Trends in Pathology and Laboratory Medicine

The major drivers in Pathology and Laboratory Medicine Services as we look to the future are discussed below.

  1. Workforce pressures. With current labor shortages which will only get worse, there is a strong drive for increased productivity among the most skilled laboratory professionals: pathologists and technologists. A key strategy is to focus their time and efforts on the highest level of work, automating (see below) and/or redefining jobs:

    • The use of PAs by pathologists is becoming increasingly common.
    • Digital microscopy and telepathology will provide the capability to review slides remotely. This will make if feasible for pathologists to provide remote consultative services and allow them to cluster in groups with a critical mass of subspecialties.
    • Methodologies from other industries are finding their way into laboratory operations in order to increase productivity and improve service. The current “buzz-words” are Six Sigma and Lean. Many laboratories are being re-engineered according to these principles in order to make better use of highly skilled staff will maintaining or improving high service levels.
    • The role of the laboratory technician/aide is expanding. These duties can include specimen collection, specimen receiving/processing, instrument loading, slide staining, urine dipstick/chemistry, and microbiology plating. Some point of care testing may be performed by technicians. To make this efficient, the functions performed by technicians should be in a central/core part of the laboratory.
  2. Automation. Ever since the first automated chemistry and haematology analyzers developed in the late 60’s/early 70’s, laboratory testing has experienced steady increases in the level of automation, the speed/throughput of instruments, and the extent of test menus on a single platform. A single instrument today with a single operator/technologist can perform the tests formerly performed by as many as five instruments. More recently, most or all of the specimen handling functions have been automated in some form. Today we see:

    • Front end processing which can include the following steps: specimen receiving, centrifugation, sample splitting/labeling, and sample sorting and racking.
    • Total laboratory automation, which is cost-effective only in large laboratories. However more laboratories are adopting it as way to deal with labor shortages.
    • Islands of automation in which clusters of similar instruments work off a single specimen sampling module. These may be discrete instruments connected by a track, or multiple instruments may be housed in a common chassis.
    • New automation, e.g. automated PCR and histology tissue processing.
  3. Informatics. Since their introduction in the early 1970’s, laboratory information systems have rapidly evolved into essential elements of laboratory operations. Newer features include:

    • Electronic medical records, eliminating the need for laboratory and other paper charts.
    • Automatic verification of results, based on defined algorithms that require technologists to only have to review abnormal/atypical results.
    • Electronic cross-matching.
    • Hand-held devices for bedside positive patient identification in phlebotomy and printing of labels.
    • Docking stations for point of care instruments to capture all patient and quality control results.
    • Computer assisted diagnosis, which identifies areas of interest in various types of slides (urinalysis, cytology, and (eventually) anatomic pathology).
    • Digital microscopy with computer assisted diagnosis and PACS-like pathology systems.
    • Voice recognition to minimize the need to medical transcriptionists.
  4. Point of Care. The list of tests that can be done on POC instruments continues to grow, challenging laboratories and hospitals.

    • Additional critical tests such as troponin and BNP are being offered. Often the reagent/cartridge cost per test is very high, and efficient laboratory systems with rapid specimen transport can offer the same level of service at lower costs.
    • Some individuals believe that POC will result in a smaller laboratory. However, most POC of tests, when performed in the laboratory, are performed on instruments that can not be eliminated due to other roles.

    The laboratory is responsible for POC test quality regardless of who performs the tests. As POC grows the impacts on the laboratory include:

    • Create a position of POC coordinator (FT/PT).
    • Create workspaces for cross-over/validation testing, equipment storage (spares in the lab), and clerical/paper work.
    • Develop training processes and spaces, regardless of whether POC is performed by laboratory or unit personnel.
  5. Molecular Diagnostics. There will be rapid growth in molecular testing in ways that will complement existing tests and will replace others. The three broad areas of change will be infectious disease, genetics, and pathology.

    • Infectious disease testing will permit (more) rapid identification of pathogens and/or their susceptibility to particular drugs. These may be performed on primary samples directly or on cultured isolates. Most applications to date have been in virology, sexually transmitted diseases, and mycobacteriology (TB).
    • Impacts in genetics will be felt in academic and esoteric laboratories that focus on areas such as cytogenetics, tissue typing, etc.
    • All aspects of pathology will be affected: surgical pathology, cytopathology, and hematopathology. Molecular techniques will extend the array of tests performed on pathology specimens much as immuno-peroxidase staining has in recent years. Specific technologies will include PCR, FISH, and microarrays.
  6. Predictive Tests. A new set to terms has been developed based on the ability to determine the molecular and/or metabolic properties of tissue so as to “customize or personalize” therapy. While much of the early excitement is in oncology, it is reasonable to assume that such technologies will evolve into many other areas including autoimmune disease, neurological disease, etc. These will be developed at research/academic institutions, but may ultimately migrate to larger community facilities. In either regard, they will improve outcomes in areas that have heretofore been intractable.