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A Journey to Pathology 3.0: Good or bad ideas?

In his recent article “Sharing lab results with patients - Good or bad idea?”, Hugh Risebrow brought back the old question about sharing the laboratory results directly with patients. Since we are looking into many new avenues for innovating and redesigning #pathology and #laboratorymedicine in the post- #COVID19 #pandemic #healthcare ecosystem, Hugh’s invitation for the debate is timely and significant. I consider it as an integral part of a Jurney to Pathology 3.0, as we should be abandoning the old transactional approach and strategically position our industry in its transformational, solution-generating role.

Many times over the last two and a half decades, in the UK and abroad, I was taking part in conversations about patient’s direct access to testing and/or results of testing requested by themselves or their physicians. When I dared to initiate the topic, it was often on my peril. I have to declare that I firmly believe that the patients should have access and own the results of their tests or any other investigation that they had been subjected to by any healthcare provider. Having said that, there needs to be a mature and pragmatic debate about the channels, methods, and interpretative framework to support the safe and optimal use of #laboratory #diagnostics.

Also, sharing lab results directly with the patients needs to be differentiated from patients or their relatives requesting and purchasing the tests themselves (B2C model). This is another significant and often marginalised topic, especially in the countries with the dominant public healthcare systems (NHS in the UK), but may be common practice elsewhere. As per last week’s Laing Buisson Diagnostic UK Market Report, the UK B2C market, comprising mainly STD, allergies and some general wellness tests, still captures annually £15-20M. B2C has always had its foothold in genomics, both directly or indirectly, sponsored by industry. As expected, for B2C enterprises, SARS-CoV-2 testing is a commercial opportunity. It is essential to recognise the disruptive potential of B2C business models. It is not about laboratory testing; it is offering targeted solutions for discrete needs of their customers incorporated in health and fitness packages or filling the gaps due to changes in lifestyle unattended by the overstretched, underfunded, slow-to-react or disinterested incumbents. As Clayton Christensen pointed out, disruption "should be framed as a marketing challenge, not a technological one".

Laboratory medicine consumerism is not something I’d wish to encourage. Instead, I would like to challenge the inertia of the incumbent healthcare systems to respond to changes in the economic, social and cultural environment and endorse intrapreneurial customer development approach to validate assumptions about the service packages that they currently provide.

However, I would like to encourage the optimal use of diagnostics. At its most basic level, the optimal use of laboratory diagnostics is about purposeful use of diagnostic tools to answer specific clinical questions. As #pathologists and #scientists, we should actively promote and help the public, patients, our frontline clinical colleagues, medical and nursing students, policymakers to use pathology and laboratory medicine tools intelligently, purposefully and with due respect.

Back to the original question; in my experience, when floated around, the idea about handing the results of laboratory tests was met by frontline physicians and laboratory professionals either by high-level caution or even passionate resistance. If I were to summarise the reasons for objection, they probably fall into two broad and overlapping categories:

1.      Concerns about the ability of the existing, fragmented, outdated and underfunded IT platforms to support information governance and interoperability required for this endeavour, and

2.      Cultural barrier, often with the shades of professional or institutional protectionism, gatekeeping instincts or professional paternalism

The cultural barrier is real. It is not ill-intended; the vast majority in the loop has the best intentions and profoundly care for the patients’ safety and well-being. With the permutations of the arguments highlighted in Hugh’s article, the established information gatekeeping pathways are the norm. However, I cannot resist making a somewhat cynical observation that many medics do not follow what they preach and often use their access to IT systems to look-up their own results requested by someone else.

To be honest, this cultural barrier has shifted a lot in the last decade or so, and I believe that the conversation now needs to move about the standards and format that should be used to enable patients’ direct access to results. We all know that we should not oversimplify this matter – it is about the referring the patients for pathology and laboratory medicine investigation and a diagnostic opinion of laboratory medicine clinicians, not just about sending a sample for, let’s say, a blood test. As it became overtly evident during the pandemic, it is not about the numeric value and the reference range. The laboratory results do not necessarily exist in a binary "positive/negative" context. They need to be interpreted in a rich context of clinical information and with the insights into the methodology, often understood to a sufficient degree only by laboratory professionals. There is often complexity, ambiguity or an incomplete picture. There are sensitive scenarios, with such potential implications that the results need to be communicated by healthcare teams. I presume that no one contemplates messaging a histopathology report with a significant finding.

We also must not forget that a patient is seeking to understand: “what does it mean to me?” and “what do I need to do next?”. In many situations, answers to these questions are straight forward. For example, “X that we monitor for your chronic condition Y is within normal limits; this means that you should do Z. We’ll get in touch with you about the follow-up test. If you wish to speak to a healthcare professional let us know by booking a call via your app”. If the interpretation with instructions could be communicated to the patients directly, how many primary or secondary care outpatient appointments or telephone calls could be avoided? We may not have had the technology and channels to do it at the scale in the past. Prompted by an article in Wired magazine, I tested a paper-based version of PSA and Cardiology abroad almost ten years ago. However, the paper could not scale up. 

Also, we should not be looking for a laboratory only, but for whole-system solutions. The forthcoming wave of telehealth, with an appropriately curated and personalised approach and interpretation, could provide the right environment for the task.

As per technology, it is doable. The solution may not be immediate, cheap or off-shelf. It may not be the garage entrepreneurs’ start-up bonanza as many covidportunistic brewing businesspeople hope. Equally, we may not be able to wait until the analysis-paralysis brigade dot all i-s and cross all t-s. We need a responsible entrepreneurial approach and system support to test and prototype ideas in direct collaboration with the patients, carers, primary and secondary care clinicians and integrate them into the fabric of the new #integrated #care ecosystem . End-to-end and interoperable, but not one shoe fits all, consistently thinking about the impact of our interventions on patients' lives.

The key is the end-to-end approach. We may need to start with sample collection- there may be new roles for self-sampling, home sampling, drive-through phlebotomy hubs. Also patient-grade POCT.... but these are topics for another post.


 

…before we go


On behalf of the South Yorkshire and Bassetlaw Pathology Transformation Programme, I would like to invite you to join us on Wednesday 3rd June at 15:00 -16:00 BST at our first #dPath20 Webinar.


We will have the privilege of meeting colleagues from the University of Montreal Hospital Centre (CHUM) to learn about their digital pathology journey. Our colleagues from Canada are implementing digital pathology across the regional Optilab network in the Montreal area. They already have very encouraging data on improvements in quality, productivity and work-life balance, and they have managed to accelerate the transition during the pandemic to improve safety and maintain their diagnostic service.

The Webinar will be presented by Dr Bich Nguyen, Director of Digital Pathology and Pathology Head of the Optilab-Montreal CHUM hub University of Montreal Hospital Centre. The session will be enabled by Tribvn Healthcare, the provider of the digital pathology software solution for CHUM.

Please register and book your place using the link: https://us02web.zoom.us/webinar/register/WN_vluvyXdjQi-rDzOwD2bDhw , or by scanning the QR code by your mobile device.

The session will be a part of #dPath20 Webinars. The Webinars will be organised by SYB Pathology Transformation Programme and our friends who share our enthusiasm for #digitalpathology and #computational #pathology.

The aim of #dPath20 is to hear about the implementation of digital pathology from those who have already “walked the digital pathology walk” and can help us with going through the forthcoming transformation of our profession and industry. 

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