Mobile Technology and Health Care

I just stumbled upon this BBC article about a TED talk from about a year ago that discusses an app called Ucheck that can be used to test urine samples for a variety of elements, including glucose, proteins and nitrites.  Instead of having to go to a lab to get these urine tests, an individual can use this app—the purchase of which includes the dipsticks and supplies needed to utilize the app—to run initial urinalysis screening tests.

I imagine the Ucheck folks have thought about and researched the pros and cons and possible issues with a system like this.  Process issues, user error, contamination (although supposedly one of the elements in the test helps to gauge contamination), among others come to my mind immediately. My biggest question, however, is what does the Ucheck app-user do next after they receive their results? How does the patient proceed if they do need additional medical attention?

The internet can make mini doctors of all of us—there is enough information to make many self-diagnoses, but not necessarily accurate ones.  My doctor recently told me they have stopped giving patients full reports from various tests because they found the patients would go home and Google everything on the report and come back to them scared and with inaccurate information.  She said this Google-ing gives everyone access to enough information to be dangerous.  Would this app give people just enough information to be dangerous?

The TED talk mentions that the app is being put to the test in a laboratory in India—if effective that certainly could be very useful in terms of providing mobile health care, particularly in remote regions of the world.  Use of the app in a controlled medical setting where there are trained laboratory and medical personnel available to interpret results is a different story than an individual using it at home.

The TED talk and related articles I found were from 2013 so I did some sleuthing to see if I could find more recent information.  I found an article noting that the FDA sent the Ucheck developers a note that the app needs to meet FDA guidelines in order to be in use.  I didn’t find follow-up information on what happened after the FDA note, but I haven’t been able to find the app through my iPhone’s app store. Perhaps it’s been put on hold?

Regardless of whether this particular app moves forward, however, medical advances using mobile technology such as these are certainly on the horizon.  Which makes for an interesting conversation.  Mobile technology could be revolutionary in some parts of the developing world where access to medical resources is scarce.  But do they provide what is needed?  Are they being used in a setting where if a diagnosis is made there are resources to treat that diagnosis?

What do you think?  Are these positive developments?  Could they be helpful and harmful?  How will regulation work?

Levy

-Marie Levy spent over five years working at American Society for Clinical Pathology in the Global Outreach department.

Live from Kyrgyzstan

Greetings from Bishkek, Kyrgyzstan! And Happy St. Patrick’s Day to those of you with Irish heritage and those who just think they’re a bit’o’Irish on this day! I have been in Bishkek, Kyrgyzstan the past week, joining colleagues to work with the Kyrgyzstan laboratories on preanalytical processes and phlebotomy techniques that are so important in patient safety and specimen integrity. Over the two weeks we are here, we are working with more than sixty people and have a very full agenda. I’m scrambling to refresh my Russian/Kyrgyz greetings and phrases, but oddly enough it’s coming back. I doubt I’ll ever master the Cyrillic alphabet, but the accents are growing more familiar.

We began last week with full-on challenges: agenda changes, delayed supplies and the ‘usual’ need to be flexible and unflappable. Our shipped supplies and materials were delayed in customs for two days, so we were “working without a net.” Our team works well together and we have been well received by our Kyrgyz colleagues so that diminishes difficulties. They are a lively and vocal group, giving us lots of opportunity for dialogue which is always a pleasure. We are finding that their knowledge is strong but their experience and skills with the standard equipment used to collect blood is lacking. Some of them have never seen or used devices we take for granted—evacuated disposable tubes and safe, sterile needles are often not available in rural parts of the country—and some of the statistics shared with us by their national infection control director are staggering. Some of the examples shared: uncapped, reused glass tubes for transport of serum to reference lab testing sites; rubber-stoppered pipettes reused after rinsing in water or alcohol; requisitions rolled up and used as “tube stuffers” that served as caps to specimen bottles; confusion on the difference between serum and plasma; single digit numbers written in wax pencil as the second (an in some cases, first) patient identifier. All are challenges they are facing in rural collection sites for lack of resources and training. Fortunately the groups we are working with are in position to change that, and it is energizing to see how much they really want safety and progress for their healthcare workers and patients. As always, I learn much more than I teach…and this week has been no exception. In between training weeks, we spent Saturday with a high level group facilitating and mentoring a country-wide process improvement project, and helping to identify and outline next steps. Working side by side with our CDC partners was an opportunity to learn and hopefully to contribute to the discussions and strategies ahead. This is where change will happen, and it’s exciting to see it up close and personal.

Next time I hope to share some customer service experiences with you, as we gather stories and experiences from our Kyrgyzstani colleagues about how they address and resolve issues at the point of service to patients. If you’d like me to ask our colleagues any questions while I’m here, email me at bsumwalt@pacbell.net . It’s a different world, but in so many ways it’s the same issues we face in our laboratories back home.

 

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Beverly Sumwalt, MA, DLM, CLS, MT(ASCP) is an ASCP Global Outreach Volunteer Consultant.

Direct To Consumer Testing: Wave of the Future?

Direct to consumer (DTC) testing is one of the fastest growing industries on the internet, and if laboratories are not careful, we’re going to be blind-sided by it. I wanted to know how this works because in general the websites for this testing have nothing whatsoever on them about the lab. I searched for lab information – accreditation, etc – and found nothing. What I found was that most of these sites are essentially online middlemen between the consumer and the labs – allowing access to lab testing and bypassing the doctor.  I decided to do an experiment and see just how easy it was.

I went online and found a DTC company and ordered tests. I skipped their specials, “test of the month” was a complete thyroid panel, and settled for their most popular, most ordered test. It is actually a group of tests which includes a CBC with differential and a chemistry panel for a total of 27 tests plus six calculated values (eGFR, HDL/total cholesterol ratio, etc). The complete test cost me $97.00 plus tax. I can tell you that those tests run at my institution would cost well over $2500.00, and even at a big reference lab, the best price I could get was about $425.00.

It was when I placed my order that any mention of a lab came into the process. Before I could place the order, I had to make sure there was a LabCorp near me.  I then went back to the website and printed the company’s requisition for the test and took it with me to a LabCorp draw station. They took the requisition, checked it against a photo ID, collected the appropriate blood samples and sent me on my way. Three days later I received an email from the online company that my results were available. I logged on, and it was just that easy.  There were all my test results with appropriate reference intervals and flags. If I want my physician to have a copy, I can have them sent or print them and take them with me.

Amazingly, this is incredibly easy to do, although I suppose you would have to know enough to know what tests to order, or be told what to order by your physician. But I now have the ability to order my own tests, and at significantly less cost than the average hospital or reference lab. If doctors begin telling their patients just what tests to get run and then to bring them the results, this DTC testing will put hospital labs out of business, at least out of the outpatient lab business. There’s no way for a hospital lab to compete with this cost structure. Now all you need is a LabCorp interface to your hospital system and the test results go right back into the chart where the doctor ordered them and the hospital lab is totally outside the loop.

Of course, you will also have people just running tests on themselves after doing some online research, but they will still have to hook up with a doctor somewhere to explain abnormal lab results. I’ve already seen some of that – calls or emails from people off the street looking for explanations of results of metabolic testing. DTC is going to open many, many cans of worms, but it’s coming, nonetheless. I suppose there might be a role for the laboratory professional here, to help the consumer understand their lab results when they do them directly. And hospital labs will always be necessary for STAT and critical tests for inpatients. But the world is changing. We need to be ready for it.

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-Patti Jones PhD, DABCC, FACB, is the Clinical Director of the Chemistry and Metabolic Disease Laboratories at Children’s Medical Center in Dallas, TX and a Professor of Pathology at University of Texas Southwestern Medical Center in Dallas.

On the Lab Medicine Website

In case you’ve missed it, here is the table of contents for the current issue of Lab Medicine. New articles are uploaded regularly, so be sure to check back often.

Theoretical knowledge helps troubleshoot wonky results, but unfortunately that knowledge is easy to forget if it’s not used every day. If you’ve worked the chemistry bench long enough to have forgotten some of theory behind the analytes, check out this series of articles to refresh your memory.

In the latest edition of our podcast series, Dr. Alex Thurman walks listeners through diagnosing a new acute leukemia in the middle of the night.

USCAP Fueled Thoughts about AP and CP

I recently returned from sunny San Diego where I attended the CAP Residents Forum and USCAP. While at USCAP, I met more than my fair share of pathologists from Canada. After all, the “C” in USCAP stands for Canadian. I was surprised to learn that pathology residency there is 5 years–they still have a clinical “intern-like” year–and their residencies are either AP only or CP (referred to as “general pathology”) only programs.

In the US, most pathology subspecialties belong to one group or the other. The one exception is hematopathology which bridges AP and CP;in some programs is considered as AP and in others as CP. So I asked how they consider hematopathology in Canada. Most of those whom I met were AP trained and told me that in terms of hemepath, they only look at bone marrows (“tissue”). The peripherals and aspirates (“liquids”) are read by hem/onc and not likely to be relinquished to pathology as it is a good source of revenue for them.

When I told them that I was trained to read peripheral blood smears, aspirates, clots, and bone marrows, they told me that was because I was “CP trained” in terms of hemepath. They also told me that when they study hemepath in Canada, (I’m not sure if I misunderstood this part) that they aren’t really trained to diagnose lymphomas well. So they prefer to go to the US to train in hemepath fellowships to get the exposure and tend to hire US-trained hematopathologists. But I was also told that Canadian residencies are transforming and now beginning to incorporate more training in lymphoma diagnosis.

So, this brings me to some thoughts on AP and CP training. I was re-reading my most recent posts and realized that some recent frustrations I’ve experienced on my surgpath rotations accentuated my natural proclivities and bias. So, first, I’d like to say that I do not dislike surgpath. But I do think that the culture and some personalities in surgpath don’t really mesh well with a research-trained physician-scientist me. I often get the comment that I am “too academic” or I’m “more like a scientist than a pathologist” (which I didn’t think was a bad thing for a CP-oriented resident).We all have our biases and there is nothing wrong with that. But I often notice that the needs of the AP portions of our programs sometimes dominate over CP.

At multiple programs I rotated through during medical school and in my current program, if there is no autopsy resident that month, residents on CP rotations are assigned autopsy duty during the week while the surgpath residents cover the weekends and holidays. AP inclined residents and attendings often try to convince me that I never know if I’ll end up practicing surgpath. Even though residents often take vacations during CP rotations or spend most of their time studying for boards and not 100% actively engaging in their CP rotations, most of the time, CP attendings just expect this sort of attitude towards CP.

And so this tension between the two pathologies sometimes befuddles me. A co-resident even asked me if I’d consider doing a little surgpath with hemepath like the general pathologists at our community hospitals do(my answer is “probably not”)or I’ve gotten the “what are you going to do with molecular training?” question as well. This is not because there is anything wrong with surgpath (I know I might rant when I’m frustrated but I think knowing surgpath can only help me with my future career choices). But I wonder why when a first year resident comes in saying they want to do dermpath, they get hooked up to do derm/dermpath research (it’s important to match for dermpath fellowships) and I have people trying to convince me that I should want to do surgpath. Why does it seem harder to accept when a resident says that they want to do a CP subspecialty (maybe with the exception of hemepath)? Have you had experiences where a tension between the AP and CP sides of pathology reared its ugly head?Why do you think this may be so?

 

Chung

Betty Chung, DO, MPH, MA is a second year resident physician at the University of Illinois Hospital and Health Sciences System in Chicago, IL.

Gut Flora and Chron’s Disease

I’m fascinated by the connection between gut flora and overall health. I just stumbled onto this article that discusses the connection between gut flora and Chron’s Disease. It’s based on this paper published in Cell. Recent articles about antibiotic’s role in obesity and papers on gut flora’s influence on the immune system  keep raising the issue: how much do common organisms like E. coli, Clostridium perfringes, and Bacteroides fragilis affect us? How can we use them to diagnose, prevent, or cure disease? I’ll be keeping my eye on future research.

 

Swails

Kelly Swails, MT(ASCP), is a laboratory professional, recovering microbiologist, and web editor for Lab Medicine.

 

Antibiotic Stewardship

The draft of the federal budget released Tuesday allocates $30 million dollars in CDC funding in order to combat antibiotic resistance. Obviously the 2015 budget isn’t finalized, but even so, it’s encouraging that the Department of Health and Human Services recognizes the need for antibiotic stewardship.

What is antibiotic stewardship, you ask? Basically, it’s a program within a healthcare community that dictates the best practices for prescribing antibiotics. Such programs would be tailored for each setting based on population demographics and antibiograms. Perhaps a program would prohibit prescribing, say, ciprofloxacin for urinary tract infections because a rise in the percentage of strains of E. coli resistant to fluoroquinolones has been noted. Maybe the program would discourage prescribing more than two antibiotics at once to a patient, or suggest antibiotics other than vancomycin (such as levoquin) when treating MRSA.

Creating a stewardship program requires input from several departments (Infectious Disease, Pharmacy, Epidemiology, and the Microbiology Laboratory) as well as acceptance by the clinician population at large. In my experience, this has been the limiting factor. Physicians don’t like being told what they can and can’t do for their patients or the insinuation that they might lack the proper knowledge about antimicrobials and microbiology to provide good patient care. This is a hurdle that hospitals will have to overcome in order to make stewardship programs a success. (Mentioning that such programs can save money and shorten hospital stays could help tip the scales.)

If you’d like to institute a stewardship program at your institution, here are a few links to get you started:

CDC’s Vital Signs about prescribing practices
Antibiotic management guidelines at John Hopkins
Professional practice resources from the Association for Professionals in Infection Control and Epidemiology
The ever-insightful Maryn McKenna over at Superbug discusses the topic at length

Does your institution have an antibiotic stewardship program? If so, what steps did you have to take in order to implement it?

Swails

Kelly Swails, MT(ASCP), is a laboratory professional, recovering microbiologist, and web editor for Lab Medicine.