J, Krasowski MD. Evaluating the utility and challenges associated with "unknown" and fictional patients in the electronic medical record. Acad Pathol 2024; 11:100141. [PMID: 39193470 PMCID: PMC11345386 DOI: 10.1016/j.acpath.2024.100141] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/01/2023] [Revised: 04/27/2024] [Accepted: 05/12/2024] [Indexed: 08/29/2024] Open
Abstract
Electronic medical records (EMRs) allow for the creation of "fictional" and unknown patients within the EMR production environment. Surprisingly, there is sparse literature regarding the use cases for these patients or the challenges associated with their existence in the EMR. Here, we identified three classes of patients in regular use at our institution: true fictional patients with medical record numbers (MRNs) used to test EMR functions in the production environment, "confidential patients" used to store sensitive data, and "unknown" patients that are assigned temporary MRNs in emergency situations until additional information can be acquired. A further layer of complexity involving the merging of records for unknown patients once they are identified is also explored. Each class of patients, real or fictional, poses a variety of challenges from a clinical laboratory standpoint, which are often dealt with on a case-by-case basis. Here, we present a series of instructional cases adapted from actual patient safety events at our institution involving fictional, confidential, and unknown patient records. These illustrative cases highlight the utility of these fictional and unknown patients, as well as the challenges they pose on an institutional and individual level, including issues that arise from merging clinical data from temporary MRNs to identified patient charts. Lastly, we provide recommendations on how best to manage similar scenarios that may arise.
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Affiliation(s)
- Kai J. Rogers
- Department of Pathology, University of Iowa Hospitals and Clinics, Iowa City, IA, USA
| | - John Blau
- Department of Pathology, University of Iowa Hospitals and Clinics, Iowa City, IA, USA
| | - Matthew D. Krasowski
- Department of Pathology, University of Iowa Hospitals and Clinics, Iowa City, IA, USA
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Krasowski MD, Hines NG, Imborek KL, Greene DN. Impact of sex used for assignment of reference intervals in a population of patients taking gender-affirming hormones. J Clin Transl Endocrinol 2024; 36:100350. [PMID: 38737625 PMCID: PMC11087993 DOI: 10.1016/j.jcte.2024.100350] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/28/2023] [Revised: 03/19/2024] [Accepted: 04/29/2024] [Indexed: 05/14/2024] Open
Abstract
Background Gender-affirming hormone therapy with either estradiol or testosterone for transgender persons can significantly impact chemistry and hematology laboratory tests. The sex used for assignment of reference intervals (RIs) in the electronic health record (EHR) will influence normal/abnormal flagging of test results. Objective To analyze common non-hormonal laboratory tests with sex-specific RIs ordered in patients with sexual orientation/gender identify (SOGI) field differences (one or more differences between legal sex, sex assigned at birth, and gender identity) in the EHR at an academic medical center in midwestern United States. Methods We utilized a previously characterized data set of patients at our institution that included chart review information on gender identity and gender-affirming therapy. We focused on the subset of these patients that had orders for 18 common laboratory tests in calendar year 2021. Results A total of 1336 patients with SOGI field differences (1218 or 91.2% identifying as gender-expansive; 892 or 66.8% receiving estradiol or testosterone as gender-affirming therapy) had a total of 9374 orders for 18 laboratory tests with sex-specific RIs. Hemoglobin, creatinine, alkaline phosphatase, alanine aminotransferase, aspartate aminotransferase, and high-density lipoprotein were the most frequently ordered tests. For patients taking estradiol, 128 of 970 (13.2%) creatinine and 39 of 193 (20.2%) hemoglobin measurements were within the RI for one sex but not the other. For those taking testosterone, 119 of 531 (22.4%) creatinine and 49 of 120 (40.8%) hemoglobin measurements were within the RI for one sex but not the other. Values above the cisgender female RI but within the cisgender male RI were common for hemoglobin, alkaline phosphatase, alanine aminotransferase, and aspartate aminotransferase in patients taking testosterone. Conclusions Clinicians should be aware of the potential impact of gender-affirming therapy on laboratory tests and what sex/gender is being used in the EHR to assign RIs.
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Affiliation(s)
- Matthew D. Krasowski
- Department of Pathology, University of Iowa Hospitals and Clinics, Iowa City, IA, 52242, USA
| | - Nicole G. Hines
- Department of Pathology, University of Iowa Hospitals and Clinics, Iowa City, IA, 52242, USA
- Carver College of Medicine, University of Iowa, Iowa City, IA, 52242, USA
| | | | - Dina N. Greene
- Department of Laboratory Medicine, University of Washington, Seattle, WA, 98195, USA
- LetsGetChecked Laboratories, Monrovia, CA, 91016, USA
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Tabish N, Monaco SE. Leveraging the laboratory information system for trainee feedback and evaluation in cytopathology. Cancer Cytopathol 2023; 131:542-545. [PMID: 37068069 DOI: 10.1002/cncy.22702] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/09/2023] [Accepted: 03/06/2023] [Indexed: 04/18/2023]
Affiliation(s)
- Nabil Tabish
- Department of Laboratory Medicine, Geisinger Medical Center, Danville, Pennsylvania, USA
| | - Sara E Monaco
- Department of Laboratory Medicine, Geisinger Medical Center, Danville, Pennsylvania, USA
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Sergi CM. Implementing Epic Beaker Laboratory Information System for Diagnostics in Anatomic Pathology. Healthc Policy 2022; 15:323-330. [PMID: 35241941 PMCID: PMC8887670 DOI: 10.2147/rmhp.s332109] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/14/2021] [Accepted: 02/12/2022] [Indexed: 11/28/2022] Open
Abstract
Medicine is expeditiously evolving, and the number of diagnostic opportunities has increased exponentially in the last decade. Electronic medical records (EMRs) have been welcomed in most institutions worldwide following an early period of suspicious behavior. Unfortunately, several cracks dictated the initial approach to hospital systems and leadership incompetency. However, the pathway for a successful decade of EMRs is paved. This narrative review illustrates some principles implementing Epic Beaker software for anatomic pathology in academic medical institutions. Implementing such software improves the diagnostic approach in the division of anatomic pathology because the pathologists can directly access an enormous amount of clinical and radiological information now at their front desk using extremely versatile windows.
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Affiliation(s)
- Consolato M Sergi
- Anatomic Pathology Division, Children’s Hospital of Eastern Ontario, University of Ottawa, Ottawa, ON, Canada
- Deparment of Laboratory Medicine and Pathology, University of Alberta, Edmonton, AB, Canada
- Correspondence: Consolato M Sergi, Tel +1 613-737-7600 x 2427, Fax +1 613-738-4837, Email
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Weaver KD, De Los Santos Y, Gaffar M, Zona MC, Gennaro T, Shenoy A, Flax S, Chamala S, Seifert RP, Esnakula AK. Wrong Tissue in Block. Am J Clin Pathol 2021; 156:700-707. [PMID: 33940603 DOI: 10.1093/ajcp/aqab011] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Abstract
OBJECTIVES Maintaining specimen identity during surgical pathology tissue processing is critical. Epic Beaker Laboratory Information System requires sequential scanning of specimen label and grossed blocks (block confirmation) to ensure specimen identity. We report our institution's experience with wrong tissue in block (WTIB) grossing errors before and after adopting block confirmation. METHODS During the first 18 months of Beaker implementation, block confirmation was not required. We then mandated block confirmation for a 3-month period. To ensure compliance, we then built a "hard stop" feature that prevents scanning any unconfirmed blocks onto a packing list. We reviewed WTIB incidents pre- and postimplementation of these solutions. RESULTS Before using block confirmation, we had WTIB incidents involving 17 (0.043%) of 38,848 cases. When we mandated block confirmation use, we had WTIB involving 2 (0.043%) of 4,646 cases. After implementing the hard stop feature, we had WTIB incidents involving 2 (0.005%) of 42,411 cases. Overall, there was an 88.4% (0.043% vs 0.005%; P < .001) reduction in WTIB incidents using block confirmation with a hard stop. CONCLUSIONS Beaker is a customizable platform that can be tailored to a laboratory's workflow. By using barcoding, implementing custom-built features, and improving workflow protocols, we significantly reduced WTIB errors.
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Affiliation(s)
- Kaitlin D Weaver
- Department of Pathology, Immunology and Laboratory Medicine, University of Florida College of Medicine, Gainesville, FL, USA
| | - Yanel De Los Santos
- Department of Pathology, Immunology and Laboratory Medicine, University of Florida College of Medicine, Gainesville, FL, USA
| | - Maira Gaffar
- Department of Pathology, Immunology and Laboratory Medicine, University of Florida College of Medicine, Gainesville, FL, USA
| | - Melanie C Zona
- Department of Pathology, Immunology and Laboratory Medicine, University of Florida College of Medicine, Gainesville, FL, USA
| | - Tyler Gennaro
- Department of Pathology, Immunology and Laboratory Medicine, University of Florida College of Medicine, Gainesville, FL, USA
| | - Archana Shenoy
- Department of Pathology, Immunology and Laboratory Medicine, University of Florida College of Medicine, Gainesville, FL, USA
| | - Sherri Flax
- Department of Pathology, Immunology and Laboratory Medicine, University of Florida College of Medicine, Gainesville, FL, USA
| | - Srikar Chamala
- Department of Pathology, Immunology and Laboratory Medicine, University of Florida College of Medicine, Gainesville, FL, USA
| | - Robert P Seifert
- Department of Pathology, Immunology and Laboratory Medicine, University of Florida College of Medicine, Gainesville, FL, USA
| | - Ashwini K Esnakula
- Department of Pathology, Immunology and Laboratory Medicine, University of Florida College of Medicine, Gainesville, FL, USA
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Seifert RP, Casler V, Al Qaysi N, Gothi SR, Williams L, Christensen PR, Flax S, Chamala S. Informatics driven quality improvement in the modern histology lab. JAMIA Open 2020; 3:530-535. [PMID: 33623889 PMCID: PMC7886543 DOI: 10.1093/jamiaopen/ooaa066] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/09/2020] [Revised: 09/23/2020] [Indexed: 11/16/2022] Open
Abstract
Laboratory Information Systems (LIS) and data visualization techniques have untapped potential in anatomic pathology laboratories. Pre-built functionalities of LIS do not address all the needs of a modern histology laboratory. For instance, “Go live” is not the end of LIS customization, but just the beginning. After closely evaluating various histology lab workflows, we implemented several custom data analytics dashboards and additional LIS functionalities to monitor and address weaknesses. Herein, we present our experience in LIS and data-tracking solutions that improved trainee education, slide logistics, staffing/instrumentation lobbying, and task tracking. The latter was addressed through the creation of a novel “status board” akin to those seen in inpatient wards. These use-cases can benefit other histology laboratories.
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Affiliation(s)
- Robert P Seifert
- Department of Pathology, Immunology and Laboratory Medicine, University of Florida, Gainesville, Florida, USA
| | - Vektra Casler
- Department of Pathology, Immunology and Laboratory Medicine, University of Florida, Gainesville, Florida, USA
| | - Nada Al Qaysi
- Department of Pathology, Immunology and Laboratory Medicine, University of Florida, Gainesville, Florida, USA
| | - Shaileshbhai Revabhai Gothi
- Department of Computer and Information Science and Engineering, University of Florida, Gainesville, Florida, USA
| | - Leah Williams
- UF Health Medical Laboratories, Gainesville, Florida, USA
| | | | - Sherri Flax
- Department of Pathology, Immunology and Laboratory Medicine, University of Florida, Gainesville, Florida, USA
| | - Srikar Chamala
- Department of Pathology, Immunology and Laboratory Medicine, University of Florida, Gainesville, Florida, USA
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Jacob D, Lal G, Voss DR, Bebber T, Davis SR, Kulhavy J, Sugg SL, Merrill AE, Krasowski MD. Evaluation of switch from satellite laboratory to central laboratory for testing of intraoperative parathyroid hormone. Pract Lab Med 2020; 22:e00176. [PMID: 32923573 PMCID: PMC7476061 DOI: 10.1016/j.plabm.2020.e00176] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/28/2020] [Accepted: 08/17/2020] [Indexed: 11/20/2022] Open
Abstract
Objectives The aim of this study was to evaluate testing turnaround time (TAT) and incision to close time in parathyroid surgeries before and after switching intraoperative parathyroid hormone (PTH) testing from a near point of care location to a central clinical laboratory. Design and Methods This retrospective study covered a ten-year period. Both testing locations used the same Roche Diagnostics PTH immunoassay but on different analyzers. The predominant site for surgeries was the main operating rooms (ORs) in an adjacent building, with a limited number of parathyroid surgeries performed at a more distant ambulatory surgery center (ASC). Under ideal conditions, TAT for near point-of-care testing was 20 min, although multiple factors could increase TAT. Incision to close time from the electronic health record was used to define time of surgery. Results A total of 897 unique patients were identified for which 3031 orders for intraoperative PTH were placed (383 unique patients and 1244 orders after switch in testing site). The average total TAT times for testing (mean ± SD) in the central laboratory were 23.9 ± 16.0 min (median, 22 min) for all specimens, 22.8 ± 7.9 min (median, 21 min) for main OR specimens, and 26.4 ± 7.1 min (median, 25 min) for ASC specimens. Incision to close time for parathyroidectomies showed decreases in mean, median, and standard deviation following testing change. Conclusions Surgery time for parathyroidectomies may remain consistent or decrease if intraoperative PTH testing is moved from a near point of care to a central laboratory. Turnaround around time for intraoperative parathyroid hormone (PTH) analysis in a central laboratory was evaluated. Surgery incision to close times were compared to 514 surgeries with intraoperative PTH performed as near point of care. Pre-analytical factors, especially transport time, were the major variable impacting turnaround time. The mean, median, and standard deviation for surgery incision to close times decreased in the switch to the central laboratory.
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Affiliation(s)
- Denise Jacob
- Department of Pathology, University of Iowa Hospitals and Clinics, Iowa City, IA, USA
| | - Geeta Lal
- Department of Surgery, University of Iowa Carver College of Medicine, Iowa City, IA, USA
| | - Dena R Voss
- Department of Pathology, University of Iowa Hospitals and Clinics, Iowa City, IA, USA
| | - Tami Bebber
- Department of Pathology, University of Iowa Hospitals and Clinics, Iowa City, IA, USA
| | - Scott R Davis
- Department of Pathology, University of Iowa Hospitals and Clinics, Iowa City, IA, USA
| | - Jeff Kulhavy
- Department of Pathology, University of Iowa Hospitals and Clinics, Iowa City, IA, USA
| | - Sonia L Sugg
- Department of Surgery, University of Iowa Carver College of Medicine, Iowa City, IA, USA
| | - Anna E Merrill
- Department of Pathology, University of Iowa Hospitals and Clinics, Iowa City, IA, USA
| | - Matthew D Krasowski
- Department of Pathology, University of Iowa Hospitals and Clinics, Iowa City, IA, USA
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Pathologist Opinions about EPIC Beaker AP: a Multi-Institutional Survey of Early Adopters. J Med Syst 2020; 44:111. [PMID: 32377870 DOI: 10.1007/s10916-020-01574-x] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/13/2020] [Accepted: 03/31/2020] [Indexed: 10/24/2022]
Abstract
EPIC Systems Corporation provides a widely used electronic medical record. Beaker Anatomic Pathology is a newly developed laboratory information system (LIS) that has been implemented at a small number of academic pathology departments. Pathologist opinions of EPIC Beaker AP have not been well described in the literature. A 37-question survey was administered to pathologists and pathology trainees to assess overall satisfaction and efficiency of report generation using Beaker AP. Data about experience in pathology, signout responsibilities, Beaker AP usage, and the legacy LIS was also collected. Seventy-four pathologists (51 faculty, 23 residents) responded to the survey (overall response rate 29.7%). Overall pathologist satisfaction with Beaker AP showed high inter-institutional variability; institutions with legacy LISs with a graphical interface had a generally neutral to negative assessment of Beaker AP. The majority of respondents disagreed with the statement "Beaker AP is easy to use and designed for my needs". Pathologists felt that Beaker AP was useful for reviewing clinical information and billing; areas of weakness included searching for prior cases and grossing efficiency. Overall, pathologists had a neutral opinion of whether generating and signing out a complete report was faster in Beaker AP, with marked inter-institutional variation. This variability was likely due to a combination of the efficacy of the legacy LIS, familiarity with Beaker AP at the time of the survey, and institution-specific optimization efforts.
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Ehlers A, Dyson RL, Hodgson CK, Davis SR, Krasowski MD. Impact of Daylight Saving Time on the Clinical Laboratory. Acad Pathol 2018; 5:2374289518784222. [PMID: 30023429 PMCID: PMC6047237 DOI: 10.1177/2374289518784222] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/23/2018] [Revised: 05/20/2018] [Accepted: 05/24/2018] [Indexed: 12/15/2022] Open
Abstract
Daylight saving time is a practice in some countries and local regions to set clocks forward (typically 1 hour) during the longer days of summer and back again in autumn. Time changes resulting from daylight saving time have the potential to impact clinical laboratory instruments, computer interfaces, and information systems. We analyzed turnaround time data for an academic medical center clinical laboratories (chemistry, hematology, blood gas analyzer, and transfusion medicine), examining how turnaround time was impacted by the daylight saving time shifts in 2017. We also determined whether the daylight saving time shift on November 5, 2017 (“fall back” by 1 hour) resulted in any “absurd” time combinations such as a receipt time occurring “before” a normally later time such as final result. We also describe challenges resulting from daylight saving time changes over a 5-year period. The only significant impact on turnaround time was for clinical chemistry samples during the autumn daylight saving time change, but the overall impact was low. Four instances of absurd time combinations occurred in the autumn time change with only a transfusion medicine example resulting in an interface error (a Type and Screen resulted “before” receipt in laboratory). Over a 5-year period, other daylight saving time impacts included problems of reestablishing interface to instruments, inadvertent discrepancies in manual time changes at different points of the core laboratory automation line, and time change errors in instruments with older operating systems lacking patches that updated daylight saving time rules after 2007. Clinical laboratories should be aware that rare problems may occur due to issues with daylight saving time changes.
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Affiliation(s)
- Alexandra Ehlers
- Department of Pathology, University of Iowa Hospitals and Clinics, Iowa City, IA, USA
| | - Richard L Dyson
- Health Care Information Systems, University of Iowa Hospitals and Clinics, Iowa City, IA, USA
| | - Christina K Hodgson
- Department of Pathology, University of Iowa Hospitals and Clinics, Iowa City, IA, USA
| | - Scott R Davis
- Department of Pathology, University of Iowa Hospitals and Clinics, Iowa City, IA, USA
| | - Matthew D Krasowski
- Department of Pathology, University of Iowa Hospitals and Clinics, Iowa City, IA, USA
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