On the right path

Gifford Batstone

Pathology is important to all clinicians, as it is a pivotal element of 70-80% of all clinical decision-making, disease monitoring and response to treatment.

When treatment decisions are made through clinical networks, it becomes vital that patient identification is consistent and that the results of pathology investigations can be interpreted safely, even when they come from more than one source.

Lord Carter, in his Independent Review of NHS Pathology Services, recognised that the modernisation of these services required an end-to-end approach, with IT developments to support this way of working.

Pathology is now at a watershed with respect to IT. My specialty was one of the first to grasp and use the potential of IT through laboratory information management systems.

In conjunction with automated analytical systems, LIMS enabled laboratories to report on specimens much more quickly, increase the accuracy of patient and sample identity and report electronically to wards and GPs.

It gave us the ability to absorb huge increases in workload with relatively little increase in staff. This approach met the needs of both requesting clinicians and the laboratories and an effective request/report cycle was established.

Pathology now recognises a changing environment, in which the request/report cycle underplays the potential value of results produced by laboratories.

The creation of networks, both clinical and pathology (collaborative pathology networks and links to specialist assay laboratories), now requires a level of interoperability way above that needed for a simple request/report mode of working.

In addition, pathology will need to address the expectations of secondary uses of pathology data for research, disease surveillance (especially for the Health Protection Agency) and service planning; all of which are dependent on high levels of interoperability.

The big challenge is how we can enhance interoperability in order that all potential users of pathology data gain the same meaning from electronically transmitted pathology results. It is important that pathology messages are accurate, unambiguous, reliable, reproducible, comparable, secure and accessible.

So what are we doing about this? The key to success has been the close collaboration between the Department of Health Pathology Programme, NHS Connecting for Health and fellow pathologists.

Creating a catalogue of tests

The first step has been to standardise pathology test names and SNOMED-CT codes through creation of a National Laboratory Medicine Catalogue (NLMC).

This work is being undertaken by pathologists through the NLMC Governance Board, hosted by the Royal College of Pathologists, funded by the DH and working collaboratively with CfH. It involves reviewing a huge number of potential catalogue items to remove duplicates and outmoded tests.

Pathology messaging

A fully electronic requesting and reporting system with the ability to meet the legitimate needs of other users of pathology data is dependent on a standard approach to messaging.

IT connectivity is being enhanced through the use of Health Level Seven version 3 (HL7v3) messages, building on existing information systems in primary care and pathology laboratories using the National Spine infrastructure; this will improve the efficiency and clinical governance of pathology messaging.

The use of robust pathology messaging standards supports electronic communications between laboratories and other care settings, including primary care. Such standards increase the speed of results processing and, most critically, enables information to pass directly between clinical systems, improving clinical governance processes.

Electronic requesting and reporting for GPs

The ‘electronic pathology test requesting and reporting for GPs’ project involves working closely with early adopter sites to learn how best to introduce the new national HL7v3 pathology message standards and the Spine Messaging Service, and ensure that the benefits for patients, the GP practice and the pathology service are achieved.

The Pathology IT team is currently working closely with GP systems and laboratory system suppliers to upgrade their existing system software so they are able to support the use of the new HL7v3 order request and result messages.

This work is progressing with proof of concept of transferring HL7v3 pathology messages using NLMC and SNOMED-CT through the Spine to a laboratory. CfH has recently signed an agreement with a GP system supplier to take this work forward to a pilot stage.

Interoperability is more than electronic standardisation

Within pathology, we have long recognised that different analytical methods often yield different results. So the potential for interoperability is being enhanced by additional routes: default units of measurement within NLMC, harmonisation of reference ranges and considering when and how results obtained by different methods can be combined.

Decision support

Helping clinicians use laboratories more effectively is important for patient care and safety – hence the need for decision support. This has three levels: rules concerning the frequency of testing; access to information concerning tests (passive decision support) and information linked to results suggesting further actions (active decision support).

DH and CfH are working together to address this need; firstly by collecting information suitable for decision support and secondly creating an editorial process to review that information.

So what will be the benefits of greater interoperability?

I believe all these actions are taking us forward towards genuine interoperability. This will ensure improved access to patient results for clinicians and greater safety and efficiency through reduction in repeat testing.

For secondary users of pathology data, improved access to information for disease surveillance, research and service planning purposes will steadily become apparent.