Breaking Silos and Building Networks in UK Laboratories
Improving patient care through seamless data transfer
Michael Schubert | | Longer Read
Michael Schubert interviews Tom Lewis
At such a pivotal point in healthcare, we are realizing the importance of seamless data sharing between laboratories – but what is getting in the way of this ambition? We speak to Tom Lewis about Getting It Right First Time, the National Pathology Exchange, and how improving the quality of patient care in the UK starts with labs.
What is Getting It Right First Time (GIRFT) and how does it interact with the clinical lab?
The program was started by an orthopedic surgeon who noticed significant variation in approaches to orthopedic surgery across the country – specifically with respect to infection rates after hip surgery. Data in hand, he went around showing people the discrepancies and using them to open up discussion – what constitutes acceptable variation? What is unacceptable?
The key to starting these conversations is not to be dogmatic about “right” and “wrong,” but to challenge people who are doing things differently. He started by designing a data pack from different sources – questionnaires, hospital episode data, national datasets, and more. When trusts come to us for support, we send them their own individual data pack, which benchmarks their responses to the national averages.
Next, we do a “deep dive” – an open discussion about the data with the three clinical leads and relevant stakeholders from the host organizations. It tends not to be a compliance-driven approach and can take you into all sorts of unexpected areas, which is what I like about it. It’s about learning from best practice and, when the approach is at its best, it’s learning from excellence.
On the laboratory side, trusts are of high quality; of course, there is some variation across the country, but it’s marginal. The real variation lies in the pre- and post-analytical phases of the service pathway, which have been neglected because pathologists have traditionally said the pre-analytical phase is not their job. As part of the GIRFT program, we have tried to show people that pathology is an end-to-end pathway – from the moment a decision is made and a specimen needs to be collected to the actions taken as a consequence of the results.
Tell us about GIRFT – its implementation, the reasoning behind it, and what makes it so valuable...
Nowadays, you can’t work in isolation from other laboratories – no lab can deliver all of the testing patients need. We’re moving toward a network model with more formal agreements between labs and more specimens moving between sites. To achieve this, you have to make sure the pathway is seamless; the patient should not see any difference. We should be completelyagnostic about where a test is done; what matters are the test specifications and whether it is undertaken as point-of-care, in a local lab, or sent away to a national or international authority. As a service user, you should be completely blind to that – and, at the moment, there is far too much variation when a specimen leaves the laboratory. This is partly due to timeliness, so the logistics are not great.
The main problem is the integration of requests and results. Many labs still send specimens away with a paper request or receive results on paper, which is slow and labor-intensive because people must transcribe the information on both ends. As a clinician, this worries me. It’s dangerous. We see avoidable transcription errors too often – a risk we should not tolerate. To overcome it, we need to adopt an integrated approach that is connected to the electronic patient record and seamless from order to result.
What successes have you seen so far?
We are a fairly small district general hospital that mainly performs a core set of tests. I believe our focus should remain on that core repertoire, even if we can do other analyses (which we often can), to avoid quality issues. We should send low-volume tests to other labs. This fits the pathology network model that seems to be developing, but involves time and effort to safely request and repeat samples.
The National Pathology Exchange (NPEx) has brought us to the point where nearly all of our biochemistry samples are sent electronically to our largest local laboratory. We immediately felt the benefits of this approach – there was one fewer person required per day for entering results, it’s more cost-effective, and it’s faster. National data laboratories who use NPEx have significantly faster turnaround times than those who don’t.
We don’t have much data on technical safety because it’s difficult to capture such rare events, but the approach is a safer way to avoid transcription errors. We are aware of people who have received life-changing – incorrect – diagnoses based on transcription errors, an avoidable problem we are trying to address.
What challenges might labs face in implementing these new large-scale approaches?
As a clinician, I don’t see a lot of the challenges – I just expect them to be resolved. The initial setup requires someone at both ends (receiving and referring) to understand how NPEx works and how it interfaces with the laboratory information management system (LIMS). Once over that initial hurdle, it is relatively easy to adopt new tests into the system and it becomes business as usual.
Some specialties – particularly microbiology – have been slow to adopt this system. Our results are more complex (or we treat them as such), so mapping within laboratory systems presents a greater challenge than for other fields. Because of this, we have to be imaginative about how results are managed in our system, but most of us don’t have the time, cognitive space, or sometimes even expertise for that kind of innovation.
Genome Mapping Technology Case Study
Frances High explains how she used optical genome mapping to analyze structural variations in a large cohort of patients with congenital diaphragmatic hernia.
Because biochemists understand the results and how LIMS communicate with each other, they are best suited to help us to overcome these challenges. Recently, I spoke to our Lyme disease reference unit about how they might report complex results to us. It was interesting to hear their biochemist talk us through it; she was very aware of the outstanding issues and how we might solve them. All it takes is a willingness on both sides to invest time upfront and listen to each other.
Has the COVID-19 pandemic influenced how you deal with these challenges?
The pandemic has been a major catalyst for our implementing NPEx in microbiology. When it hit the UK in February 2020, there was a clear need to “ramp up” testing, but I was skeptical about our ability to rapidly meet this need. At the start, we relied almost entirely on the larger Royal Devon and Exeter Hospital for testing and, although we still rely on them somewhat, we now deliver a large amount of local testing ourselves. If we compare this to where we stood earlier in the year, we can recognize and appreciate just how far we have come.
Without electronic result management, we could not have had that initial reliance on larger local hospitals – and without NPEx delivering results, the hospitals would not have received our specimens and turnaround times would have been too slow. There was such unanimity of purpose when the pandemic hit that implementation was relatively easy. Within a day, we had NPEx set up and our turnaround times improved significantly – specimens taken in the emergency department in the morning were reported back to our LIMS by midday. We already had good logistics in place but, without NPEx, the necessary testing would have been undeliverable.
COVID-19 has also opened the door for us to consider why we don’t use NPEx for other tests. We should be doing this across the board. There’s no reason for us to deliver less crucial tests – such as chlamydia – on-site but, because they are high-volume tests, it has been easier for us to do them ourselves. There’s always room for improvement and NPEx opens up new ways of thinking about our ability to network, the tests we are doing, where we are doing them, and when.
Are there any tests following in the footsteps of COVID-19?
We have some hepatitis tests following that route, but that might be it for now. Right now, most people are only thinking about COVID-19, so trying to shift the focus to other areas is challenging. We have recently trained a new staff member to help expand our efforts and get back to normal life – or what the new version of normal might be – because we know that, if we invest this time upfront, we’ll see significant downstream gains.
How can programs like NPEx and GIRFT help labs cope with increasing amounts of data?
The increasing amount of data is not a problem – it’s an opportunity. At the moment, data aren’t comparable across the UK, which makes it difficult to set benchmarks; NPEx can help drive a commonality of data structure. We conducted a nursery school data analysis with GIRFT, but we really need people who can extract information and wisdom from large datasets. It would be interesting to explore how NPEx could improve the national data repository as well as data transfer.
NPEx is a new way of working and we do really see it as a non-negotiable – it isn’t a nicety that we should be adding onto the pathway, it is a core essential deliverable. Others will say you need a common LIMS – if you are in the same laboratory network, you are on the same LIMS and the problem is solved. But that’s difficult to achieve and, depending on IT infrastructure constraints, a common LIMS may even be impossible. You can speed this process up by combining existing LIMS (using NPEx as the glue), but it can be frustrating when people believe a common LIMS will be the answer to their problems – and it isn’t.
If labs get on board, what lies in their future?
We hope to achieve a distributed network designed according to function. For instance, you might have a distributed network of national labs that deliver complex testing and a secondary network underneath that of less complex testing, DGH units, and point-of-care testing. NPEx could be the glue for such networks, which rely on the ability to move data around the system.
That didn’t happen with the COVID-19 testing rollout, which might have worked much better if all of our testing capabilities were combined. It would have given us the opportunity and resilience to move data around and to stop seeing the lab as the focus of the pathology service – and, instead, put the patient at the center of our efforts.
Tom Lewis is Consultant Microbiologist at North Devon NHS Trust, Devon, UK, and Pathology Lead for Getting It Right First Time.