Critical Value in Dermatopathology—Where Time and Communication Are Essential

Critical values are defined as “laboratory results that indicate a life-threatening situation for the patient.” Because of their demanding nature, the appropriate healthcare professional must be notified urgently of a critical value. 

In the field of dermatopathology, the College of American Pathologists defines a critical value as a critical diagnosis such as “a medical condition that is clinically unusual or unforeseen and should be addressed at some point in the patient’s course.”

All laboratories, including dermatopathology labs, are required to exercise effective communication when it comes to reporting critical diagnoses and must have a written protocol in place. This is in accordance with laboratory regulations outlined by CLIA (Clinical Laboratory Improvement Amendments; CLIA ’88) and the Joint Commission (TJC) National Safety Goals.

Dermatology clinics should understand what qualifies as a critical or a significant unexpected diagnosis. By examining how labs identify and manage critical diagnoses, defining the referring provider/lab partnership, and understanding how results are shared, we can expedite treatment and improve patient care.

Management of Critical Diagnosis in the Lab

Immediate and decisive action is required in the dermatopathology lab to identify and report critical diagnoses to the dermatologist as soon as possible. Every dermatopathology laboratory should have a written protocol outlining the diagnoses that are considered critical. In most instances, a new diagnosis of invasive melanoma is considered a critical diagnosis, as well as a life-threatening diagnosis such as staphylococcal scalded skin syndrome, graft versus host disease, or toxic epidermal necrolysis. Unalarming in appearance, each of these skin disorders could lead to serious health complications if not treated quickly. 

Once identified as critical or significant, the laboratory is responsible for documenting how and when the results are communicated with the dermatology clinic. If the diagnosis is shared over the phone, there should be a record of who made and received the call. In addition to ensuring the clinic accepts and understands the results, the lab keeps a record to comply with existing laboratory regulations.

The Referring Provider/Lab Partnership

When a clinic and laboratory form a new partnership, the dermatologist and lab open communication lines to clarify the types of results they define as urgent or critical.

Though 75 percent of laboratories have a written policy for handling critical and significant unexpected diagnoses, clinics need to ensure their lab’s processes meet the needs of patients and practices (for instance, if a dermatologist establishes that he or she wants a notification for melanoma in-situ as well as invasive melanoma, or for unexpected cases of Tinea spp). By communicating regularly regarding cases, mutual trust will develop over time between the lab and the clinic.

Sharing Urgent Results

The most crucial step in the critical diagnosis process comes when the dermatologist shares the results with patients and points them towards treatment. The urgency is real, as the rate of survival decreases 5 percent for patients with stage I melanoma treated between 30 and 59 days compared with those treated in the first 30 days after diagnosis. 

To ensure fast and precise action, it is helpful when labs share critical values directly to the EMR in addition to a phone call. Full-service dermpath labs like PathologyWatch transfer results and digital images electronically, enabling clinics to correlate with dermatopathologists instantly. At the same time, accessing the diagnosis in the EMR makes it easy for dermatologists to quickly share the results with patients on a tablet or laptop, reducing worrisome waiting periods.

Whenever a dermatology clinic sends a batch of request sheets to the lab, there are chances for revealing critical diagnoses. By clarifying what constitutes a critical value, defining the referring physician/lab partnership, and examining the best way to share results, you can increase optimal treatment and recovery for patients.

Managing Pathology Orders and Results

Dermatology clinics carry the responsibility of providing patients with correct test results from dermatopathology laboratories. With 9,500 Americans diagnosed with skin cancer every day, the weight of managing pathology orders and results is critical to ensure every patient’s diagnosis is received and shared in an organized, accurate, and timely manner.

Experienced dermatologists know there’s more involved in processing pathology results than sending out request forms and waiting for results to return. By being proactive, defining the lab’s responsibilities, evaluating paper and electronic workflows, and exploring the advantages of an EMR interface, you can ensure your dermatology clinic provides optimal quality of care to your patients.

The Clinic’s Responsibility

Patients hold their dermatology clinics accountable for sharing biopsy results, which means it is up to the providers and their staff to receive, organize, and deliver pathology results directly to patients. While it takes an average of 12 years of schooling and training to become a dermatologist, it only takes a few moments to lose a patient’s trust.

Labs return their reports to clinics through various channels, including fax, web portal, courier, and mail. The dermatology practices keep track of these results and share them with their patients. Proactively opening the communication lines between the clinic and the lab is the best way to make sure nothing slips through the cracks. By checking in with the lab frequently to follow up on cases, a dermatologist can stay on top of any delays or missing reports while answering questions that may help to produce more definitive diagnoses. 

According to Tammie Ferringer, MD, open communication between the clinic and the lab is “totally appropriate and should occur.” The dermatopathologist advises, “Calling is absolutely acceptable, and it is usually easier to get ahold of a dermatopathologist than a lot of dermatologists because they’re seeing patients constantly.” 

The Lab’s Responsibility

The dermatopathology lab is obligated to deliver case results and alert the clinic of any unexpected or urgent diagnoses. Labs deliver their diagnoses using documented communications, keeping records of faxes, correspondence, and deliveries. However, the lab’s obligation stops once the clinic receives the results. The dermatology practice coordinates and shares the results with their patients. 

Paper Workflow

Dermatology clinics have the option of sending requests and receiving diagnoses via traditional paper or electronically. Even though 70.2 percent of dermatologists report using an EHR in their practice, many still prefer to use paper when communicating with labs. 

One disadvantage of paper is the task of matching outgoing orders with incoming results. With some dermatology practices seeing 40–50 patients per day, managing a paper workflow can create a bottleneck and impact the time to deliver results to patients. 

Current events also point towards electronic records as a safer solution for clinics to consider. “We’re in the era of social distancing, so it’s time to embrace EMRs and other technologies that make it safer for us to do our jobs,” notes Mark D. Kaufmann, MD, FAAD. “This will help us be responsible in the COVID-19 era, as well as create new efficiencies in terms of billing and coding.”

Interfacing the EMR

Working with a lab that interfaces electronically with a dermatology clinic’s EMR introduces a new level of streamlined reliability. In an instant, office staff can see which orders are still outstanding and which diagnoses are ready to be reviewed and shared with patients, with some interfaces using color codes to flag new or urgent results.

In addition to simplifying sorting, searching, and managing requests, an EMR interface, like the one provided by PathologyWatch, includes immediate access to whole-slide images and access to academic-level dermatopathologists. PathologyWatch makes it easy to pull up digital images and review them independently or with the patient.

Your dermatology clinic moves quickly to ensure your patients receive accurate results with an acceptable turnaround time. If you take time to evaluate your practice role, understand the lab’s obligation, compare paper and electronic workflows, and consider an EMR interface, you’ll find ways to improve the management of pending specimen lists and report distribution to serve your patients better.

Pathology Laboratory Supply Management and Specimen Transportation: Three Essential Considerations

It is essential for dermatology clinics to partner with a pathology lab that can effectively meet supply management and specimen transportation demands. With the number of active pathologists decreasing by 17.53 percent in recent years, the pressure is on to keep slides moving out the door with confidence.

By maintaining an adequate inventory of specimen containers, knowing how to prepare samples and request forms for shipping, and learning about transportation options, your practice can ensure that your tissue samples reach the pathology laboratory safely and on time. 

Specimen Containers 

When a dermatology clinic aligns with a pathology laboratory, it is the lab’s responsibility to keep the practice stocked with specimen containers to preserve and deliver tissue samples. These containers must be freely available to help practices return timely and accurate results to their patients.

Wide-mouth specimen containers carry 10 percent neutral buffered formalin. With approximately 18 months of shelf life, formalin is a liquid fixative that preserves the tissue while enhancing the appearance under the microscope. 

Specimen containers come in various sizes to meet the dimensions of small biopsies and large surgical samples. The tissue is sealed inside the container, and the patient’s name, age, sex, and other identifiers are recorded on the clear container’s label. Then, the material is placed in a biohazard bag and packaged to be picked up.

Request Forms and Shipping Bags

The clinic attaches the required documentation to the specimen using the request forms supplied by the pathology lab or, if applicable, automatically generated within the EMR. Because specimen mislabeling occurs in 0.2 to 0.3 percent of all laboratory cases, this step requires strict attention.

The request form provides details about the patient and the specimen, including the sample’s type and location, biopsy date, patient details, clinical information, medical reference numbers, and insurance information. Because not all laboratories can bill every insurance, dermatology clinics often are required to work with multiple labs that offer different insurance coverage.

When everything is in order, the request form and specimen container are enclosed in secure shipping bags and readied for transport. Should additional bags, request forms, or specimen containers be needed, the pathology laboratory should make it easy to place orders online or by phone. 

Specimen Transportation

The lab is tasked with picking up specimens from the dermatology clinic and delivering them safely to the pathology laboratory. As Mayo Clinic Laboratories states, “Specimens must be packed and shipped properly for accurate testing, which helps ensure that patients receive optimal treatment.”

To alleviate risk and ensure the highest diagnostic quality, couriers should be trained in safety and the handling of hazardous waste while complying with HIPAA and OSHA regulations. However, couriers can only transport specimens to local labs, sometimes limiting dermatology clinic access to only local dermatopathologists. Also, couriers typically don’t offer electronic tracking to keep clinics apprised of their location. 

Using medical material supply chain services from UPS and FedEx gives dermatology clinics easy access to respected pathology authorities outside of their region. This includes academic-level reads from the specialists at PathologyWatch, who can use digital pathology to collaborate with experts worldwide. UPS and FedEx offer advanced tracking, so clinics always know their patients’ samples’ exact location. With proven reliability and contingency plans, they provide reassurance that the specimens will reach the lab.

For optimal specimen tracking and security, clinics are recommended to create a tracking log of all specimens placed within a package. A copy of this log should be placed within the package as a shipping manifest. A vigilant laboratory will ask for this information, which will allow them to immediately verify the successful transportation of the specimens sent. If there is a discrepancy between the shipping manifest and the materials received, the clinic can be immediately notified, and the specimen can be recovered. While electronic orders can also help in this process, the best practice is to include a shipping manifest within the package.

Developing dependable supply management and specimen transportation to share tissue samples with the lab is critical in running a successful dermatology clinic. Having a reliable reserve of specimen containers, request forms, and shipping supplies, while understanding the advantages of different transportation options, can ensure specimens are packed and shipped correctly and safely for accurate testing.

Improving Pathology Workflow with an EMR Interface

Precise and punctual communication between dermatology clinics and pathology labs is essential to provide patients with accurate results and swift turnaround times. Because over 90 percent of all tumors are confirmed by pathologists, physicians that utilize an EMR are increasingly interfacing with pathology laboratories to relay case results.

Integrating an EMR interface between your practice EHR and the lab can help increase operational efficiency, streamline staff workloads, and improve the quality of patient care and satisfaction.

Operational Efficiency 

Your patients expect an organized and efficient experience every time they interact with your clinic, and you can hold your laboratory to those same standards. Relying on a laboratory with outdated means of communication can negatively impact the quality of your experience, as well as impact patient care. 

Today, three out of five dermatologists have adopted an EMR into their practices. Interfacing with your laboratory’s information system takes full advantage of this record-keeping technology, creating a communication portal that instantly organizes and shares case data results. Integration into pathology reporting means clinics can use their existing EMR systems to automatically receive, review, search, and sort results on demand without additional clinic support staff involvement.

In Utah, Allen-Taintor Dermatology was used to sometimes waiting up to two weeks to receive results from the lab, which sometimes failed to send slides. Because the clinic wanted to review the slides before calling patients, this consistent issue was a concern. Once they began using PathologyWatch, Allen-Taintor Dermatology saw improved staff workflow efficiency, including a 75 percent reduction in dermatologist review time, which further improved efficiency. Patient satisfaction likewise improved because the physicians could review the results with their patients on digital slides.

System Setup

For those using an EMR in clinic, the advantages of an interface are clear. Building an interface between your EMR and the laboratory in a way that optimizes workflow efficiencies is not always straightforward and requires an experienced IT professional.

By partnering with a trusted full-service dermatopathology laboratory like PathologyWatch, clinics can rely on experienced engineers to architect their interfaces in a way that optimizes their EHR capabilities to maximize internal clinic efficiencies.  

Streamline Workloads

For many clinics, paper continues to be the gold standard for documenting and sharing records. For clinics that have moved to an EHR, however, additional benefits can be realized if your laboratory is fully integrated. For example, a well-designed interface can make handwriting requisition forms and physically making carbon copies a thing of the past. You can also reduce the probability of errors by digitally sending that information to the laboratory, as clinic data must be re-entered into the LIS and attached to the sample when received on paper forms. 

Patient Satisfaction

Delivering reliable and timely results to your patients should be a high priority for every dermatology clinic and dermatopathology laboratory. After patients have a biopsy taken, many experience an uneasy suspense while waiting for their results. This was the case for Allen-Taintor Dermatology. Once they were able to utilize digital biopsy images to show patients their pathology during visits, their high patient satisfaction increased even more. EMR interfaces and optimal laboratory processes can reduce the turnaround time from when a biopsy is taken to when a result is received, resulting in a better quality of care and patient satisfaction.

An additional benefit to patient safety and satisfaction is that interfaces can also improve data integrity and results delivery, decreasing the risk of a data entry error in both the clinic and laboratory.

In summary, building and utilizing a well-developed interface between the clinic EMR and laboratory system can help to improve operational efficiency, simplify staff workloads, and improve the quality of patient care and satisfaction.

FAQ Interview with PathologyWatch CEO Dan Lambert

What is the single most innovative technology you are currently delivering to health systems or medical groups? 

We deliver digital pathology services and EMR integration solutions to dermatology clinics in many locations. Dermatologists are able to discuss cases with expert pathologists from many different locations in a way that has never been done before. We’re also developing AI tools that are specific to dermatopathology. Ultimately, humans and the AI working together in pathology will mean lives saved, and we’re at the beginning of this process.

How is your product or service innovating the work being done in these organizations to provide care or make systems run more smoothly?

PathologyWatch greatly reduces the amount of time spent on duplicating data between systems—the reports are accurately and automatically entered into the dermatologist systems. We’re eliminating the faxed reports and walled-garden report access. Digital pathology and EMR integration alone have streamlined clinical workflows and improved the quality of care within dermatology clinics.

What is the primary need fulfilled by the product or service?

The primary need is improved quality of care with decreased cost. We are attacking this problem in the narrow field of dermatology/dermatopathology, but the principles and technology can be expanded well outside of that area. We plan to expand from dermatology to other fields of outpatient medicine within the next two years.

What is the ROI of said product or service? 

Our clients have seen up to 75 percent decrease in sample turnaround time, as well as up to 75 percent decrease in the time it takes for physicians to review pathology reports (per internal case study reports).

What are some examples of implementation and outcomes use cases?

  • Improved operational efficiency with digital workflows
  • Improved patient satisfaction as the physician and patient review pathology together
  • Improved patient outcomes because of faster turnaround times
  • Improved staff efficiency

(For more information, see the Allen-Taintor and Prairie Lakes Healthcare case studies.)

Who are some of the clients and organizations served by the company?

How has innovation advanced the field of healthcare or the practice of care? 

  • Increased availability to high-quality care in underserved areas: Geography is no longer a limiting factor, providing opportunities for underserved areas to receive academic-level dermatopathology reads.
  • Improved speed and availability of samples for improved patient outcomes: Dermatologists are able to view their slides 24/7 digitally with a web browser (on-demand ability to correlate with pathologic findings).
  • Expanded access: Forty-five percent of the world does not have access to cancer diagnostics. AI has the potential to solve this problem.

How is innovation changing lives specifically? 

Through patient education, patients are now able to better understand why they do or do not need surgery, because physicians can display the digital pathology images for them. Patient diagnoses are improved, as dermatologists can more quickly and easily correlate pathologic findings with clinical features. Patients are more satisfied with their care, as they are receiving answers more quickly, especially in difficult cases where consultations would normally take additional days or sometimes weeks.

What is the company’s go-forward strategy? What’s next? Which problem is the organization working on now and in the future? 

We’re focused on optimizing workflows and technology specific to dermatology and dermatopathology. We plan to expand into other areas of pathology in the future, as well as work to solve the lack of access to pathology globally through the utilization of AI. Ultimately, our goal is to provide affordable, available, and accurate diagnoses to the world’s population.

What are the most significant lessons learned by delivering the innovation, product, and/or service to health systems and/or medical groups?

  • Healthcare systems are extremely difficult to work with, as they sometimes employ outdated systems with limited ability to quickly and easily adapt to current technological changes.
  • Very few successful healthcare companies are “just software.” You can’t build it and expect they will come. It takes making the right relationships with payers and providers.
  • As the healthcare industry continues its digital transformation, significant opportunities exist to improve patient outcomes and improve the efficiency and effectiveness of the overall healthcare system.
  • There are many ways to build algorithms. Think long and hard about your end-use case when architecting it and deciding whether to take a supervised or unsupervised approach to building out your algorithms.

Integration with Pathology Reporting

Dermatology patients rely on their physicians to provide accurate diagnoses and effective treatment plans. With three out of four providers indicating electronic medical/health (EMR/EHR) systems enhance patient care, integration with pathology reporting is a valuable transition every clinic should consider.

You want the most cost-effective and reliable method to link information between your dermatology clinic and the laboratory’s lab information system (LIS). By breaking down the limitations of traditional paper communication, learning about interfaces, examining the two types of integration, and understanding the interface challenges, we’ll cover all of the basics you need to know about integrating an electronic interface to elevate your practice and improve patient care.

Traditional Paper

Many dermatology clinics continue to rely on traditional paper when it comes to lab correspondence. When ordering tests, these practices handwrite requisition forms and manually create carbon copies, so a record stays in the office. Once received by the lab, the requisition information is typed into the LIS and matched to the biopsy. When the lab completes the patient report, the paper is attached and sent back to the clinic via fax, mail, or courier.

The exchange of paper between clinics and labs is tried and true for many; however, it does open the door to certain errors that can impact patient care, such as the amount of time it takes to write out forms and re-enter the same data into the LIS. The longer it takes to process and receive information, the longer it will take a patient to receive a diagnosis. It also increases the chance for errors to occur during user translation. Repeatedly entering the same data into patient records invites opportunities for human error. Despite these drawbacks, many clinics continue to use paper as a standard, especially if an efficient electronic health record is not being utilized.

Interface Benefits

While working with paper can lead to inaccuracies or delays, an electronic interface can decrease turnaround times and errors. These benefits appeal to tech-savvy dermatologists, who have a 63 percent adoption rate of EHR technology.

A significant benefit of integrating the clinic EHR with pathology reporting is that fields and data entered into one system can communicate with an entirely different system. As a result, users from the clinic and the lab can search the same patient data or perform quality lookbacks through their EMR using their current systems. This reduces data entry errors and can also allow for identification of improperly labeled specimens, reducing patient risk.

Types of Interfaces

Choosing the right electronic interface can help increase a lab’s efficiency and workflow. 

There are two types of interface for you to consider: unidirectional and bidirectional. A unidirectional interface can only transmit information one way. It can either send orders from the clinic to the lab or receive results from the lab to the clinic. The latter requires clinics to continue to submit paper orders.

Using a bidirectional interface provides a convenient two-way line of communication between the clinic and the lab. Sending and receiving digital orders can reduce time and mistakes, though a bidirectional interface requires programming for both locations. Both types of interfaces are utilized with success, depending on the unique workflow of each practice.

System Setup

Once an electronic interface is selected, real work is required before it can be activated. As more than half of dermatologists see over 50 patients per day, the initial investment of time and effort will pay off in the long run with productivity and dependability.

Interfaces are not simple plug-and-play systems. Individually coded, they require IT support to set up a secure line using a unique virtual private network (VPN) or other similar structure. Programmers use health language 7 (HL7) to reliably transfer patient records and study orders between the clinic and the lab. Full-service dermpath labs like PathologyWatch are designed to shoulder the burden of integrating an electronic interface into your practice.

Today’s EMR systems are full of complexities and functionality, with one leading vendor providing 3,100 automated treatment plans and procedures for dermatologists. By looking at the differences between a paper and digital workflow, exploring different types of integration, and understanding installation, you can assess whether integration with pathology reporting can help you get the most out of your EMR and your practice.