It is common for Clinics to offer Lab services to Patients. More often than not, Labs are externally outsourced by the Clinic, with only the sample collection being done at the clinic. This has a significant impact on the patient experience. They get a 1-window service for Consultation, Billing, Sample Collection, Lab Results, and Report Followup, all without ever stepping out of the Clinic. This trend has caught up with Clinics across the globe, as an additional convenience to Patients which leads to both repeat business and an extra source of revenue for the Clinic.

While the trend of In-House Labs has caught on, Clinic Management Systems have not caught up in their support of this service. Traditional EMRs stop themselves at the point of letting the practitioner record Lab results, while the traditional LIMS (Lab Information Management Systems) is an overkill – too complex and bloated to use for the requirements of an Internal Lab workflow.

This article specifically focuses on running an In-House Clinic Lab which outsources its back-end. If a clinic opts to offer this service, it needs to also ensure that it is not stuck to pen or paper or plagued by a nagging fear of medico-legal issues in spite of having things digitized. Lab Results should not fall into the crack. Adverse results even one that came in years ago should be able to generate an audit trail of what actions were taken at the Clinic once the results came in. Human negligence should not be a factor in ensuring every result is looked into, and a decision is required to be taken on each, without which the result cannot just get lost. This article will cover such best practices and more for In-House Labs. It is these best practices that should have support in the Clinic Management System being opted for.

1. Ordering Investigations
This is the first step toward investigation management. A Practitioner during the course of a Consultation may order some investigations from the EMR. Once the investigation is ordered the same should be notified to the Lab Technician in charge of the Clinic laboratory. This process “must” be automated to ensure that the Lab is always fully synced with what is happening during the Consults. Leave no chance of a human error.

On the contrary, if all a software does is generate a printout for the patient to take to the In-House Lab, it requires re-entry of the data already written out once in the EMR, which can lead to typo errors, extra work, and extra wait for the Patient. Billing is also then not integrated into what is happening with the Patient. It is just too painful to not have this basic level of automation.

 

2. Collection of Sample
The person collecting the Sample is generally different to the person doing the test and recording the result. So first and foremost, “Collecting the Sample” should be available as a step on its own.

Next, the accessibility of a sample collector is usually restricted. They usually do not have permission to see the results of the sample he collected. Check if this Chinese wall exists in the system being evaluated.

Then, there can be two ways in which a sample might be collected-
(a) The patient is in the Clinic and simply walks up to the Lab desk to give the sample;
(b) The lab technician visits the patient to collect the sample.

In either of the cases, the technician collecting the sample should be able to bag it, only after identifying clearly and labelling the sample. This is best done by putting on Barcode stickers on the box or vial in which the sample has been collected. So support for barcode stickers is required.

What do the Barcodes contain in it? They are sample reference numbers – a number that uniquely identifies the patient and investigation order details. These barcodes can be read by any standard 2D/3D Barcode Scanners that are available on Amazon. If the back-end is outsourced to an external Lab, a bunch of barcode stickers will be provided by them to be used as and when required. In such cases, the sticker is put on the box first, and then the sticker’s reference number is scanned in the system (using a barcode scanner) against the patient’s test, thereby creating a map between the external barcode and the test ordered in the system. Alternatively, if the respective backend Lab does not provide such stickers, check if the system can get these barcodes auto-generated. A good one will, as identification of the Sample, and eliminate even the possibility of human error.

The next few steps happen outside of the clinic. Therefore they are mentioned only for the sake of completeness and do not need support in the clinic. Let’s review these steps quickly:

• Once a sufficient number of samples have been collected, the external Lab will collect the same from the clinic for processing.
• The Pathologist or Radiologist will then actually do the test at the External Lab
  Once done, they will record their findings and observations at their end.
• They will then transmit the results to the lab electronically or by email or as a paper report.

The next step will cover what should be done once the results are received from the external Lab.

 

3. Recording of Result
The Lab technician has got the test done. Now it’s time for him to record the findings and observations for the Practitioner to review.

The result can be recorded by manually typing it in, or by uploading as an attachment the report received from the external Lab into the Clinic Management system being used, or by way of direct integration between the system EMR and the external Labs’ IT system. Either option is fine, but the clinical management system being used must support all 3 options. This is because while direct integration would be the best and easiest approach, it is not readily available from all lab vendors, so, the option to type in manually has to exist, and since manually typing can quickly get overwhelmed as the no. of patients availing of the service increase, the option to bypass manual work and simply attaching the scanned lab report must also be available So ask for support for all of the 3 workflows.

Once the results are recorded, the next step is to get the result reviewed by the Practitioner.

 

4. Review of Result
The workflow should prevent a single result from slipping through any cracks till it’s reviewed. Every result that has been recorded by the Technician must be signed-off by the Practitioner. And here too the decision-making process for the Practitioner has to be made simple. Options should be in binary
a. Either call the Patient in for a follow-up – in case of a borderline or adverse result OR;
b. Archive the result by marking it as NDA – “No Abnormality Detected”.

If the process is set up in this manner, it will compel the Clinic Staff to get each result reviewed and take action accordingly. When the above-mentioned process is managed through software, a digital trail of a specific individual result even from years ago, can be extracted by the Clinic in a click, should they ever be questioned or audited on the same.

 

5. Follow-Up:
This is the final step of Investigation Management. Every result the Practitioner has reviewed and not marked as NAD must be followed up. The follow-up is usually done by a Nurse based on the instructions provided by the Practitioner. The Nurse should ideally try to call the Patient, followed by email, and if all fails they should send out a postal mail at the registered address of the patient, to schedule another appointment.

While all of this may also not result in the patient confirming an appointment, these activities will be very important, should the clinic ever get questioned on the efforts made by it for a positive report on cervical cancer from an infrequent patient who sues the clinic after 5 years, and her lawyer questions the clinic in a legal notice, “what did you do once the Pap smear report came in positive for my patient?” The clinic should at that point be able to dismiss such suits by generating a complete trail of what was done, provided a decent system was in use for management.

Moreover, the results being recorded in the lab, should also be auto-synced on the Patient’s chart and get updated in the Medical Summary.

 

6. Bonus Point – Walk-ins
When maintaining in-house labs, it is common to also get walk-ins who have come in without having made an appointment for the consultation. To handle such walk-ins, it is necessary to have the ability to generate an order for them on the fly and bill them for the specific set of Investigations they need. Please double-check that the ability to handle walk-ins is also supported by the system being considered for clinic management purposes.

 

Final Note
To sum it up, while migrating to a new system, or moving on from pen and paper, opt for a system that is modern, current and reflective of the needs of today. Yesteryear software systems may be good but they often tend to not reflect the shifting ground realities. So do check and see before taking a leap jump – if running an in-house Lab, check support for these 5+1 best practices in the system being considered for managing In-House Labs.

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