Brain to Brain CycleBrain to Brain Cycle
Dr. Bill BartlettDr. Bill BartlettConsultant Clinical ScientistConsultant Clinical Scientist
Dept Clinical Biochemistry & ImmunologyDept Clinical Biochemistry & Immunology
Heart of England NHS Foundation TrustHeart of England NHS Foundation Trust
Birmingham B9 5SSBirmingham B9 5SS
Our Business: -Our Business: -
Information Information ManagementManagement
Knowledge Knowledge ManagementManagement
MeasurementMeasurement
Importance of Laboratory Importance of Laboratory MedicineMedicine
70 to 80% of decisions in diagnosis based on 70 to 80% of decisions in diagnosis based on laboratory outputs.laboratory outputs.
70 – 80% of the interactions of health care 70 – 80% of the interactions of health care professionals involve laboratory outputs.professionals involve laboratory outputs.
Our Work and the Our Work and the QualityQuality of Our Work of Our Work Under pins the Delivery of High Quality Under pins the Delivery of High Quality
Health CareHealth Care
What do we do for a living?What do we do for a living?
We save lives.We help diagnose, monitor & treat diseaseWe screen for diseaseWe carry out and support R&DWe teach
How do we do these thingsHow do we do these things
We Measure
We Use Our Brains & We Use Our Brains & Help Others User use Help Others User use TheirsTheirs
We Use Our Brains & We Use Our Brains & Help Others User use Help Others User use TheirsTheirs
What Is It?What Is It?
Phrase was first used by George Lundberg Phrase was first used by George Lundberg in the context of laboratory testing.in the context of laboratory testing.– (JAMA 1981:245:1762-1763)(JAMA 1981:245:1762-1763)
Refers to a process that ideally links a Refers to a process that ideally links a clinical problem to an clinical problem to an appropriateappropriate action, action, taken on the patients behalf, based on the taken on the patients behalf, based on the results of laboratory tests. results of laboratory tests.
Question - Answer - Interpretation -Action.Question - Answer - Interpretation -Action.
KnowledgeKnowledge
Information Information Processing & Processing &
FlowFlow
Data IntegrityData Integrity
Appropriate Appropriate Pre-analytical Pre-analytical
ProcessesProcesses
Appropriate Appropriate Analytical Analytical ProcessesProcesses
Appropriate Appropriate Post-analytical Post-analytical
ProcessesProcesses
I don’t feel well Doc!What is the nature andcause of his disease?
•Ask the right questions.
•Interpret the answers.
•Collate the information.
•Arrive at working diagnosis.
•Request: -
•Pathology
•Radiology
•Other Opinions
•Admit?
•Wait
The Process: -
?INPUT•Information•Samples
AnalyticalPhase
Output•Information•Questions
Pathology: Request to Result
What is the Process
Request
Sample
Transport
Pre Analytical
Analytical
Validation
Interpretation
Report
Apply Output
9 Steps
Pre - Analytical
Analytical
Post -Analytical
Phases
Value in Understanding the CycleValue in Understanding the Cycle manage the process to reduce complexity.manage the process to reduce complexity.
remove the choke points, consolidate and automateremove the choke points, consolidate and automate
become pro-active in helping clinicians to: -become pro-active in helping clinicians to: - use the laboratory services appropriately.use the laboratory services appropriately. use the product of the process which is information.use the product of the process which is information.
How will managing the cycle impact on How will managing the cycle impact on healthcare?healthcare?
Delivery of a more efficient diagnostic Delivery of a more efficient diagnostic process:process: - -– better targeting of resourcesbetter targeting of resources– shorter bed stays?shorter bed stays?– faster processing of patients?faster processing of patients?
Brain to Brain CycleBrain to Brain Cycle
•Complex.Complex.
•Applies to every requestApplies to every request
•Every cycle results in costs outside of Every cycle results in costs outside of pathology (e.g. longer bed stays?)pathology (e.g. longer bed stays?)
• Any error reinitiates cycleAny error reinitiates cycle
• Information flows and accuracy are Information flows and accuracy are critical.critical.
•Complex analytical processes = timeComplex analytical processes = time
• Repeat cycles = cost!Repeat cycles = cost!
• Need to use information generated. Need to use information generated. Failure to do so = unnecessary costFailure to do so = unnecessary cost
• Wrong results or misinterpretation Wrong results or misinterpretation = cost= cost
Managing the CycleManaging the Cycle
How do we dispose of the complexity How do we dispose of the complexity and increase effectiveness?and increase effectiveness?
•Direct skills into value added Direct skills into value added
processes.processes.
Diagram Courtesy of Dr CG Fraser, Dundee
•Intelligent RequestingIntelligent Requesting
•Provide informative reports, to Provide informative reports, to
the right place, in the right time the right place, in the right time
frame.frame.
•Understand Process and simplify
•Deal with the Analytical AneurysmDeal with the Analytical Aneurysm..
Requesting & ReportingRequesting & ReportingThe Key to a Patient Focus?The Key to a Patient Focus?
Need to help users: -Need to help users: -– Ask the right questions.Ask the right questions.– Provide the right inputs.Provide the right inputs.– Apply the outputs effectively.Apply the outputs effectively.
We need to: -We need to: -– deliver the required outputs to the right deliver the required outputs to the right
place within the required time frameplace within the required time frame..
To Be Effective We Need To To Be Effective We Need To Ensure That: -Ensure That: -
the correct questions are asked.the correct questions are asked. the correct inputs are provided.the correct inputs are provided.valid analytical processes are applied.valid analytical processes are applied.useful outputs are delivered in an useful outputs are delivered in an
appropriate time frame.appropriate time frame.our outputs are applied effectively.our outputs are applied effectively.
Asking the right questions.Asking the right questions.
Requestors have varying degrees of knowledge, Requestors have varying degrees of knowledge, experience, expertise. experience, expertise. (Nurse/Pharmacist/Doctor).(Nurse/Pharmacist/Doctor).
Tools: -Tools: -– Brain - limited capacity/ exposureBrain - limited capacity/ exposure– Books, Journals - VolumeBooks, Journals - Volume– Protocols (NSFs) - VolumeProtocols (NSFs) - Volume– Triage systems – Presentation panels (Headache, gut Triage systems – Presentation panels (Headache, gut
ache etc, chest pain)ache etc, chest pain)– Expert systemsExpert systems
Additional inputs, previous results, Hx, RxAdditional inputs, previous results, Hx, Rx
User EducationUser Education
Less emphasis on laboratory medicine in Less emphasis on laboratory medicine in medical curriculamedical curricula
Exponential rise in the size medical Exponential rise in the size medical evidence base.evidence base.
Fewer people with increased demands on Fewer people with increased demands on their time.their time.
More protocol driven processes required?More protocol driven processes required?
Evidence into practice?Evidence into practice?
Job of the lab Job of the lab medicine specialist to medicine specialist to work with clinicians work with clinicians to turn evidence into to turn evidence into practice.practice.
Take the evidence Take the evidence and build it into the and build it into the requesting interface.requesting interface.
Integrate systems Integrate systems with expert systems with expert systems
Electronic/Intelligent Electronic/Intelligent RequestingRequesting
Accurate flows of information.Accurate flows of information. Time efficient.Time efficient. Linking requesting with results.Linking requesting with results. Linking requesting with care pathways.Linking requesting with care pathways. Ability to see outstanding requests.Ability to see outstanding requests. Building in protocols and links to information Building in protocols and links to information
sources.sources. Enable the partially informed requestor.Enable the partially informed requestor. Closing the loop between electronic systems.Closing the loop between electronic systems.
Big Expensive UserBig Expensive User
And for my next And for my next request, I would request, I would like to tick all the like to tick all the
boxes.boxes.
What’s in a Request?What’s in a Request?
Decide what is to be measuredDecide what is to be measured
Decide in what sample to measure it, (blood, Decide in what sample to measure it, (blood,
urine, faeces, tissue, CSF, etc)urine, faeces, tissue, CSF, etc)
Apply knowledge about the stability of the Apply knowledge about the stability of the
analyte (requirement for sample stabilisers, analyte (requirement for sample stabilisers,
preservatives, cold transport etc)preservatives, cold transport etc)
Decide where to sample from (e.g. arterial versus Decide where to sample from (e.g. arterial versus
venous sampling, swabs from which areas to venous sampling, swabs from which areas to
identify infections)identify infections)
What’s in a Request?What’s in a Request?
Identify the most appropriate time to take the Identify the most appropriate time to take the sample (knowledge of biological rhythms, sample (knowledge of biological rhythms, effects of drugs on analysis, effects of feeding effects of drugs on analysis, effects of feeding on analytes (e.g. blood glucose))on analytes (e.g. blood glucose))
When to involve and inform the people who When to involve and inform the people who know how to measure the analyteknow how to measure the analyte
Initiate the request for analysisInitiate the request for analysis Take the appropriate samplesTake the appropriate samples Ensure that the samples and relevant Ensure that the samples and relevant
information are passed to the laboratoryinformation are passed to the laboratory
Pre - Analytical
Analytical
Post -Analytical
Phases
Requesting ModuleRequesting Module
WardWardWorkWork
StationStation
LabLabWorkWork
StationStation
Intranet/WebIntranet/Web
PASPASNHS No, DoBNHS No, DoBNameName
Pathology 01 Ice Pathology 01 Ice ServerServer
SQL RequestsSQL Requests
SQL ResultsSQL Results
Haematology
Blood Bank
Chemistry
Cell Path
Microbiology
Immunology
TTeelleeppaatthh
PPaatthhoollooggyy 0011
GGTTEE PPAASS
FTPFTP
TELNETTELNET
Hard Copy & Hard Copy & Bar codeBar code
GPGPWorkWork
StationStation
GP Clinical GP Clinical SystemSystem
ICE ClientICE Client
Hard Copy & Hard Copy & Bar codeBar code
PDFPDF
Web/VPNWeb/VPN
Hard Copy & Hard Copy & Bar codeBar code
Pre - Analytical
Analytical
Post -Analytical
Phases
Pre-analytical PhasePre-analytical Phase
Critical PhaseCritical PhaseGarbage in Garbage outGarbage in Garbage outLabour intensiveLabour intensiveComplex ProcessesComplex Processes
– ErrorsErrors– Choke PointsChoke Points
AutomationAutomation
AutomationAutomation
Pre - Analytical
Analytical
Post -Analytical
Phases
Current CapacityCurrent Capacity Heartlands: 6800/hr Chemistry 340/hr immunoassayHeartlands: 6800/hr Chemistry 340/hr immunoassay::
--
Solihull: 1700/hr chemistry, 170/hr immunoassay:Solihull: 1700/hr chemistry, 170/hr immunoassay: -SWA/ Modular PESWA/ Modular PE
*340 tests/h340 tests/h*up to 340 samples/hup to 340 samples/h*50 reagent channels (slots)50 reagent channels (slots)
*3600 electrolytes /hr3600 electrolytes /hr*3200 photometric test/hr3200 photometric test/hr*22- 44 reagent slots per P80022- 44 reagent slots per P800
ISE 900/1800 moduleISE 900/1800 module ISE tests (Na, K, Cl)ISE tests (Na, K, Cl) ISE 900: up to 900 tests/hISE 900: up to 900 tests/hP 800 moduleP 800 module Photometric testsPhotometric tests Throughput: up to 800 tests/hThroughput: up to 800 tests/h 22-44 channels, (reagent slots)22-44 channels, (reagent slots) flexible settingflexible setting
E 170 moduleE 170 moduleImmunology, ECL technologyImmunology, ECL technologyThroughput:up to 170 tests/hThroughput:up to 170 tests/h25 channels (reagent slots)25 channels (reagent slots)
Mass SpectrometryMass Spectrometry
Near Patient TestingNear Patient Testing
What is acceptable performance?What is acceptable performance?
AccuracyAccuracyImprecisionImprecision
– Short/Long termShort/Long termWithin lab/between labWithin lab/between labWithin organisationWithin organisation
Turn around timeTurn around timeFailure ratesFailure rates
Fitness for purpose: -Fitness for purpose: -
How do you assess this? Analytical Goals Method design and validation against goals
– Analytical goals– Clinical decision limits– Reference change values
Practicability Process design and validation against goals
Pre - Analytical
Analytical
Post -Analytical
Phases
Apply Outputs Effectively.Apply Outputs Effectively. Combine information, data and knowledge to provide a Combine information, data and knowledge to provide a
meaningful report to the point of care.meaningful report to the point of care. Enriched reports to aide medics.Enriched reports to aide medics.
– Disease probabilities based on nosologyDisease probabilities based on nosology
– Graphical representationsGraphical representations
– Novel reporting formats based on pattern recognition?Novel reporting formats based on pattern recognition?
– Hyperlinks to data sources decision aides.Hyperlinks to data sources decision aides.
– Automatic referral to areas of expertise Automatic referral to areas of expertise (local/national)(local/national)
Information for patients.Information for patients.
Pacific Knowledge SystemsPacific Knowledge Systems
www.pks.com.au. Tailors the report to the patient
Request
Sample
Transport
Pre Analytical
Analytical
Validation
Interpretation
Report
Apply Output
Traditional focus of laboratory systems
Request
Sample
Transport
Pre Analytical
Analytical
Validation
Interpretation
Report
Apply Output
New systems New systems functionality will functionality will address these areas and address these areas and more (e.g.):more (e.g.): - -
• Integrated lab handbooks• Logistics planning/ordering• Integration with expert
systems• Billing• Document control• Data mining• Knowledge and information
management• Surveillance• AuditWeb Enabled.
The BeginningThe Beginning
OrOr
The EndThe End
