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Managing test demand by clinicians: computer assisted guidelines.

Introduction The need to manage demands made by clinicians on the analytical resources of laboratory medicine is not new. Influencing use of laboratories by clinicians has been a consistent theme in the literature for some 20 to 30 years, early papers appearing soon after the introduction of automated analytical systems. Despite the efforts of a dedicated few, until recently misutilisation (that is, over and under use) of laboratory resources has been perceived by the majority as a chronic condition which the laboratory service must endure. Few strategies for modifying the behaviour of clinicians have been sufficiently successful to be widely adopted and the laboratory investigation of patients with similar clinical conditions continues to vary widely both within and between hospitals. However, the imperatives of the purchaser/provider environment, in which consistent standards and quality of care, clinical audit, and the efficient use of resources are all important factors, have signalled the need to re-examine this old problem. Guidelines, usually informally communicated, detailing how patients are to be managed in a variety of clinical situations are not new. They provide the basis of most medical education and training, and provide an effective method ofmanaging test demand.' However, the widespread, formal introduction of guidelines for management and investigation of patients has been resisted by some, often for emotive reasons such as a perceived reduction in clinical freedom, the introduction of "robotic" medicine, and interference with training, etc., because the clinician believes he/she knows better how to treat his/her patient, or because of the effort required in drawing them up or ensuring that they are used routinely. Despite this, guidelines are now increasingly being promoted as a way of improving care by reducing unintended or unjustified variation in clinical practice and, as a consequence, of managing test demand. There is growing evidence that a guideline based approach to laboratory investigation of patients offers laboratory medicine a practical solution to the misutilisation of resources and to management of demand, without detriment to clinical freedom or practice. Issues of terminology, design, and implementation must be addressed and some alteration in traditional ways of working may be required, but perhaps some of these are needed anyway. Background The Audit Commission2 supported the concept of management of demand and suggested that this requires a combination of traditional strategies together with restriction of test repertoire and the introduction of locally agreed investigation guidelines. Whilst the formulation of locally agreed guidelines presents a considerable challenge, their implementation in a consistent way has often proved impossible. Computer assisted guidelines have now been shown to be effective in specialist units.3 Routine use of a system at the Queen Elizabeth Hospital, Birmingham, over the past two years has resulted in significant savings in medical stafftime, significant reductions in the number of laboratory investigations requested, and improved continuity of management in spite of frequent changes in junior medical staff. In this system laboratory and patient demographic data are acquired automatically from relevant feeder systems via the hospital electronic communications network. Laboratory investigations appropriate to the individual patient's clinical condition and recent pathology are proposed at terminals in ward areas. The proposed investigations reflect locally agreed guidelines which relate to defined clinical classifications which are symptom, disease, subdisease, or drug trial based. The houseman, or other clinical staff, assign patients to one or more of these classifications which predetermine the investigations required. These classifications and the investigations proposed daily by the system for each patient are reviewed by the medical staff who may update the classification or add or delete investigations or simply accept the proposed schedule. The system provides a convenient way of communicating requests to the laboratory and reviewing results as well as comprehensive feedback of laboratory usage which facilitates audit and refinement of the guidelines. This proactive approach is currently being applied experimentally in acute general medicine and preliminary findings are encouraging. Other forms ofcomputer assistance are available. The system used at the Queen Elizabeth Hospital, Birmingham, can deny inappropriate investigation proposed by the user by pointing out deviation, or possible deviation, from locally agreed practice. Computer systems incorporating this type of reactive support are becoming established in hospitals in the United States where critical care plans (that is, management guidelines) are increasingly accepted as assisting the delivery of consistent standards Wolfson Computer Laboratory, Queen Elizabeth Medical Centre, Birmingham B15 2TH M Peters