One of the key activities of a laboratory is maintaining complete and comprehensive documentation of all activities carried out. Every step of the testing process, from requisitioning tests, to specimen acquisition, labeling, handling, and storage; to specimen testing; to reporting test results must be documented. In addition, documentation is a key activity of laboratory management from approvals of policies and procedures, to personnel issues from training and competency assessment, to hiring, and disciplinary activities. We must also include facilities issues as well, from maintaining temperature records, to inventory control We must also not forget maintenance, calibration, and performance specification records, among other aspects of the lab operation.
How we document has changed more radically than what we document. Remember all the excitement of beginning the new Millenium? We could not have imagined how rapidly these changes would actually occur! A whole new vocabulary has emerged: EHR, EMR, LIS, ACO, PCMH, PCLE; not to mention IM, texting, etc.
Not only have we moved from paper to electronic record keeping; we have moved data input, access and retrieval from desk-top to lap-top to smart phones. We are not just referring to technical and personnel record keeping; this includes patient (test) records (still quaintly referred to as Charts) as well. But the most radical innovation of all is the tremendous increase in capacity for interconnectedness of all databases. It is now worldwide. Testing can be performed by laboratories half a world away with results instantly transmitted; instruments can be repaired remotely; personnel training can be achieved via webinars; lab directors qualified via on-line training.
Imagine: potentially, any records generated by your laboratory, from technical records (quality control, maintenance, calibrations; operational histories including corrective actions; all patient test results), to personnel records (yes, really!) to operational records (laboratory finances, coding used, organization) all have the potential to be shared, worldwide, both for good purposes as well as for harm. These technological changes, when used to enhance the quality of patient care are nothing short of revolutionary. The development of Accountable Care Organizations (ACO); the concepts of the Patient Centered Medical Home (PCMH), as well as Patient Centered Laboratory Excellence (PCLE) could not have come about without the ability to have instant world-wide communication of patient data. But behind that, from a laboratory perspective, is the same growth in capacity. This enhances the quality of laboratory work done by sharing all manner of operational information from guaranteeing the qualifications of all testing personnel to proximate or remote oversight of instrument operation, supply inventory, and quality assessments.
What an age we live in!