Demand management in the preanalytical phase


Tim Lang, Dr, FRCPath, Consultant Clinical Scientist Clinical Biochemistry Department, University Hospital of North Durham, UK

Labquality Days - Nordic Congress on Quality in Laboratory Medicine


Test ordering and collection of samples are important tasks in the pre-analytical phase of the laboratory diagnosis pathway. Over recent years the European Federation for Clinical Chemistry and Laboratory Medicine (EFLM) Working group for Preanalytical Phase (WG-PRE) has strived to make quality improvements and harmonize the many aspects of this phase [1]. At the same time laboratories are under pressure to deliver a high quality service to meet the needs of their patients against ever expanding workloads,  increase costs, reduced revenue and inappropriate testing. They are challenged to identify this waste in their processes and remove unnecessary steps in their patients’ journeys.


There are many solutions available to assist the laboratory in identifying these unnecessary/inappropriate tests and implementing appropriate steps to avoid them [2]. It is also the clinician’s responsibility to protect their resources and promote value in their clinical care, which the laboratory can support by working in partnership [3]. There are several demand management solutions available that focus on the pre-analytical phase thereby potentially managing the requesting prior to any collection of sample or at the very least protecting precious resources such as consumables and laboratory time. These solutions can be grouped into five areas: education, rules aimed at restricting test requests, redesign of request forms, computerised physician order entry (CPOE) and reimbursement models [4]. An example of such a demand management tool is the use of minimum retesting intervals to restrict the requesting of a test, based on the properties of the test and the clinical situation in which it is used. To address some of the variance in practice and lack of evidence base the Clinical Practice Section of the Association for Clinical Biochemistry (ACB) prepared a set of consensus/evidence based recommendations on when a test should be repeated [5]. The National Minimum Re-testing Interval Project prepared over 100 recommendations in a number of clinical areas. This project has now been expanded to produce 373 recommendations covering all areas of laboratory medicine [6].


The implementation of a demand management tool is dependent upon that the system used to deliver it correctly identifying the patient and matching the request with the patient’s medical record. This will allow the laboratory information system to interrogate the patient’s previous pathology results to allow identification of duplicate or inappropriate requests. Ideally real time notification to the requestor of a potential redundant test should be available so that the requestor can make an informed choice on the clinical need of the test and record any reason for overriding the rule. CPOE and order communication software provide opportunities for the laboratory to effectively managed their workload and meet the increasing demands of service



1. Lippi et al (2014). Preanalytical quality improvement. In pursuit of harmony, on behalf of European Federation for Clinical Chemistry and Laboratory Medicine (EFLM) Working group for Preanalytical Phase (WG-PRE) Clin Chem Lab Med 2014; DOI 10.1515/cclm-2014-1051.

2. Fryer AA, Smellie WSA (2012) Managing demand for laboratory tests: a laboratory toolkit. J Clin Pathol doi:10.1136/ jclinpath-2011-200524

3. Protecting resources, promoting value: a doctor’s guide to cutting waste in clinical care. Academy of Medical Royal Colleges, 2014

4. Encouraging Quality Pathology Ordering in Australia’s Public Hospitals –Final report (2012). (accessed 23 Jan 2013)

5. Lang TF (2013). National Minimum Re-testing Intervals Project: A final report detailing consensus recommendations for minimum re-testing intervals for use in Clinical Biochemistry. Association for Clinical Biochemistry 2012.

6. Lang TF and Croal B. The UK National Minimum Re-testing Intervals in Pathology Project Clin Chem Lab Med 2015; 53, Special Suppl, ppS572