Wednesday, November 9, 2011

Innovation and the Medical Laboratory - part 2


Innovation and the Medical Laboratory – Part 2
In the early 19th Century (around 1811-12) a group of textile (artisans) workers became concerned that the use of mechanized looms were going to interfere with their artistry and their profession.  Their employers were using fewer people with lesser capability.  They saw this as an affront to their talent and skill.  Their response was to damage the looms.  

This act of protest was interpreted as a public statement about the broad changes associated with the Industrial revolution.  The British government response was to make an equally public statement about the hazards of interfering with industrial change and either shipped the perpetrators off to Australia or had them executed.  The group (henceforth called a movement) was tagged with the label Luddites (named after another loom destroyer on an earlier age).  

Over the years the term Luddite has shifted from one identifying folks involved in job-protection to a more general concept of resistance to change, with particular reference to resistance to technological change.

I am not a Luddite, in the modern sense.  I am by-and-large an “early-adopter” of new technologies.  But I also watched the impact of a lot of new technologies have done to the medical laboratory. 

My first connections with the medical laboratory were in the late 1960’s when most tests were done manually and with next to no standardization or quality monitoring (read the works of  F.W. Sunderman on Proficiency Testing in the 1940’s and 50’s).  In 1957 the Autoanalyzer was invented and let to the introduction of equipment into the medical laboratory shortly after (Technicon, SMA, SMAC) all of which created a platform that ultimately lead to more consistency in testing, but also changed test order practices with more patients having more tests more frequently.  

Changes in microbiology followed suit, about 10 years after chemistry with early equipment as the Sensititre, Radiometric Bactec.   The laboratory business exploded with activity. 

More recently (and by that I mean very recently) Anatomic Pathology is now going through a dimension of change that will have profound effects.  As we move towards increased automated digital pathology there will be higher consistency in performance with broader distribution of knowledge and a striking decrease in the number of AP pathologists required to do what they do now.  A single room in virtually any city will be able to service the interpretive needs for thousands, if not millions of patients around the world.  Maybe not today, but soon.

With each generation of change came increased capability, increased speed, and from a strictly technical perspective better analytic sensitivity, more sophisticated data handling, and some levels of data management. 

Unfortunately a lot of this progress has had its dark side as well: more and more liberal testing patterns with inappropriate testing of patients both in terms of poor patient and test selection.  Increased numbers of laboratories using fewer and fewer staff with decreasing technical training.  [Note: The Luddites of 200 years ago were actually visionaries].  And all that has led to substantial levels of laboratory errors and continuing challenges to laboratory Quality.  Not to be excessive, but one can argue that many of the problems that we have today would be avoided if we had a better control on the frequency of testing and they procedures requested.  [As I hear it, this may not be too far off, as organizations such as the US Congress and HHS look at restructuring the fees for laboratory testing.]

My point is this.  Medical laboratories have a long and distinguished history of innovative technical automation change that has improved the lives of many through better and more available diagnostics and monitoring.  It would probably be a fair and honest statement that innovative change has been the single-most powerful driver in medical laboratory.  

But it has occurred all too frequently within a technology and enterprise silo, and in many regards absent from critical planning such as human resources training and management, quality management, and risk. 

A theoretical calculation:  if introduction of technical change had been more effectively controlled and we were now doing fewer but better selected tests, would we be further ahead, about even, or behind if we consider the impacts of proper diagnosis, along with the impacts of no diagnosis and also the number of people that are harmed or inconvenienced by excessive inappropriate and uninterpretable testing.

As I work through my awakening to the impacts of innovation and quality on a personal level, I have come to two understandings.  First, being a cautious Luddite is  maybe not such a bad thing, and second, that Pogo might have been more right than we would want to acknowledge:  "We have met the enemy and he is us."

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