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Technical Briefs |
Department of Laboratory Medicine, University of Washington, Seattle, WA
aaddress correspondence to this author at: Department of Laboratory Medicine, Campus Box 357110, 1959 NE Pacific St, Room NW120, University of Washington Medical Center, Seattle, WA 98115-7110, Phone: (206) 598-6131, e-mail: ahoof{at}u.washington.edu
Abstract
Background: Training of clinical pathologists is evolving and must now address the 6 core competencies described by the Accreditation Council for Graduate Medical Education (ACGME), which include patient care. A substantial portion of the patient care performed by the clinical pathology resident takes place while the resident is on call for the laboratory, a practice that provides the resident with clinical experience and assists the laboratory in providing quality service to clinicians in the hospital and surrounding community. Documenting the educational value of these on-call experiences and providing evidence of competence is difficult for residency directors. An online database of these calls, entered by residents and reviewed by faculty, would provide a mechanism for documenting and improving the education of clinical pathology residents.
Methods: With Microsoft Access we developed an online database that uses active server pages and secure sockets layer encryption to document calls to the clinical pathology resident. Using the data collected, we evaluated the efficacy of 3 interventions aimed at improving resident education.
Results: The database facilitated the documentation of more than 4 700 calls in the first 21 months it was online, provided archived resident-generated data to assist in serving clients, and demonstrated that 2 interventions aimed at improving resident education were successful.
Conclusions: We have developed a secure online database, accessible from any computer with Internet access, that can be used to easily document clinical pathology resident education and competency.
In 1999 the Accreditation Council for Graduate Medical Education (ACGME) approved 6 core competencies for residents, patient care, medical knowledge, practice-based learning and improvement, interpersonal and communication skills, professionalism, and systems-based practice (1). As for any medical specialty, clinical pathology residency programs are responsible for training their residents to meet these competencies. However, documentation of a resident’s progress toward competency is difficult.
Clinical pathology residents serve as liaisons between the laboratory and clinicians, providing interpretation and consultation regarding laboratory testing. As preparation for practice as board-certified pathologists, they are given graded responsibility in managing hospital laboratories. Exposure to patient care usually occurs while residents are on call for the laboratory, providing consultation on issues ranging from test approval to blood product use. Residency directors are responsible for assessing resident competence, but providing accurate data for such assessment is often difficult.
When taking call for the laboratory, residents are exposed to expansive medical literature to help guide them in their decision-making. On-line tools such as laboratory information databases (2) and Young’s Effects Online (3) can provide a starting point, but site-specific questions are frequent. As the rotation of residents taking call progresses from month to month and year to year, similar questions arise and the benefit of previous efforts in assisting other clinicians is lost unless an archive has been developed. To facilitate the improved patient care possible with access to previous research by clinical pathology residents, we developed a database of calls handled by our residents.
When not taking call, residents are required to amass a knowledge base that is sufficient to qualify them to serve as medical directors of laboratories. Residents typically amass this knowledge via rotations through the different laboratory divisions. These rotations include time spent performing the tests alongside technologists, interpreting results that need pathologist input, advising medical management decisions, and facilitating the transfer of new technologies to live laboratory testing. Unfortunately, time spent on call can interfere with these experiences. We describe the web-accessible database we’ve established and a quality improvement project to free up time for rotating residents to learn the information they need to be proficient.
Clinical pathology residents typically reside outside the hospital while on call. In addition, the calls they receive may indicate problems with client service from part of the laboratory or the laboratory as a whole. The database therefore includes 2 important features. First, it is accessible from any computer in the world with Internet access, and data are secured with a firewall and secure sockets layer encryption. Second, server-side software generates legible, formatted reports of each call. These reports can be circulated to the pertinent laboratory directors even if the residents do not work with them directly. In addition, deidentified reports of work performed by the resident can be generated to serve as documentation of progress toward proficiency in clinical laboratory medicine.
In the process of deidentification, fields known to contain Personal Health Information (PHI) are "stripped" from this formatted output. No mechanism has been implemented, however, to easily remove these fields permanently because we consider the database an addendum to the patient’s medical record, which we maintain intact in electronic format as long as is feasible. Furthermore, there is no known method or algorithm to remove PHI from free text-fields.
The devoted server runs Windows 2000 Server with the Microsoft Access database queried via the Open Database Connectivity (ODBC) protocol. Active server pages are used to generate HTML-tagged pages for remote clients, and HTML forms are used to enter data (Fig. 1
). This application has been used on Windows and Macintosh platforms running common browsers, including Internet Explorer and Firefox. Free text searching is available across all relevant fields. Records are uniquely identified by 3 of a total of 21 fields available, and a hidden field contains a time stamp of modifications to the records. Residents familiar with HTML are able to include links to outside web pages and publications. Log files are maintained that can be used to associate a user with each edit. Therefore, database integrity is maintained over time.
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The server generates reports in rich text format available for download by the client computer. The entire application was written and put online in 65 h and requires 15 min per week to monitor security and operational logs. Back-up of the database is performed nightly with Windows Server software. A simplified, adaptable version is supplied to academic training centers at no cost and is licensed by the University of Washington.
In the fall of 2005 the department made an effort to respond to resident and faculty concerns regarding the increased time commitment required of residents on call. Three changes were instituted to help alleviate the problem. First, the task of interpreting 1:1 mixing studies during work hours was shifted to the resident on the coagulation service, when one was assigned. Second, calls originating within the microbiology laboratories during work hours were directed to the senior postdoctoral fellow in clinical microbiology. Similarly, the third intervention directed work-hour calls from the chemistry laboratories to the senior postdoctoral fellow in clinical chemistry. We used the database to evaluate the success of these interventions.
During the first 21 months the database was online, it accrued 4712 calls. In our program 1 resident is on call 24 h a day, 7 days each week. This averages to 7.2 calls per day; of which 58% were received during business hours (8 AM to 5 PM), and 57% originated outside the laboratory. The resident covers calls for 2 hospitals and our community outreach services, which combined generate 
15 000 billable tests each weekday and a total of 90 000 per week. Because the volume of calls changes during the calendar year, we compared overlapping calendar months of the years before and after the interventions (n = 8 months per year). For this comparison, 3460 calls were available. The total number of calls received during work hours fell from 1067 to 963, which was not statistically significant. The residents who entered the calls classified them into 15 different categories (Table 1
). Using Microsoft Access and Excel, we sorted and calculated the number of calls per day for each call classification. For the majority of classes of calls, the change in call number was not statistically significant (Table 1
); however, 4 classes of calls did demonstrate significant changes in the number of calls during work hours from 2004–2005 to 2005–2006. Three classes of calls, 1:1 mixing study interpretation, approval and coordination of STAT testing for organ donor evaluation, and critical value notification, all decreased. Interestingly, calls for evaluation of underlabeled and mislabeled specimens increased in number from the first to the second year.
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These data permitted us to directly evaluate the interventions instituted for the resident class of 2005–2006. First, the significant decrease in 1:1 mix interpretations from 0.43 to 0.10 calls per day demonstrated the effectiveness of the shift in responsibility to the resident on the coagulation service. Second, the reduction in critical value notifications from 0.16 to 0.09 per day confirmed that most critical values that technologists could not deliver to responsible clinicians were actually microbiology cultures that became positive after patient discharge. The microbiology fellow benefited from this new responsibility, and the residents had more time to focus on learning opportunities in other areas of the laboratory. The increase in the number of mislabeled specimen calls reflected an administrative change in which all decisions to reject or accept mislabeled or underlabeled specimens were shifted from an attending to the resident on call. The change in the number of work-hour STAT organ donor evaluations was likely due to a change in behavior by the organ procurement organization served by the department; however, no formal policy change was instituted. At least 2 of the interventions were demonstrated to benefit resident education.
As ACGME guidelines and protocols for documentation continue to grow, the database also provides documentation for the educational opportunities provided to each of the residents, thus facilitating the increasingly overwhelming task of complying with new recommendations while improving resident education. Other medical disciplines have used online documentation of resident learning. The Computerized Obstetrics and Gynecology Automated Learning Analysis, a software suite built by a group of Canadian training programs in obstetrics and gynecology, documents resident encounters with patients (4). The residents identify and enter into the database critical learning opportunities that warrant further research. By identifying the gaps in their knowledge, residents were able to build a knowledge base and a set of resources for quickly answering difficult problems presented by their patients. Questionnaires revealed that residents who used the online database felt more comfortable with their abilities to succeed as lifetime learners than did residents at schools without such databases. Online tools are also used in otolaryngology, emergency medicine, and thoracic surgery residency programs (5)(6)(7)(8). The database described herein similarly empowers clinical pathology residents and training programs.
In summary, we have developed an online database that is accessible from any computer with Internet access. This system can be used to document resident competency and simplify consultations with clinicians, improving patient care and laboratory service. As we have demonstrated, it can also be used to guide improvements in resident education. Above all, this online database will facilitate compliance with ACGME recommendations aimed at providing proficient physicians for the next century. Our future goals for the database are to expand its use by making it freely available to other institution, and to continue to study its impact on resident education and clinical service.
Acknowledgments
We thank the Laboratory Medicine residents for their contributions to the database from 2004–2006 and Dr. Petrie Rainey for many helpful discussions.
References
The following articles in journals at HighWire Press have cited this article:
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  T. K. Amukele, A. N. Hoofnagle, and M. L. Astion Use of a Resident On-Call Database to Characterize Failures in Communicating Critical Laboratory Results Clin. Chem., August 1, 2009; 55(8): 1590 - 1591. [Full Text] [PDF]
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 E. Diamanti-Kandarakis, S. Livadas, S. A Kandarakis, A. Margeli, and I. Papassotiriou Serum concentrations of atherogenic proteins neutrophil gelatinase-associated lipocalin and its complex with matrix metalloproteinase-9 are significantly lower in women with polycystic ovary syndrome: hint of a protective mechanism? Eur. J. Endocrinol., April 1, 2008; 158(4): 525 - 531. [Abstract] [Full Text] [PDF]
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