Conversational computing: case history: cytotechnologists at a North Carolina hospital lab log notes and test results via voice, using the technology to cut their turnaround times by nearly 20 percent

Health Management Technology, Nov, 2004

Fast turnaround is important any lab--particularly one building a successful outreach business--since it is a key factor in attracting new clients. But a laboratory cannot afford to sacrifice quality or accuracy, because the consequences could be life-threatening.

The process for screening GYN Pap cases requires a meticulous attention to detail on the part of trained cytotechnologists, who must screen each cell in a sample in a very methodical fashion to identify and record any abnormalities. However, large reference labs often treat such cases as a commodity, since to them the real business value is the clinical lab volume that offices generate.

A smaller, anatomic-only laboratory like High Point Regional Health System's must be able to complete them quickly and accurately in order to compete and build trust among the physicians it serves, says Pathology Director Steve Olsen. The High Point, N.C.-based healthcare organization's anatomic pathology laboratory supports a 373-bed hospital and a healthy, growing outreach business delivering service to 60 physician offices within a 30-mile radius, which includes for-profit GYN Pap cases and tissue testing.

Nature of Cytology Tests

Other types of diagnostic testing produce some type of number or other metric from which a diagnosis is rendered, which is largely quantitative in nature. However, cytology is the study of exfoliated or "loose" cells that are placed on a slide by either scraping cells, as in a mouth swab or endoscopy, or smearing cells, as done for a Pap smear, or by newer fluid-based automation, as in the case of Cytyc's ThinPrep technology.

This type of "screening test" still remains largely subjective in nature, and much of the test result's validity rests with the expertise of the individual performing the screening. The cytotechnologist's job is to determine if changes in the cells are consistent with a certain type of abnormality and flag those cases for further testing.

Once a slide is prepared, the cytotech will cover 125 percent to 150 percent of the slide, rescreening some cells while moving back and forth from one corner of the slide in an "S" type fashion viewing it through a microscope. Traditionally, the cytotechs at High Point, as is the case in many cytology labs, would make note of their observations and later enter the data into the computer system. In screening Pap cases, precision is of the utmost concern. Recording important observations, such as the presence of endocervical components in a tissue sample, can prove to be a very painstaking and, at times, tedious process when toggling back and forth between a notepad or computer screen and the microscope.

Additionally, it is common practice at High Point, as elsewhere, to enlist the assistance of a transcriptionist or other clerical person to enter the findings into the system, which the cytotech would then have to verify for accuracy and electronically sign out the case if no abnormalities were round. This process of screening, then transcribing and verifying prior to signing out each case, proved to be an inefficient use of the cytotech's time. Any type of handoff, in which one person interprets another's handwritten notes or check boxes, also opens the possibility of entry errors, necessitating that the cytotech very carefully review each case, comparing the findings entered to his notes prior to signing it out and moving on to the next case.

In general, cytology tests carry a relatively higher margin of error as compared with diagnostic tests due to the qualitative nature of the testing. The Clinical Laboratory Improvement Amendments and Joint Commission on Accreditation of Healthcare Organizations set standards for various areas of the laboratory. They recognize that screening tests are not 100 percent accurate and, as such, have their own measurements for an acceptable standard of care.

Even so, if a significant abnormality is found in a Pap smear, the laboratory must rescreen the previous five years of negative slides to aid in determining the seriousness of the patient's condition. In the event that cell abnormalities may have been missed previously, the laboratory may be asked to prove that it has followed proper quality assurance procedures. Examining the cytotech's track record may be a factor in making that determination; therefore, a true electronic signature is a critical component of the final report.

Voice Streamlines Process

When deciding on a new information system, Olsen and the other decision-makers at High Point were intrigued by a cytology-specific voice application--Vox Papuli (VoxPap) by Milford, Mass.-based Psyche Systems Corp.--as a complement to its WindoPath anatomic pathology software. High Point had considered other methods of input or verification, but found that they all required the cytotech's time to record, enter and verify information--time that could be freed up for other work. Ultimately, the need for rapid input and data verification for its Pap cases drove the decision, to try this interactive voice, or "conversational computing," technology. High Point purchased licenses for each of its three cytotechs.