With the ongoing
public focus on medical errors, histology and cytology laboratories
around the country likely are tired of the continued pressure to respond
to address this issue. Improvement of process flow is not a new topic.
Medical laboratories have always tried to operate efficiently, and any
laboratory errors have been scrutinized by lab professionals with an eye
toward systematic elimination. Nonetheless, clinical laboratories,
driven by Six Sigma and LEAN analyses, have made valiant attempts in
recent times, once again, to improve their processes and reduce errors
with workflow changes. Steps have been counted, tables have been
rearranged, and new methods have been developed.
What has changed recently is the importance and
the impact of current information systems on the medical laboratory's
goals. When it comes to the histology and cytology departments,
traditionally, information systems' ability to support efficient process
workflow has been hampered — not due to lack of desire by vendors.
Rather, the designers of information systems have had to wait for the
appropriate tools to be developed, and those tools are now available for
The brilliance of bar coding in histology
Chief among the recently available tool set is the widespread availability
of bar-coded cassettes in the histology laboratory. The challenge in the
development of these cassettes was the requirement for a bar code small
enough to print on the edge of the cassette but with enough room for
human-readable information. The imprinted information had to withstand
processors, wax, scraping, and other types of mechanical manipulation.
Labelers are now available from General Data, Thermo, Leica, and Triangle
Biomedical Sciences, to name a few, and these allow information systems to
automatically generate cassettes with bar-code and specimen information
printed on the edge of the cassette. This new process yields a significant
decrease in mislabeled cassettes, while generating more labeled cassettes
per hour than any manual process could achieve. From a lab professional's
perspective, far fewer hand cramps occur because a histotechnologist no
longer has to spend hours trying to write legibly on a cassette's small
Similarly, the ability now exists to print slides
or slide labels with bar codes; vendors such as Zebra and Thermo come to
mind. Coupled with bar-coded cassettes, the histotechnologist can scan a
cassette and have the computer system generate the slide or labels that
are relevant for a specific block. Again, this reduces legibility errors
and significantly increases throughput. Imagine the difference between
writing a patient name, case number, slide, and block identifier on
every slide compared to simply scanning a cassette.
With this critical bar-coding step for workflow
improvement, the most significant materials of the laboratory can be
tracked. In order to improve a process, the process has to be quantified
or measured. With bar codes on cassettes and slides, information systems
can now track the time spent at each step of processing, be it at the
grossing station, stainers, or, finally, at the pathologist's desk. With
this information in hand, medical laboratories can adjust and fine-tune
their operations to meet specific needs and requirements.
Bar coding improves cytology's workflow, too
Not to be left out, the cytology department
is also taking full advantage of the recent tools available to
information-system vendors. As with histology, bar-coded slides are
automatically generated by information systems. In some cases, these
slides or slide labels are generated at order entry, while other
vendors generate the slide or labels upon scanning the specimen
vial. The same gains enjoyed by the histology department are now
available in cytology. Materials are tracked throughout the medical
lab, thus reducing the opportunity for lost specimens.
Pap smears contribute a significant percentage of
the total volume of cases processed by most cytology departments. For
larger departments, the use of automated imaging is becoming more
commonplace. Today, information systems generate either bar-coded slides
or labels that these imagers can use to identify the unique sample. In
some instances, optical character recognition, or OCR, identifiers are
placed on the slide or label to facilitate that process.
In recent years, the advent of human
papillomavirus (HPV) testing has become routine; and in certain
situations, HPV testing is even supplanting the traditional Pap smear.
Here again, information systems have developed new mechanisms to
automatically order HPV testing based on an assortment of ordering
criteria. Initially, HPV tests were reflexively ordered via information
systems based only on an abnormal Pap-smear result. More recently,
information systems have evolved to a rules-based ordering mechanism
whereby HPV test orders are placed based on many different factors:
patient age, previous HPV result, and ordering clinician preference —
just a few examples of the factors considered by newer ordering
The histology and cytology laboratories are
busier than they have ever been. Increasing focus on process flow and
improved efficiencies has become the new rallying cry. To assist in
their effort, leading-edge information system vendors have adopted newly
minted products to assist laboratories. By taking advantage of the best
that these information systems have to offer, the histology and cytology
departments can keep abreast of current trends and stay at the forefront
Michael Milhalik works as vice president of
marketing and sales with Pathview Systems in Anna, TX.
MS, F(CAP), F(ACB), Division Head, General Laboratory, Calgary
Laboratory Services, Calgary, AB, Canada, and member of MLO
editorial advisory board.