E JIFCC2016 Vol 27 No 1

February 2016 ISSN 1650-3414
Volume 27 Number 1
Communications and Publications Division (CPD) of the IFCC

Editor-in-chief : Prof. Gábor L. Kovács, MD, PhD, DSc
Department of Laboratory Medicine, Faculty of Medicine, University of Pecs, Hungary
e-mail: ejifcc@ifcc.org
The
Journal of the
International
Federation of
Clinical
Chemistry and
Laboratory
Medicine
In this issue
Foreword of the editor

Gábor L. Kovács 3
Harmonization of clinical laboratory test results
Jillian R. Tate, Gary L. Myers 5
Harmonization of clinical laboratory information – current and future strategies
Mario Plebani 15
Harmonization initiatives in Europe
Ferruccio Ceriotti 23
The International Consortium for Harmonization
of Clinical Laboratory Results (ICHCLR) – a pathway for harmonization
Gary L. Myers, W. Greg Miller 30
Harmonization of clinical laboratory test results: the role of the IVD industry
Dave Armbruster, James Donnelly 37
Deriving harmonised reference intervals – global activities
Jillian R. Tate, Gus Koerbin, Khosrow Adeli 48
Critical risk results – an update on international initiatives
Lam Q., Ajzner E., Campbell C.A., Young A. 66
Analytical challenges in the genetic diagnosis of Lynch syndrome

– difficult detection of germ-line mutations in sequences surrounding homopolymers
Castillejo M.I., Castillejo A., Barbera V.M., Soto J.L. 77
The first green diagnostic centre and laboratory building in Indonesia

Joseph B. Lopez, Endang Hoyaranda, Ivan Priatman 84
In this issue: Harmonization of Clinical Laboratory Test Results

Editor in Chief: Gábor L. Kovács, MD, PhD, DSc
The current issue of the eJIFCC is devoted to lab- Biochemists (AACB), the AACB Harmonization
oratory harmonization. Harmonization is a fun- Committee was formed in 2011. As chair of the
damental aspect of quality in laboratory medi- committee since its inception, Jill coordinates
cine and its ultimate goal is to improve patient many of the AACB’s harmonization activities in-
outcomes through the provision of accurate cluding workshops and the formation of work-
and actionable laboratory information. Two ex- ing parties involved with various aspects of har-
cellent and renowned laboratory scientists (Ms. monization, e.g. AACB Committee on Common
Jillian Tate from Australia and Dr. Gary L. Myers Reference Intervals, AACB-RCPA Working Party
from the US) were asked to invite specialists on on Management of Critical Laboratory Test
harmonization and guest-edit the issue. Results. Over this time, she has guest-edited
special issues on harmonization for The Clinical
Jill Tate is a Senior Scientist working in the
Biochemist Reviews and Clinica Chimica Acta.
Department of Chemical Pathology at the
Pathology Queensland Central Laboratory in Jill’s main passion in the routine laboratory
Brisbane, Australia and currently co-ordinates for over 30 years has been to work in the pro-
the laboratory’s Research and Development tein electrophoresis area and she has written
Unit which collaborates closely with local, na- widely on serum free light chain measure-
tional and international clinical and laboratory ment. Standardization and harmonization of
groups. She has been involved with harmoni- free light chain measurements remain contro-
zation activities since the 1990’s through work versial. Currently she is co-guest editing a spe-
with lipoprotein(a) standardization and the cial proteins issue on protein electrophoresis
IFCC Working Group on the Standardization of and serum free light chain measurement for
Lp(a) Assays, then with cardiac troponin and Clinical Chemistry and Laboratory Medicine,
the IFCC Committee on the Standardization of due out in May this year. Above all Jill is en-
Markers of Cardiac Damage. Between 2008 and thusiastic about the role of the profession in
2014 Jill chaired the IFCC WG-TNI, which is de- Laboratory Medicine and believes that harmo-
veloping a secondary reference material for the nization is an important way that the profes-
standardization of troponin I assays. In October sion can add value to Laboratory Medicine.
2010 in Gaithersburg, USA, the AACC held their Gary Myers, PhD, currently serves as Chair of the
inaugural harmonization meeting. Following Joint Committee for Traceability in Laboratory
this meeting, which was attended by Jill on be- Medicine. He also serves as Chair of the Council for
half of the Australasian Association of Clinical the International Consortium for Harmonization
Page 3
eJIFCC2016Vol27No1pp003-004
Gábor L. Kovács
of Clinical Laboratory Results (ICHCLR). His most biomarkers used to assess chronic disease sta-
recent position was Vice President, Science and tus, particularly for cardiovascular disease and
Practice Affairs for the American Association for diabetes. Dr. Myers served as Secretary for the
Clinical Chemistry (AACC). Prior to joining AACC, Scientific Division of the International Federation
Dr. Myers served as Chief, Clinical Chemistry of Clinical Chemistry and Laboratory Medicine
Branch at the United States Centers for Disease from 2009-2014. In 2015 Dr. Myers received
Control and Prevention (CDC). During his 33+ year AACC’s Outstanding Lifetime Achievement Award
career at CDC he directed programs to improve in Clinical Chemistry and Laboratory Medicine.
and standardize the laboratory measurement of He served as AACC President in 2007.
Page 4

Guest editors: Jillian R. Tate1, Gary L. Myers2
1
Pathology Queensland, Royal Brisbane and Women’s Hospital, Brisbane, Qld, Australia
2
Chair, Joint Committee for Traceability in Laboratory Medicine, Smyrna, Georgia, USA;
International Consortium for Harmonization of Clinical Laboratory Results
ARTICLE INFO EDITORIAL
Corresponding author: Clinical laboratory testing is now a global activity with

Jillian R. Tate
Department of Chemical Pathology
laboratories no longer working in isolation but as re-
Pathology Queensland gional and national networks, and often at interna-
Royal Brisbane and Women’s Hospital tional levels. We now have all of the electronic gadget-
Herston, QLD 4029
Australia
ry via internet technology at our fingertips to rapidly
Phone: 61-7-3646-0082 and accurately measure and report on laboratory test-
E-mail: jill.tate@health.qld.gov.au ing but are our test results harmonized?
Key words:
harmonization, standardization, laboratory WHAT IS HARMONIZATION
medicine, total testing process OF LABORATORY TESTING?
In the context of Laboratory Medicine, harmonization
of laboratory testing refers to our ability to achieve
the same result (within clinically acceptable limits)
and the same interpretation irrespective of the mea-
surement procedure used, the unit or reference in-
terval applied, and when and/or where a measure-
ment is made.
Laboratories may use different analytical methods
that may not be harmonized, possibly with differ-
ent units of reporting. We should not assume that
the differing numbers can be directly compared es-
pecially if the transfer of results from the laboratory
to the report recipient does not highlight differences
in units of reporting or in assay methods in use. To
Page 5
Jillian R. Tate, Gary L. Myers
the contrary, the assumption made by patients, needed to achieve harmonization of clinical lab-
clinicians and other healthcare professionals is oratory information (1, 2). He emphasises the
that clinical laboratory tests performed by dif- importance of considering the complete harmo-
ferent laboratories at different times on the nization picture to ensure the comparability of
same sample and specimen are comparable in laboratory information in all aspects of the total
their quality and interpretation. testing process (TTP) including the request, the
sample, the analysis and the report.
WHY IS HARMONIZATION NEEDED
IN LABORATORY MEDICINE? As discussed by Plebani and others in this is-
sue, a systematic approach to harmonization is
When laboratory test results differ the potential needed that requires the following:
exists for misinterpretation of results, wrong
treatments and adverse patient outcomes. It is 1. Awareness by the Laboratory Medicine com-
our responsibility as laboratory professionals to munity that there is a need for harmonized
identify where gaps exist in laboratory testing processes not only for the analytical phase
and endeavour to harmonize these where pos- but across all steps of the TTP (3);
sible, thereby minimising misinterpretation of 2. Awareness that harmonization processes are
test results. complex; hence a systematic and evidence-
based approach that reflects best laboratory
WHO IS HARMONIZATION practice is needed;
OF LABORATORY TESTING INTENDED FOR?
3. An organizational plan or roadmap for the
The key stakeholders who will benefit from har- set-up and implementation of each harmo-
monization are the patients, the clinical labora- nization activity is a pre-requisite and must
tory community, diagnostic industry, clinicians, identify and describe the problem in detail,
professional societies, information technology identify relevant groups including external
providers, consumer advocate groups, regu-
bodies when forming a working group, de-
latory and governmental bodies. The clinical
termine a funding source, gather technical
laboratory community includes all disciplines
information and data from various sources,
of Laboratory Medicine. As potential consum-
consider the solutions, produce a discus-
ers of laboratory testing ourselves, we expect
to receive not only the Right result on the Right sion paper, seek feedback comments from
patient at the Right time in the Right form, but the relevant stakeholders through discus-
also the Right test choice with the Right inter- sion and revise recommendations, publish
pretation with the Right advice as to what to do endorsed recommendations, promote and
next with the result. This should be irrespective implement them, then monitor and survey
of the laboratory that produced the result and their introduction (4-6);
is achievable through harmonization (1). 4. Communication with main stakeholders,
i.e. pathologists, scientists, clinical groups,
AN OVERVIEW OF HARMONIZATION regulatory bodies, IT developers, and con-
In this harmonization issue Mario Plebani, who sumer groups is central to the success of
has been a proponent of harmonization in any harmonization project with a consen-
Laboratory Medicine for over 20 years provides sus outcome arrived at through cooperation
an overview of the current and future strategies and discussion (4,7,8).
Page 6
What is the status of harmonization of promising harmonization initiatives among

activities globally? the EFLM member societies, and specifically to
In Europe there is a recent initiative to pro- harmonize nomenclature, units and reference
mote harmonization activities among the 40 intervals where possible at a European level. As
European Federation of Clinical Chemistry and described by Ferruccio Ceriotti in this issue (9),
Laboratory Medicine (EFLM) member societ- based on the results of a survey questionnaire
ies. The Working Group on the Harmonization some activities promoting the dissemination of
of the Total Testing Process (WG-H), chaired best practice in blood sampling, sample storage
by Ferruccio Ceriotti, was formed the aims be- and transportation, in collaboration with WG on
ing to survey national European harmoniza- the Preanalytical Phase (WG-PRE), are already
tion initiatives, coordinate the dissemination being promoted (10-13). See Table 1.
Table 1 Harmonization of the Total Testing Process (TTP) – global
harmonization activities
TTP International and national

Harmonization activity
phase stakeholders
Pre- 1. Test requesting 1. ACB Clinical Practice Section –
analytical – demand management and reflex testing National Minimum Retesting Interval
– harmonized test profiles Project (UK)
2. Guidelines/position papers 2. CDC, CLSI, EFLM WG-CM,
EFLM WG-G, EFLM WG-PRE, AACC
3. Patient preparation and sample 3. EFLM WG-PRE, RCPAQAP KIMMS
collection
4. Sample handling and transport 4. EFLM WG-PRE
5. Quality indicators 5. IOM, IFCC WG-LEPS, EFLM TF-PG
Analytical 1. Traceability – promoting use of 1. BIPM, JCTLM, ILAC, EQAS
traceable assays
2. Development of commutable 2. NIST, IRMM, WHO, IFCC
secondary reference materials (RM) WG-Commutability
3. Harmonization of measurement values 3. ICHCLR, IFCC
for methods where no RM or reference
measurement procedure
4. Harmonization of Mass Spectrometry 4. APFCB WP-MS Harmonization,
(MS) methodology AACB MS Harmonization SIG,
CDC Hormone Standardization program,
COST DSDnet –WG-3: Harmonization of
Laboratory Assessment
Page 7
Post- 1. Standardization of reporting units 1. IFCC C-NPU, IUPAC, IFCC WG-HbA1c,

analytical Pathology Harmony (UK), RCPA PITUS
(Australia)
2. Standardization of reporting 2. Pathology Harmony (UK), RCPA PITUS

terminology (Australia)
3. Harmonization of calculated parameters 3. ACB Albumin-adjusted calcium, AACB

WP-Calculations
4. Common reference intervals (RIs) 4. IFCC C-RIDL, Nordic countries (NORIP),

across multiple platforms for traceable Pathology Harmony (UK), Turkey, Japan,
analytes Canada (CALIPER and CHMS), Australia
& New Zealand (Common RIs project)
5. Platform-specific RIs and decision limits 5. AACB Harmonisation Committee

for immunoassay analytes where there is (Australia & New Zealand), CALIPER &
method bias CHMS (Canada)
6. Standardization of report formatting 6. RCPA PITUS (Australia)
7. Critical laboratory results (CLR) – 7. EFLM, CLSI, AACB-RCPA WP-CLR

harmonized processes for management (Australia)
and communication of critical results;
list of critical tests
8. Interpretative commenting 8. IFCC WG-Harmonisation

– harmonization of commenting for EQA of Interpretative Commenting for EQA
9. Biological variation – harmonized 9. EFLM WG-BV

approach to validation of quality of BV
data for use with RCV interpretation
(EFLM project)
10. Surveillance of: 10. IFCC WG-LEPS, RCPAQAP
– pre-analytical and post-analytical KIMMS, EFLM TFG-Harmonisation of
processes performance criteria for EQA program
– common RIs surveillance,
– calculations RCPAQAP Liquid Serum Chemistry,
– test profiles calculations, RIs and test profiles
– interpretative commenting program (Australia)
– report formatting
11. Quality indicators 11. EFLM WG-POST, EFLM WG-PSEP
Page 8
Post-post 1. Promotion of clinical and laboratory 1. IFCC Taskforces, AACC Strategic

analytical relationships Clinical and Laboratory partnerships
2. Lab Tests Online (LTO) – a global 2. LTO around the globe
educational tool
3. Patient focus 3. ACB, EFLM WG-PFLM
AACB: Australasian Association of Clinical Biochemists;

AACC: American Association for Clinical Chemistry and Laboratory Medicine;
ACB: Association for Clinical Biochemistry and Laboratory Medicine (UK);
APFCB: Asia-Pacific Federation for Clinical Biochemistry and Laboratory Medicine;
BIPM: Bureau International des Poids et Mesures;
CALIPER: Canadian Laboratory Initiative on Pediatric Reference Intervals;
CDC: Centers for Disease Control and Prevention;
CHMS: Canadian Health Measures Survey;
CLSI: Clinical and Laboratory Standards Institute;
C-NPU: Committee on Nomenclature: Properties and Units (IFCC and IUPAC);
C-RIDL: Committee on Reference Intervals and Decision Limits (IFCC);
COST-DSDnet: European Cooperation in Science and Technology initiative action BM1303,
“A Systematic Elucidation on Differences of Sex Development”;
DSDnet; Working group 3; http://www.dsdnet.eu/wg-3.html;
EFLM: European Federation of Clinical Chemistry and Laboratory Medicine;
EQAS: External Quality Assurance Scheme;
ICHCLR: International Consortium for Harmonization of Clinical Laboratory Results (AACC);
IFCC: International Federation of Clinical Chemistry and Laboratory Medicine;
ILAC: International Laboratory Accreditation Cooperation;
IOM: Institute of Medicine;
IRMM: Joint Research Centre Institute for Reference Materials and Measurements;
IUPAC: International Union of Pure and Applied Chemistry;
JCTLM: Joint Committee for Traceability in Laboratory Medicine;
KIMMS: Key Incident Monitoring and Management Systems (RCPAQAP);
LTO: Lab Tests Online;
NACB: National Academy of Clinical Biochemistry (AACC);
NIST: National Institute of Standards and Technology;
NORIP: Nordic Reference Interval Project;
PITUS: Pathology Information Terminology and Units Standardisation (RCPA);
Page 9
RCPA: Royal College of Pathologists of Australasia;

RCPAQAP: Royal College of Pathologists of Australasia Quality Assurance Programs;
RM: reference material;
SIG: Special Interest Group;
TFG: Task and Finish Group (EFLM);
TF-PG: Task Force on Performance goals in Laboratory Medicine (EFLM);
WG-BV: Working Group on Biological Variation (EFLM);
WG-CM: Working Group on Cardiac Markers (EFLM);
WG-G: Working Group on Guidelines (EFLM);
WG-LEPS: Working Group on Laboratory Errors and Patient Safety (IFCC);
WG-PFLM: Working Group on Patient Focused Laboratory Medicine (EFLM);
WG-POST: Working Group on Postanalytical Phase (EFLM);
WG-PRE: Working Group on Preanalytical Phase (EFLM);
WG-PSEP: Working Group on Performance Specifications for the Extra-analytical Phases (EFLM);
WHO: World Health Organization.
In Table 1 many of the EFLM harmonization ac- different measurement procedures for the
tivities involving pre-analytical, post-analytical same laboratory test where there is no refer-
and post-post analytical activities are described. ence measurement procedure available. Gary
As noted by Ceriotti, a PubMed search for the Myers and Greg Miller describe how an in-
words “harmonization” or “harmonisation” re- ternational consortium for harmonization of
sulted in 972 items, with a sharp increase in the clinical laboratory results (ICHCLR) has been
numbers of publications in the last 5 years. It is formed to organize these global harmoniza-
apparent that in many countries clinical chem- tion efforts (5, 16).
istry societies and other professional groups
including External Quality Assurance Schemes The role of the ICHCLR infrastructure is to
(EQAS) are working on harmonization projects address: 1) prioritizing measurands by medi-
(Table 1). cal importance, 2) coordinating the work of
different organizations, 3) developing tech-
A pathway for global harmonization of assays nical processes to achieve harmonization
While the metrological concepts of stan- when there is no reference measurement
dardization, calibration traceability to refer- procedure or no reference material and 4)
ence materials and measurements, and mea- promoting surveillance of the successes of
surement uncertainty are described in the harmonization. A key focus of the ICHCLR
International Organization for Standardization is cooperation with other organizations al-
(ISO) standards ISO 17511 (14) and 18153 ready actively working to improve harmoni-
(15) and assure the accuracy and equivalence zation of laboratory test results such as the
of clinical laboratory results, harmonization International Federation of Clinical Chemistry
is required to achieve uniform results among and Laboratory Medicine (IFCC).
Page 10
The major advantages of harmonized test professional organizations and each other to at-
results include the use of common decision tain harmonization, and still retain viable busi-
limits specified in clinical guidelines across nesses. In their view industry support can be
all methods and uniform interpretation of re- best achieved when harmonization initiatives
sults. An example of a current IFCC standard- are coordinated and prioritized. Major factors
ization project involving harmonization is that to be considered are:
for thyroid function tests with the Committee
1. Competing project priorities for companies;
on the Standardization of Thyroid Function
Tests led by Linda Thienpont using a step-up 2. Requirements by regulatory agencies for re-
harmonization approach. Other up-to-date registration and associated additional costs
information about measurands in need of and other manufacturing issues;
harmonization is available online at: http:// 3. Need for cooperation between companies
www.harmonization.net, together with a through contributing to the prioritization of
toolkit with information about harmonization projects, design of experiment, etc.;
protocols.
4. Device manufacturer’s typically register
What is the role of the IVD industry products with the US FDA using a predicate
in harmonization? device to demonstrate product acceptance.
In such cases proof of substantial equiva-
The In Vitro Diagnostics (IVD) industry is ex-
lence is essential to demonstrate the assay
pected to provide traceability information in-
is safe and effective. Ideally companies want
dicating that their routine assays are traceable
to compare their assay with a traceable ref-
to reference materials and/or reference meth-
erence assay that is listed on the JCTLM
ods. However, traceability does not necessar-
website (Joint Committee for Traceability in
ily ensure comparability of patient test results.
Rather, both harmonization and metrological Laboratory Medicine);
traceability of assays are required to provide 5. Does a harmonization effort add value to
test results that are clinically equivalent be- patient care? The cost of harmonization
tween different manufacturers’ analytical sys- which includes physician education, patient
tems (5). In their paper on the role of the IVD safety and investment in product redevel-
industry in the harmonization of clinical labora- opment needs to be assessed against the
tory test results, Dave Armbruster and James clinical benefit of harmonization.
Donnelly describe here the six “pillars” that are
needed to achieve traceability and harmoniza- How do we derive harmonized
tion (17). These are: 1) reference measurement Reference Intervals?
procedures; 2) reference materials; 3) refer- In the post-analytical phase laboratory test re-
ence measurement laboratories; 4) universal sults are compared to reference intervals (RIs)
reference intervals; 5) EQA programs using or decision limits depending on the analyte
commutable samples with reference method measured. However, where the same values
target values to allow accuracy-based grading are interpreted differently due to differences
of manufacturers’ assays; and 6) harmonized in RIs or decision limits this may lead to inap-
basic terminology and units. propriate over- or under-investigation or treat-
As both authors state, the new challenge for ment of the patient. The use of harmonized
the IVD industry is to work with the many or common RI across different platforms and/
Page 11
or assays aims to give the same interpretation used by other laboratories in your region where
irrespective of the pathology provider or the it is possible and appropriate for your local popu-
method, provided the same unit and termi- lation. Validation of reference intervals by local
nology are used. Harmonization of RIs occurs laboratories is central to the adoption of com-
optimally for those analytes where there is mon RIs nationally as is validation of flagging
sound calibration and traceability in place and rates to ensure the expected number of results
evidence from between-method comparisons
outside the RI is acceptable.
shows that bias would not prevent the use of
a common RI. How do we manage critical risk results?
Jill Tate, Gus Koerbin and Khosrow Adeli pro- Que Lam, Eva Ajzner, Craig Campbell and
vide an opinion in this issue on how to derive
Andrew Young write in this issue about the
harmonized reference intervals (18). A pre-
current situation and existing practices for
determined checklist approach to acquiring
the evidence for common RIs provides an ob- the management of critical risk results (19).
jective means of developing and assessing the They describe the need for more evidence
strength of the evidence. The selection of the from outcomes studies of critical risk results
RI will depend on various sources of informa- management to support laboratory practices
tion including local formal RI studies, published and the need for harmonized terminology.
studies from the literature, laboratory surveys, New harmonized terminology has recently
manufacturer’s product information, relevant been proposed, e.g. “high-risk results”, re-
guidelines, and mining of databases. sults requiring immediate medical attention
Several countries and regions including the and action, and “significant-risk results”, re-
Nordic countries, United Kingdom, Japan, sults which signify a risk to patient well-being
Turkey, and Australasia are using common RIs and require follow-up action within a clinically
that have been determined either by direct justified time limit (20). The authors discuss
studies or by a consensus process. In Canada the recently released Clinical and Laboratory
the Canadian Society of Clinical Chemists Standards Institute (CLSI) guideline CLSI GP47-
Taskforce is assessing the feasibility of estab- Ed1 for the management of laboratory test re-
lishing common reference values using data
sults that indicate risk for patient safety (21),
from the formal reference interval studies of
as well as presenting the Australasian recom-
CALIPER (Canadian Laboratory Initiative on
mendations. In order to promote best labo-
Pediatric Reference Intervals) and CHMS (The
Canadian Health Measures Survey) as the ba- ratory practice, Lam et al. recommend that
sis. Development of platform-specific common laboratories consider risk assessment when
reference values for each of the major analyti- compiling alert tables and involve laboratory
cal systems may be a more practical approach users when setting up protocols. They state:
especially for the majority of analytes that are “Harmonization in this area cannot simply be
not standardized against a primary reference a matter of shared definitions and procedures,
method and are not traceable to a primary or but must involve the determination and im-
secondary reference material. plementation of best practice. The challenge
The authors encourage laboratories to consider is to define best practice and to obtain the evi-
adopting reference intervals consistent with those dence required to support this”.
Page 12
CONCLUSIONS 8. Beastall GH. Adding value to laboratory medicine: a

professional responsibility. Clin Chem Lab Med 2013;
It is obvious that harmonization does not 51:221-7.
happen overnight but is a long term consen- 9. Ceriotti F. Harmonization initiatives in Europe. eJIFCC
sus process that ideally is based on hard evi- 2016;27:23-29.
dence that has been systematically compiled 10. Simundic AM, Cornes M, Grankvist K, Lippi G, Nybo
and has involved close interaction between M. Standardization of collection requirements for fast-
the laboratory and the clinician to ensure suc- ing samples: for the Working Group on Preanalytical
Phase (WG-PA) of the European Federation of Clinical
cessful implementation. It must be a shared Chemistry and Laboratory Medicine (EFLM). Clin Chim
responsibility of all stakeholders interested Acta 2014;432:33-7
in patient care. Harmonization aims to add 11. Simundic AM, Cornes M, Grankvist K, Lippi G, Nybo
value to Laboratory Medicine measurements M, Kovalevskaya S, Sprongl L, Sumarac Z, Church S.
and their interpretation. Harmonized test Survey of national guidelines, education and training
results will ensure that clinical guidelines on phlebotomy in 28 European countries: an original
report by the European Federation of Clinical Chemis-
that call for the use of laboratory tests can try and Laboratory Medicine (EFLM) working group for
be universally implemented. Harmonization the preanalytical phase (WG-PA). Clin Chem Lab Med
still allows for innovation through discus- 2013;51:1585-93.
sion and the input of new ideas. It should 12. Lippi G, Banfi G, Church S, Cornes M, De Carli G,
extend beyond clinical chemistry across to Grankvista K, Kristensena GB, Ibarza M, Panteghini M,
all other pathology and Laboratory Medicine Plebani M, Nyboa M, Smellie S, Zaninotto M, Simundic
A-M, on behalf of the European Federation for Clinical
disciplines as the problems are not unique Chemistry and Laboratory Medicine Working Group for
to chemistry. Preanalytical Phase. Preanalytical quality improvement.
In pursuit of harmony, on behalf of European Federation
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Page 14
Harmonization of clinical laboratory

information – current and future strategies
Mario Plebani
Department of Laboratory Medicine, University Hospital of Padova, Padova, Italy
ARTICLE INFO ABSTRACT
Corresponding author: According to a patient-centered viewpoint, the me-

Prof. Mario Plebani
Dipartimento Strutturale
aning of harmonization in the context of laboratory
Medicina di Laboratorio medicine is that the information should be compa-
Azienda Ospedaliera Università di Padova rable irrespective of the measurement procedu-
Via Giustiniani, 2
35128 Padova, Italy
re used and where and/or when a measurement is
Phone: 0498212792 made. Harmonization represents a fundamental as-
E-mail: mario.plebani@unipd.it pect of quality in laboratory medicine as its ultimate
Key words: goal is to improve patient outcomes through the
harmonization, standardization, traceability, provision of an accurate and actionable laboratory
interchangeability, quality, patient safety, information. Although the initial focus has to a large
quality indicators, total testing process
extent been to harmonize and standardize analytical
processes and methods, the scope of harmonization
goes beyond to include all other aspects of the total
testing process (TTP), such as terminology and units,
report formats, reference intervals and decision lim-
its, as well as tests and test profiles request and cri-
teria for interpretation. Two major progresses have
been made in the area of harmonization in laboratory
medicine: first, the awareness that harmonization
should take into consideration not only the analyti-
cal phase but all steps of the TTP, thus dealing with
the request, the sample, the measurement, and the
report. Second, as the processes required to achieve
harmonization are complicated, a systematic approa-
ch is needed. The International Federation of Clinical
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Mario Plebani
Chemistry and Laboratory Medicine (IFCC) has HARMONIZATION: CURRENT PROJECTS

played a fundamental and successful role in the
As recently highlighted by Tate and Coll ”clinical
development of standardized and harmonized
laboratory testing is now a global activity, and
assays, and now it should continue to work in
laboratories no longer work in isolation” (10).
the field through the collaboration and coope-
Therefore, there is an increasing awareness of
ration with many other stakeholders.
the importance and urgency to achieve harmo-
nization in all steps of the total testing process

(TTP) for ensuring comparability and inter-
changeability of laboratory information.
INTRODUCTION
Patients, clinicians and other healthcare pro- Harmonizing the pre-analytical phase
fessionals assume that clinical laboratory tests Several initiatives and projects are in progress
performed by different laboratories at different for harmonizing both the pre-pre-analytical
times on the same sample and specimen can as well as the pre-analytical processes. In the
be compared and that results can be reliably initial steps of the cycle, the issue of demand
and consistently interpreted (1). Unfortunately, management which focuses on ensuring ap-
these assumptions are not always justified be- propriate requesting is receiving an increasing
cause many laboratory test results are still hi- importance. A step forward in this area has
ghly variable, poorly standardized and harmo- been achieved through the acceptance of the
nized. Harmonization represents a fundamental definition of “inappropriate test demand” that
aspect of quality in laboratory medicine as its appears to be “a request that is made outside
ultimate goal is to improve patient outcomes some form of agreed guidance” (11). The type
through the provision of an accurate and ac- of guidance may vary from national and inter-
tionable laboratory information (2). Although national guidelines to locally agreed behaviours
the initial focus has to a large extent been to but the basic concept is the application of sci-
harmonize and standardize analytical processes entific evidence rather than anecdote to clini-
and methods, the scope of harmonization goes cal practice (8). Among the several progress,
beyond to include all other aspects of the total a special attention should be deserved to the
testing process (TTP), such as terminology and National Minimum Retesting Interval Project
units, report formats, reference intervals and promoted by the Clinical Practice Section of the
decision limits, as well as tests and test profiles Association for Clinical Biochemistry (ACB) in
request and criteria for interpretation (3, 4). the UK uses a “state of the art” approach to set
Major reasons to focus on a global picture of consensus/evidence based recommendations
harmonization are represented by: a) the na- on when a test should be repeated. (12).
ture of errors in laboratory medicine and the ev- The importance to standardize patient prepara-
idence of the high rates of errors in the pre-and tion and sample collection requirements to min-
post-analytical phases (5, 6), b) the evidence of imize the uncertainty from the pre-analytical
large variations in terminology, units and refer- phase has already activated efforts to provide
ence ranges (7), c) the increasing demand for better evidence and recommendations. (13,
improving appropriateness in test request and 14). Further work to optimize sample transpor-
result interpretation (8), and, finally, d) the risks tation procedures as well as the identification of
for patient safety related to previous issues (9). indicators for their monitoring has been done,
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Mario Plebani
and this is a premise for future harmonization its aspects through improvements in: a) defining
initiatives in this field (15-17). In addition, the the quality and quantity of human samples to
harmonization of procedures for evaluating the be used for standardization and harmonization
quality of biological samples, the criteria for studies (27, 28), b) identifying new and more
their acceptance and rejection even through robust mathematical models and statistical
the use of automated workstations and serum treatments of the data (29, 30). A major lesson
indexes has been largely reported and promot- we learnt, is that standardization and harmo-
ed (18-21). nization should not be applied only to clinical
chemistry measurands, but to the whole field of
Harmonizing analytical results laboratory medicine, including molecular diag-
Although the terms “standardization” and “har- nostics (31). It should be highlighted that one of
monization” define two distinct, albeit closely the most impressive and effective examples of
linked, concepts in laboratory medicine, the final harmonization in laboratory medicine is the ex-
goal is the same: the equivalence of measure- pression of prothrombin results as international
ment results among different routine measure- normalized ratio (INR). PT results are corrected
ment procedures over time and space according mathematically into INR by raising the PT-ratio
to defined analytical and clinical quality specifi- to a power equal to the international sensitivity
cations (22). index (ISI) thus harmonizing results stemming
While standardization, which allows the es- from different thromboplastins from patients
tablishment of metrological traceability to the on treatment with vitamin K antagonists (32).
System of Units (SI), represents the recom- Therefore, the debate on harmonization should
mended approach, for a multitude of measur- not be limited to clinical chemistry scientists but
ands the SI does not yet apply, in particular when should involve all fields of laboratory medicine
the components in the measurand comprise to provide comparability and interchangeability
a heterogeneous mixture. Over the past two of all tests usually performed in clinical labora-
decades, several clinical laboratory tests have tories, including “omics”.
been standardized through the development of Under the patient-centered viewpoint, the sup-
reference measurement procedures, the IFCC posed diatribe between standardization and
playing a major role in this project. In particu- harmonization should concentrate on more
lar, the standardization of glycated haemoglo- joint efforts to provide equivalence of measure-
bin contributed to significant improvements in ment results among different routine measure-
diabetes (23). Other important projects are in ment procedures and different clinical laborato-
progress in order to standardize measurands of ries over time and space.
high clinical value such as cardiac troponin (24)
and carbohydrate-deficient transferrin (25). Harmonizing the post-analytical phase
However, as a matter of fact, for a huge num-
Several issues in the post-analytical phase are in-
ber of measurands neither a reference method
creasingly acknowledged as fundamental steps
nor reference material are available (26). For all
these measurands, harmonization of available for achieving higher harmonization and effec-
methods and diagnostic systems should be pro- tiveness of laboratory information.
moted. In the last few years, significant progress Current evidence collected in the UK and in
has been done establishing an overarching con- Australia demonstrates a significant variation
trol system of the harmonization process in all in the units used for some tests and even more
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Mario Plebani
widespread variation in the way they are repre- harmonization initiatives and established com-
sented on screens and paper, as well as the way mon reference intervals in apparently healthy
they appear in electronic messages (33). This, in adult populations from five Nordic countries
turn, creates a potential for misinterpretation for 25 of the most common clinical chemistry
of laboratory results and risk for patient safety analytes (39) Several more recent initiatives
(7). As test results are increasingly transferred have already provided data for adopting com-
electronically, the argument for adopting a sin- mon reference intervals in huge geographical
gle standardized set of units needs immediate areas such as Asia (40), Canada (41-43) and
uptake (34). Australasia (44). In the Australasian approach,
Reference intervals are the most widely used selection of a common reference interval re-
decision-making tool in laboratory medicine quires a checklist assessment process be ad-
and serve as the basis for many of the interpre- opted to assess the evidence for their use and
tations of laboratory results. Numerous stud- is based on the criteria summarized in Table 1.
ies have shown large variation of reference in- The final decision on the common reference
tervals, even when laboratories use the same interval to be used involves weighing up each
assay thus contributing to different clinical in- piece of evidence. Importantly, the proposed
terpretation, risk for patients and unnecessary reference limits should also be supported by
test repetition (35, 36). The importance of ob- flagging rates which provide an indication of
taining reference intervals traceable to referent the clinical considerations of a reference inter-
measurement systems has been reported (37) val (46). However, the use of asterisks should
and evidence-based approaches to harmonize require further considerations because pa-
reference intervals have been promoted (38). tients and people who have no training in labo-
The Nordic Reference Interval Project (NORIP) ratory medicine now have direct access to their
was one of the earliest reference interval laboratory test results.
Table 1 Selection of common reference interval (RI): criteria to be adopted
1. Define analyte (measurand)

2. Define assays used, accuracy base, analytical specificity, method-based bias
3. Consider important pre-analytical differences, actions in response to interference
4. Define the principle behind the RI (e.g. central 95%)
5. Describe evidence for selection of common RIs data sources (literature, lab surveys,
manufacturers, data mining and the allowable bias goal as quality criterion for acceptance)
6. Consider partitioning based on age, sex, etc
7. Define degree of rounding
8. Assess clinical considerations of the RI
9. Consider use of common RI
10. Document and implement
Adapted from ref 45, modified.
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Mario Plebani
Various practices, a number of different termi- on indicators in the TTP have been developed
nologies and extremely different values have in some countries, there was no consensus for
been described in the literature affecting the the production of joint recommendations focu-
quality of critical results management. Large sing on the adoption of universal QIs and com-
variability in critical results practices have been mon terminology in the total testing process.
reported not only when comparing different A preliminary agreement has been achieved in
geographical areas but even in the same coun- a Consensus Conference organized in Padua in
try (47). Very recently, a study on the outcomes 2013, after revising the model of quality indi-
of critical values notification, demonstrated cators (MQI) developed by the Working Group
that in more than 40.0% of cases, they were un- on “Laboratory Errors and Patient Safety” of the
expected findings, and that notification led to a International Federation of Clinical Chemistry
change of treatment in 98.0% of patients admit- and Laboratory Medicine (IFCC). The consen-
ted to surgical and in 90.6% of those admitted sually accepted list of QIs, which takes into
to medical wards, thus confirming their impor- consideration both their importance and appli-
tance for an effective clinical decision-making cability, could be actually tested by all poten-
(48). Several initiatives and recommendations tially interested clinical laboratories to identify
on the harmonization of critical result manage- further steps in the harmonization project (55).
ment have been released (49-52) and, finally, a Preliminary performance criteria based on data
better awareness of the importance of this is- collected have been proposed to allow a ben-
sue for improving the quality of laboratory ser- chmark between different laboratories and to
vices and patient safety has been achieved. support improvement initiatives (56).
Quality indicators FUTURE STRATEGIES

The definition, implementation and monitoring Although standardization and harmonization
of valuable analytical quality specifications have in laboratory medicine have been recognized
played a fundamental role in improving the qual- as essential requirements for improving quali-
ity of laboratory services and reducing the rates ty and value for patients for a long time, some
of analytical errors. However, a body of evidence major barriers have affected the success of
has been accumulated on the relevance of the such projects. In fact, the processes required to
extra-analytical phases, namely the pre-analyt- achieve harmonization are complicated, costly,
ical steps, their vulnerability and impact on the and time consuming: a systematic approach,
overall quality of the laboratory information. therefore, is needed. This should be based on
The identification and establishment of valuable an infrastructure with “well-defined procedu-
quality indicators (QIs) represents a promis- res, transparent operations, effective commu-
ing strategy for collecting data on quality in the nication with all stakeholders, and a consensus
total testing process (TTP) and, particularly, for approach to cooperation” (57). This systema-
detecting any mistakes made in the individual tic approach and roadmap represent essential
steps of the TTP, thus providing useful informa- steps for more successful harmonization initiati-
tion for quality improvement projects (53). In ves. The increasing demand for standardization
addition, QIs represent a fundamental require- and harmonization in laboratory medicine re-
ment for the accreditation of clinical laborato- quires incremental progress in addressing these
ries according to the International Standard ISO issues through the cooperation between many
15189 (54). While some interesting programs stakeholders: laboratory professionals and their
Page 19
Mario Plebani
scientific societies and federations, clinicians, in have been made in the area of harmonization
vitro manufacturing industry, accreditation and in laboratory medicine: first, the awareness that
regulatory bodies, and patients’ representati- harmonization should take into consideration
ves (2). Several organizations, such as the IFCC, not only the analytical phase but all steps of the
the European Federation of Clinical Chemistry TTP, thus dealing with “the request, the sample,
and Laboratory Medicine (EFLM), the American the measurement, and the report”. Second, as
Association for Clinical Chemistry (AACC), the the processes required to achieve harmoniza-
World Health Organization, the recently formed tion are complicated, a systematic approach is
International Consortium for Harmonization of needed. A further achievement is the recogni-
Clinical Laboratory Results (ICHCLR) that are tion of the need to also apply the concepts of
working in the field should cooperate and in- harmonization and standardization in clinical
tegrate their efforts to avoid duplication of ini- research and in projects of translational medi-
tiatives and to provide joint programs. Other cine (58). The cooperation between laboratory
scientific organizations such as the Clinical and professionals, clinicians, IVD manufacturers, ac-
Laboratory Standards Institute (CLSI) and the creditation and regulatory bodies is essential.
Joint Committee for Traceability in Laboratory
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Page 22

Ferruccio Ceriotti1, 2
1
Laboratory Medicine Service, San Raffaele Hospital, Milano, Italy
2
Chair, EFLM WG-H (Working Group on Harmonisation of total testing process)
Corresponding author: Introduction: Modern medicine is more and more

Ferruccio Ceriotti
Laboratory Medicine Service
based on protocols and guidelines; clinical laboratory
San Raffaele Hospital data play very often a relevant role in these docu-
Via Olgettina 60 ments and for this reason the need for their harmo-
20132 Milano, Italy
Phone: +39 02 26432282 nization is increasing. To achieve harmonized results
Fax: +39 02 26432640 the harmonization process must not be limited to
E-mail: ceriotti.ferruccio@hsr.it only the analytical part, but has to include the pre-
Key words: and the post-analytical phases.
harmonization, total testing process
Results: To fulfill this need the European Federation
of Clinical Chemistry and Laboratory Medicine (EFLM)
has started several initiatives. A Working Group on
harmonization of the total testing process (WG-H) has
been created with the aims of: 1) surveying and sum-
marizing national European and pan European har-
monization initiatives; 2) promoting and coordinating
the dissemination of especially promising harmoni-
zation initiatives among the EFLM member societ-
ies; and 3) taking initiatives to harmonize nomen-
clature, units and reference intervals at a European
level. The activity of the WG started this year with
a questionnaire targeted at surveying the status of
various harmonization activities, especially those in
the pre- and post-analytical phase categories, among
the European laboratory medicine societies.
Page 23
Ferruccio Ceriotti
Conclusions: Based on the results of the ques- of harmonization in all medical fields. A PubMed
tionnaire, some activities promoting the dissemi- search for the words “harmonization” or “har-
nation of best practice in blood sampling, sample monisation” in the title field resulted in 972
storage and transportation, in collaboration with items, with a sharp increase in the numbers of
WG on the pre-analytical phase, will be promot- publications in the last 5 years (fig. 1).
ed, and initiatives to spread to all the European The importance of harmonization in Laboratory
countries the use of SI units in reporting, will be Medicine and the reasons for improving it are
undertaken. Moreover, EFLM has created a Task clearly stated in several papers (1-6). The mes-
and Finish Group on standardization of the color sage that comes from these papers is that the
coding for blood collection tube closures that is standardization of the analytical phase is crucial,
actively working to accomplish this difficult task but the harmonization process has to include
through collaboration with manufacturers. the total testing process, from the pre-pre-ana-
lytical to the post-post-analytical phase (2-6).

Starting from these considerations, the Executive
Board of EFLM (European Federation of Clinical
INTRODUCTION
Chemistry and Laboratory Medicine) decided
In the last few years there has been a continu- to create an ad hoc working group within the
ous growth in the awareness of the importance Science Committee.
Figure 1 Papers in PubMed with the word “harmonization” or “harmonisation”

in the title (last 25 years)
120
100
Number of papers
80
60
40
20
0
1990
1991
1992
1993
1994
1995
1996
1997
1998
1999
2000
2001
2002
2003
2004
2005
2006
2007
2008
2009
2010
2011
2012
2013
2014
2015
Year
Page 24
Ferruccio Ceriotti
The Working Group on the “Harmonisation of EFLM SURVEY ON HARMONIZATION

total testing process” (WG-H) has the following OF TOTAL TESTING PROCESS
terms of reference:
The survey aimed to collect information on the
• Survey and summarize national European harmonization activities already carried out,
and pan European harmonization initiatives. or currently on-going, by the different nation-
• Promote and coordinate the dissemination al societies of Europe. It was mainly based on
of at least two especially promising harmo- the ideas presented in the references 4 and 5
nization initiatives among the EFLM Member and covered the 3 main phases of the clinical
Societies. laboratory process: pre-analytical (8 questions),
analytical (5 questions) and post-analytical (8
• Undertake initiatives to harmonize nomen- questions). It was distributed to the Presidents
clature, units and reference intervals at a and National Representatives of the 40 EFLM
European level. Member Societies in 2 phases. In the first phase
The plan of action for the first two years is the held at the end of March 2015 the complete
following: survey consisting of 21 questions was sent out.
1. WG-H will act as a collector of the harmoni- After an evaluation of the replies received from
zation initiatives arising from other WGs or 22 National Societies, it was decided to send
a second reduced version (with only 9 of the
Task and Finish Groups of EFLM and from
original 21 questions) and to focus on the most
National Member Societies active in the field
relevant aspects of the pre- and post-analytical
and will disseminate them to all the EFLM
phases. This second questionnaire was sent in
Member Societies to monitor their applica-
July 2015 only to the representatives of the 18
tion and effects.
National Societies that did not reply in the first
2. WG-H will survey and promote the use of phase. This second phase was successful and
harmonized nomenclature for measurands we received 14 replies, with only 4 countries
and promote the use of amount of substance not responding, hence allowing us to draw an
units in the European countries. almost complete picture of the European situ-
3. WG-H will promote the implementation of ation regarding the harmonization activities in
common reference intervals for the measur- the pre- and post-analytical phases.
ands where this approach is feasible. I will present hereafter only the results relative
The European situation regarding harmoniza- to the 9 questions that received a reply from 36
tion is particularly critical essentially for two out of 40 countries.
reasons: there are many different countries
Questions on harmonization activities
(the members of EFLM equal 40), each one with
in the pre-analytical phase
unique traditions, culture and legislation as well
as many different languages. The first initiative 1. Is it common practice in your country to use
taken by the WG-H was a survey aimed at iden- “profiles” (e.g. liver function, electrolytes, etc.)
tifying those harmonization initiatives already for test requesting?
in place in the different European countries and 2. If YES, did/does your society produce some
to obtain a picture of the units of measurement document on harmonization of test request-
presently in use. ing profiles?
Page 25
Ferruccio Ceriotti
The questions aimed at identifying how wide- 4. Did/does your society publish indications for
spread the practice of requesting tests by pro- optimal timing for test repetition or minimal
files instead of test by test was and if the so- retesting intervals?
cieties gave any indication of their intention Most of the replies (30) were negative with 6
to standardize the content of each profile (e.g. positive. However, only the UK has officially
Electrolytes as only sodium, potassium and published a document (7). The minimum retest-
chloride or to include also bicarbonate and ing interval is an important element for govern-
anion gap). Twenty countries replied that the ing the appropriateness of test requesting and
use of profiles is common practice, but only 7 initiatives to expand similar documents at the
of them had undertaken test profile harmoni- European level are planned.
zation initiatives and only 3 sent us their prac- 5. Did/Does your society produce a document
tice documents indicating the suggested profile on quality of the diagnostic samples or have
contents (Russia, Kazakhstan, The Netherlands); some activity currently on this topic?
unfortunately all were in the national language
This is a very sensitive topic, especially in this pe-
and were not understandable (a translation is in
riod when centralization and laboratory consoli-
progress). dation is occurring throughout Europe. Twenty-
3. Did/does your society, alone or in collabora- two societies replied ‘No’, 14 ‘Yes’ and two of
tion with clinical societies, elaborate guide- them (Spanish and German Societies) sent us
lines for diagnostic approaches to specific very detailed documents. The EFLM working
diseases? (e.g. myocardial infarction, coeliac group on the pre-analytical phase (WG-PRE) is
disease, etc.) working on this matter and specific documents
are in preparation.
Eighteen societies gave a positive reply and we re-
ceived several documents. The topics addressed Another important harmonization activity in
were the following: Autoimmune diseases, the pre-analytical phase is the harmonization
Coeliac disease, Chronic Kidney Disease (CKD), of blood sampling processes. Several European
Diabetes and Gestational Diabetes, Dyslipidemia scientific societies have produced documents
and Lipoprotein reporting, Myocardial infarction on this topic namely: Italy (8, 9), Croatia (10),
Slovenia, Norway, Russia, and The Netherlands.
(MI), Proteinuria, Thyroid diseases and Thyroid
Moreover the EFLM WG-PRE has already pre-
disease in pregnancy, Tumor markers.
pared a specific document (11) after conducting
Several topics (diabetes, MI, CKD, tumor mark- a survey of national guidelines, education and
ers) were covered by guidelines in various coun- training in phlebotomy (12).
tries; the material received was heterogeneous An important initiative for the safety of the op-
and, as expected, in many different languages. erator during blood drawing is the European
The WG-H has not yet been able to examine all Directive 2010/32/EU implementing the Frame
of them in detail, but probably there is a need work Agreement on prevention from sharps inju-
to promote European or international guide- ries in the hospital and healthcare sector concluded
lines from which each country can derive its by HOSPEEM (European Hospital and Healthcare
own document. In this way all 40 countries will Employers’ Association) and EPSU (European
be able to propose a harmonized approach Federation of Public Service Unions) (13). This
to the diagnosis of at least the most common directive has been converted in national law by
diseases. each member state, but its application is not yet
Page 26
Ferruccio Ceriotti
complete and the use of safety-engineered devices define a road map to arrive at a uniform coloring
for blood sampling has to be fully implemented. of the tube caps produced by the different manu-
A comprehensive overview of harmonization facturers with the aim of reducing the possible
activities in the pre-analytical phase was pub- errors when changing manufacturer or when re-
lished by the EFLM WG-PRE (14). ceiving tubes from different laboratories (15). All
A further harmonization initiative of EFLM stakeholders, including all manufacturers working
is the creation of a Task and Finish Group on in the field, have been invited to join a dialogue
Standardization of the colour coding for blood to establish a universally acceptable colour cod-
collection tube closures. This group is trying to ing standard for blood collection tube closures.
Table 1 Current use of SI units in Europe
Use of SI Intention to Use of SI Intention to
Nation Nation
units promote SI units promote SI
1 Albania <10% NO 21 Latvia - -
2 Austria - - 22 Lithuania >80% Yes
3 Belgium 50 – 80% Yes 23 Luxembourg - -
Bosnia
4 100% Yes 24 Macedonia >80% Yes
Herzegovina
5 Bulgaria 100% NO 25 Montenegro >80% Yes
6 Croatia >80% Yes 26 Norway >80% Yes
7 Cyprus <10% NO 27 Poland 50 - 80% Yes
8 Czech Republic >80% NO 28 Portugal 10 – 25% NO
9 Denmark >80% Yes 29 Romania 10 – 25% Yes
10 Estonia 50 – 80% Yes 30 Russia 100% Yes
11 Finland >80% Yes 31 Serbia 100% Yes
12 France 100% Yes 32 Slovak Republic >80% Yes
13 Germany 25 – 50% Yes 33 Slovenia 100% Yes
14 Greece <10% Yes 34 Spain <10% Yes
15 Hungary >80% NO 35 Sweden >80% Yes
16 Iceland >80% Yes 36 Switzerland >80% Yes
17 Ireland <10% Yes 37 The Netherlands >80% Yes
18 Israel <10% Yes 38 Turkey <10% Yes
19 Italy <10% Yes 39 Ukraine 100% Yes
20 Kosovo - - 40 UK >80% Yes
Page 27
Ferruccio Ceriotti
Questions on harmonization of sharing easily the documents within Europe.

in the post-analytical phase EFLM WG-PRE has produced several docu-
1. Did/does your society make documents or ments on which harmonization of several as-
guidelines on use or definition of autovalida- pects of the pre-analytical phase can be based.
tion rules? Implementing these on a European scale and
verifying the effectiveness of their application
Six societies replied ‘Yes’, but only Switzerland will be the real challenge for the future. The har-
supplied a document that is now in evaluation monization and standardization of the analyti-
for possible promotion at the European level. cal phase is already covered at the international
2. Do you have any data on the diffusion of the level by IFCC and by the American Association for
use of SI unit (amount of substance units, e.g. Clinical Chemistry’s International Consortium
mmol/L) in your country? on Harmonization of Clinical Laboratory Results
3. Did/does your society promote officially the (AACC ICHCLR) (1). EFLM is now working on the
use of SI units? definition of quality performance specifications
(16) that represent the basis for the harmoniza-
4. Would your society be in favour of initia- tion of analytical quality.
tives devoted to the introduction of SI units
(mmol/L)? The most problematic situation regards the
post-analytical phase. The unit of measurement
The replies to these questions are summarized problem is really important. While most of the
in Table 1 (above). northern European countries (excluding Ireland)
After the distribution of the survey we posed a declare an almost total adoption of the amount
further question on the use of katal for the ex- of substance (mole) unit for expressing the lab-
pression of enzyme catalytic activity. Five coun- oratory results, the southern countries (Spain,
tries replied that µkat/L is the unit used by all Italy, Albania, Greece, Turkey, Cyprus) are still
of the clinical laboratories in Slovenia, Slovakia, using traditional units and in some countries
Sweden, Czech Republic and Ukraine, 22 use like Italy, clinical laboratories use up to 5 dif-
U/L and we received no replies from the 13 oth- ferent units for the same test (e.g. Free T3: pg/
er countries. mL, ng/L, pmol/L, pg/dL and ng/dL). Moreover,
many of the countries that adopted the SI units
Another critical issue of the post-analytical
do not use katal for reporting enzymatic activity.
phase that requires harmonization is the com-
It may be easier to ask countries that adopted
munication of critical values. EFLM has estab-
katal to change back to international units rath-
lished a Task and Finish Group with the aim of
er than moving all the others to katal. Changing
surveying the critical result management proce-
old habits is difficult, and requires coordination
dures and policies laboratories currently have
and collaboration; however, some countries like
and how critical values are established and used
Albania, Cyprus and Portugal have declared that
in European laboratories.
they are not in favor of any change. WG-H will
promote initiatives in the southern European
CONCLUSIONS
countries to gradually move toward a larger use
There are several harmonization initiatives in of the SI units, starting with electrolytes. Finally
place in different European countries, but these the problem of reference intervals remains un-
initiatives are not coordinated. The problem of touched. Initiatives, similar to the Australasian
the different languages precludes the possibility one (17), are very difficult at the European level.
Page 28
Ferruccio Ceriotti
There is an initiative in the UK (18) and the pre- 10. Nikolac N, Šupak-Smolčić V, Šimundić AM, Ćelap I.
vious studies of the Nordic Countries (19) but I Croatian Society of Medical Biochemistry and Laboratory
Medicine: national recommendations for venous blood
do not foresee pan European initiatives in the sampling. Biochemia Medica 2013;23:242-54.
short period except for a few specific analytes.
11. Simundic AM, Cornes M, Grankvist K, et al. Standard-
Most of the work has yet to be done – we are ization of collection requirements for fasting samples: for
the Working Group on Preanalytical Phase (WG-PA) of
just at the beginning. Communication and col-
the European Federation of Clinical Chemistry and Labo-
laboration with the National Societies will be ratory Medicine (EFLM). Clin Chim Acta 2014;432:33-7.
the key to achieving some progress in this field 12. Simundic AM, Cornes M, Grankvist K, et al. Survey of
which is crucial not only for our profession but national guidelines, education and training on phlebot-
for medicine as a whole. omy in 28 European countries: an original report by the
European Federation of Clinical Chemistry and Labora-
tory Medicine (EFLM) working group for the preanalytical
REFERENCES phase (WG-PA). Clin Chem Lab Med 2013;51:1585-93.
1. Miller WG, Myers GL, Gantzer ML, et al. Roadmap for 13. http://eur-lex.europa.eu/legal-content/EN/
harmonization of clinical laboratory measurement proce- TXT/?uri=CELEX:32010L0032. Accessed October 31st 2015.
dures. Clin Chem 2011;57:1108–17.
14. Lippi G, Banfi G, Church S, et al. Preanalytical qual-
2. Plebani M. Harmonization in laboratory medicine: the ity improvement. In pursuit of harmony, on behalf of Eu-
complete picture. Clin Chem Lab Med 2013;51:741–51. ropean Federation for Clinical Chemistry and Laboratory
3. Tate JR, Johnson R, Barth J, Panteghini M. Harmoniza- Medicine (EFLM) Working group for Preanalytical Phase
tion of laboratory testing — A global activity. Clin Chim (WG-PRE). Clin Chem Lab Med 2015;53:357–70.
Acta 2014;432:1-3.
15. Simundic AM, Cornes MP, Grankvist K, et al. Colour
4. Tate JR, Johnson R, Barth J, Panteghini M. Harmoniza- coding for blood collection tube closures - a call for har-
tion of laboratory testing — current achievements and monisation. Clin Chem Lab Med 2015;53:371-6.
future strategies. Clin Chim Acta 2014;432:4–7.
16. Panteghini M, Sandberg S. Defining analytical perfor-
5. Aarsand AK, Sandberg S. How to achieve harmonisa- mance specifications 15 years after the Stockholm con-
tion of laboratory testing — the complete picture. Clin ference. Clin Chem Lab Med. 2015;53:829-32.
Chim Acta 2014;432:8–14.
17. Tate JR, Sikaris K, Jones GRD, et al. Harmonising Adult
6. Plebani M, Panteghini M. Promoting clinical and lab- and Paediatric Reference Intervals in Australia and New
oratory interaction by harmonization. Clin Chim Acta Zealand: An Evidence-Based Approach for Establishing
2014;432:15–21. a First Panel of Chemistry Analytes. Clin Biochem Rev
7. http://www.acb.org.uk/docs/default-source/guide- 2014;35:213-35.
lines/acb-mri-recommendations-a4-computer.pdf. 18. http://www.pathologyharmony.co.uk/. Accessed Oc-
Accessed October 31st 2015. tober 31st 2015.
8. Lippi G, Caputo M, Banfi G, et al. Raccomandazioni per il 19. Rustad P, Felding P, Lahti A, Hyltoft Petersen P. De-
prelievo di sangue venoso. Biochim Clin 2008;32:569-77.
scriptive analytical data and consequences for calcula-
9. Lippi G, Mattiuzzi C, Banfi G. Proposta di una “check- tion of common reference intervals in the Nordic Refer-
list” per il prelievo di sangue venoso. Biochim Clin 2013; ence Interval Project 2000. Scand J Clin Lab Invest 2004;
37:312-7. 64:343-70.
Page 29
The International Consortium for Harmonization

of Clinical Laboratory Results (ICHCLR)
– a pathway for harmonization
Gary L. Myers1, W. Greg Miller2
1
Chair, Joint Committee for Traceability in Laboratory Medicine, Smyrna, Georgia, USA
2
Professor of Pathology, Director of Clinical Chemistry, Virginia Commonwealth University Health System,
Richmond, Virginia, USA
Corresponding author: Results from clinical laboratory measurement proce-

Gary Myers dures must be equivalent to enable effective use of
Chair, JCTLM
Smyrna, Georgia, USA clinical guidelines for disease diagnosis and patient
International Consortium for Harmonization management. Analytical results that are harmonized
of Clinical Laboratory Results (ICHCLR) and independent of the measurement system, time,
c/o AACC, 900 Seventh Street, Suite 400
Washington, DC 20001, USA
and location of testing is essential for providing ad-
equate patient care. The key to generating harmo-
Key words: nized results is establishing traceability to an accept-
harmonization, traceability,
harmonization consortium, measurand, ed reference standard where available. Awareness
comparable test results of the benefits of having traceable measurement re-
sults that are harmonized has increased along with
efforts to develop approaches to enable and facilitate
the implementation of harmonization. Although sev-
eral organizations are addressing harmonization of
test procedures, centralized and cooperative global
oversight is needed to ensure that the most impor-
tant tests are being addressed and resources are op-
timally used. Working with its domestic and interna-
tional partners, the American Association for Clinical
Chemistry (AACC) has created an International
Consortium for Harmonization of Clinical Laboratory
Results. Advances in this area will improve the qual-
ity of patient care.
Page 30
Gary L. Myers, W. Greg Miller
The ICHCLR – a pathway for harmonization
THE PROBLEM: INTRODUCTION ACHIEVING HARMONIZED

LABORATORY TEST RESULTS
Many clinical decisions are based upon clinical
guidelines that use a fixed laboratory test re- There are basically two important aspects or
sult for treatment decisions. A basic problem in requirements to achieve harmonized or equiv-
laboratory medicine is that different laboratory alent results. The first requirement is that all
measurement procedures that intend to mea- measurement procedures must measure the
sure the same measurand may give different same quantity. Secondly all measurement pro-
results for the same specimen. If different labo- cedures should be traceable to a common ref-
ratories get different results, clinical guidelines erence system. There is an ISO Standard 17511
become compromised and a patient may get that describes traceability and puts forth a
the wrong treatment. Many clinical studies may pathway for establishing a traceable link to a
use a central laboratory with a single method;
reference system, where one exists (3). Figure
however, guidelines resulting from such a study
1 shows the traceability scheme based on the
cannot be effectively implemented until all oth-
ISO Standard. Since it is not practical in the clini-
er methods are harmonized to the central labo-
cal laboratory to use a reference measurement
ratory procedure. Other types of clinical studies
procedure for routine testing, it is important
may use multiple laboratories that use differ-
ent methods in which case data cannot be ag- that the patient’s result is traceable to the refer-
gregated to develop guidelines until the results ence measurement procedure. Establishing this
from the different methods are harmonized. “traceability chain” is accomplished through
the materials and methods depicted in Figure 1.
Over the past two decades, there have been
In many instances it may be necessary to substi-
a number of harmonization successes that
tute a panel of patient samples when reference
have contributed to significant improvements
materials are not available or deficiencies of the
in identifying and managing individuals with
reference materials limit their use. For example,
chronic diseases, such as diabetes and heart
many existing reference materials are not com-
disease (1, 2). But despite these successes, the
total number of laboratory tests for which a ref- mutable with patient samples and therefore
erence system is available remains very small not suitable to be used to calibrate routine clini-
(approximately 80). cal laboratory test procedures (4).
It is important to recognize that calibration
WHAT IS HARMONIZATION traceability does not ensure accuracy for an
Harmonization is achieving uniform results individual patient’s sample. The imprecision of
among different measurement procedures for the measurement procedure may be too large,
the same laboratory test. Harmonization usually the measurement procedure may not be spe-
implies there is no reference measurement pro- cific for the measurand, interfering substances
cedure available. Harmonization includes con- may influence the result or the measurand it-
sideration of nomenclature, patient preparation, self may not be well defined and the molecular
specimen collection and handling, result value, form of clinical interest may not be understood.
reporting units and interpretative information. Consequently different methods may be mea-
The topic for this report focuses on achieving suring something a little bit different making it
harmonized test results. impossible to achieve harmonization of results.
Page 31
Figure 1 Traceability scheme
Source: ISO 17511
WHAT TO DO unmet needs for harmonization of clinical labo-

ratory measurement procedures (5). The key
The AACC convened an international leadership
point in the roadmap was a recommendation to
conference in 2010 to address some of the is-
develop an infrastructure to coordinate harmo-
sues that hamper calibration and traceability in
laboratory medicine. Professional organizations nization activities worldwide. The infrastructure
and in vitro diagnostics (IVD) manufacturers needed to address the following key points: 1)
were invited to send representatives to partici- prioritizing measurands by medical importance,
pate in this leadership conference. Ninety indi- 2) coordinating the work of different organi-
viduals from 12 countries representing 62 orga- zations, 3) developing technical processes to
nizations and IVD manufacturers participated in achieve harmonization when there is no refer-
the conference to review the issues and come ence measurement procedure or no reference
up with recommendations for improving cali- material and 4) promoting surveillance of the
bration traceability in laboratory medicine. The successes of harmonization. These four goals
output from this conference was a proposed were intended to address the key issues identi-
roadmap that established a pathway to address fied by the conference participants.
Page 32
One of the key attributes of this new infra- Figure 2 shows the organizational infrastruc-
structure is a focus on cooperation with other ture for the International Consortium for
organizations already actively working to im- Harmonization of Clinical Laboratory Results
prove harmonization of laboratory test results. (ICHCLR) created to fulfil the roadmap recommen-
Cooperation is accomplished in part by estab- dations. The AACC, which supported the devel-
lishing a communication portal that provides in- opment work, agreed to serve as the Secretariat
formation on what harmonization activities are and host organization for this new consortium.
being conducted by organizations in different The principal components of the ICHCLR include;
countries. A communication portal is essential a Council made up of a small number of profes-
to minimize duplication of effort and resources. sional organizations which is responsible for the
governance and administration of the program,
FORMATION OF A HARMONIZATION a Harmonization Oversight Group (HOG) which is
CONSORTIUM
the principle group responsible for the operation
Following the international leadership confer- and management of harmonization activities,
ence, a steering committee was established to an Organizational Member category which pro-
fully develop the consortium organization. vides an opportunity for organizations (e.g., IVD
ig
Figure 2 An infrastructure for harmonization
International Consortium for

Harmonization of Clinical Laboratory Results
Strategic
Council Organizational
Partners
Member
Group
Governance, Harmonization Operations

Administration Oversight Management
Group
Harmonization Special
Implementation Working
Groups Groups
Secretariat/Host - AACC
Page 33
manufacturers, professional societies, standard- given measurand. If an organization, such as the

setting organizations, etc.) to become a member International Federation of Clinical Chemistry
of the ICHCLR and appoint a representative to be and Laboratory Medicine (IFCC) that is active
a member of the HOG, and a Strategic Partners in harmonization work, is interested to accept
Group which is open to interested stakeholders a project, then the HOG will refer a project to
to officially join and contribute to the consor- that organization and provide a link on the web
tium by submitting measurands in need of har- site so progress can be tracked. Alternatively,
monization and nominating experts for consid- the HOG may recommend that a project to har-
eration to serve on the HOG. monize the measurand be initiated. The HOG
As the HOG is the central organizing body will then identify a champion and appoint a
for managing harmonization activities in the Harmonization Implementation Group (HIG)
Consortium, a key responsibility is to communi- to develop a technical plan for harmonization
cate with strategic partners, which include clini- with the ultimate goal to achieve listing in the
cal practice groups, laboratory practice groups, database maintained by the Joint Committee for
IVD manufacturers, public health organizations, Traceability in Laboratory Medicine (JCTLM).
metrology institutes, standards organizations, The JCTLM uses ISO standards to review refer-
regulatory organizations and proficiency testing ence measurement procedures (ISO 15193),
and external quality assessment organizations. reference materials (ISO 15194) and reference
It is extremely important that all of these orga- measurement laboratories (ISO 19195) for con-
nizations are engaged in the process and know formance to ISO criteria. The JCTLM database
what is going on. Another major responsibility (www.bipm.org/jctlm/) lists approved refer-
of the HOG is to evaluate measurand propos-
ence measurement procedures, reference ma-
als submitted by interested stakeholders and
terials, and reference measurement services
determine their priority and technical feasibility
that the IVD industry can use as the basis for
for harmonization. To accomplish this, a Special
measurement procedure calibration traceabil-
Working Group of experts can be convened to
ity. What is missing from the ISO standards is a
evaluate a submitted proposal and make rec-
standard that addresses traceability to a harmo-
ommendations back to the HOG. Criteria for
nization protocol that does not use a reference
prioritization include: medical need, is the test
measurement procedure or certified reference
associated with a particular clinical practice
guideline, frequency of testing, and perfor- material. To fill this need the HOG developed
mance of routine tests methods in proficiency and submitted to the ISO Technical Committee
testing and external quality assurance schemes 212, a preliminary work item proposal on har-
(EQAS) programs. The HOG will post prioritiza- monized measurement procedures. This pro-
tion information on the Consortium website posal is being addressed by Working Group 2 as
so that stakeholders around the world will be a new standard that will allow JCTLM listing of
aware of what measurands are in need of har- processes to achieve harmonization.
monization. The prioritized list will allow stan-
dards organizations and IVD companies to de- WEBSITE PORTAL
cide how to direct limited resources to improve As mentioned previously, a key attribute of the
harmonization of clinical laboratory test results. ICHCLR is the establishment of a communica-
The web site also includes information on what tion portal to share information on harmoniza-
organization is pursuing harmonization of a tion activities from around the world. A website
Page 34
Figure 3 Harmonization website resources page
portal for this purpose has been established at world. Individuals or organizations can submit
www.harmonization.net. Figure 3 is a screen a measurand to the Consortium for inclusion on
shot of the harmonization website resources the priority list through the website. A fully elec-
page. The site provides information on the tronic process provides an efficient mechanism
Council, the HOG, and the Strategic Partners for submitting measurands for consideration.
Group. The site contains resources to support
global harmonization of clinical laboratory TOOLBOX FOR HARMONIZATION
measurement procedures including: a link to
the “Roadmap” paper, an AACC position state- Special attention is drawn to the toolbox of tech-
ment on harmonization, minutes from meet- nical procedures to be considered when devel-
ings of the Council and HOG, Strategic Partners oping a process to achieve harmonization for a
Update Reports, operating procedures for the measurand. The toolbox was created by a task
ICHCLR and a copy of the toolbox of technical force during the formation of the Consortium
procedures to be considered when developing and contains useful information as a starting
a process to achieve harmonization for a mea- point for harmonization. There are two key pro-
surand. There is a separate section dedicated tocols detailed in the toolbox, 1) the integrated
to measurands which provides information on harmonization protocol and 2) a step-up design
the status of harmonization and standardization for harmonization. The integrated protocol is
of measurands from organizations around the meant to be an assessment study which is a
Page 35
very carefully designed experiment incorporat- in many important ways. Harmonized test re-
ing clinical samples, pooled clinical samples, sults will ensure that clinical guidelines that
admixed clinical samples to assess linearity and call for the use of laboratory tests can be ap-
any candidate reference materials that may be propriately implemented. Reliable screening to
available. The protocol integrates into one care- detect diseases early, when they are easier to
fully designed experiment the ability to obtain treat; appropriate diagnoses of diseases; cor-
information to enable decisions on feasibility rect and consistent treatment decisions; and
to achieve harmonization given the tools avail- effective monitoring of responses to treatment
able, the preferred approach to harmonization will be important outcomes of more extensive
that is likely to succeed and based on this infor- harmonization of clinical laboratory test results.
mation a commitment to proceed by interested Furthermore, by reducing incorrect interpreta-
stakeholders. tions of laboratory test results, harmonization
The Step-up design is intended for use when can help prevent treatment errors and unnec-
there is no reference measurement procedure essary — and expensive — follow-up diagnostic
and no reference material. This particular pro- procedures and treatments based on inaccu-
tocol was developed under the leadership of rate laboratory test results. The ICHCLR encour-
Professor Linda Thienpont in the context of the ages all interested stakeholders to recognize the
IFCC Committee for Standardization of Thyroid critical role of clinical laboratory testing in im-
Function Tests (6). The step-up design is a se- proving health outcomes and to join the ICHCLR
quence of patient sample comparisons between in promoting the need for achieving harmoniza-
clinical laboratory procedures where success at tion of laboratory tests results.
one phase allows the harmonization process to
“step up” to the next phase. The phases are de- REFERENCES
signed to determine whether the methods cor- 1. Little RR, Rohlfing CL, Wiedmeyer HM, Myers GL, Sacks
relate with each other, which is an essential pre- DB and Goldstein DE for the NGSP Steering Committee.
The National Glycohemoglobin Standardization Program:
requisite to achieve harmonization, if there is an A five-year progress report. Clin Chem 2001;47:1985-92.
adequate response over the measuring interval, 2. Warnick GR, Kimberly MM, Waymack PP, Leary ET,
if there is adequate specificity for the measur- Myers, GL. Standardization of measurements for choles-
and and an adequate value assignment, such as terol, triglycerides and major lipoproteins. LABMEDICINE
2008;39:481-90.
an all methods mean or a trimmed all methods
mean that may be agreeable on a consensus ba- 3. ISO. In vitro diagnostic medical devices — measurement
of quantities in biological samples — metrological trace-
sis. After several qualification phases, a panel of ability of values assigned to calibrators and control ma-
patient sera is fit for purpose to harmonize a set terials. 1st ed. ISO17511:2003(E). Geneva: ISO; 2003.ISO
of clinical laboratory measurement procedures. 17511
Sustainability is assured by a second panel to 4. Miller WG, Myers GL, Rej R. Why commutability mat-
harmonize new methods entering the market ters. Clin Chem 2006;52:553-4.
and to be used to transfer values to subsequent 5. Miller WG, Myers GL, Gantzer ML, Kahn SE, Schönb-
runner ER, Thienpont LM, Bunk DM, Christenson RH, Eck-
panels to maintain consistency of the scheme. feldt JH, Lo SF, Nübling CM and Sturgeon CM. Roadmap
for harmonization of clinical laboratory measurement
PATH FORWARD procedures. Clin Chem 2011;57:1108-17.
6. Van Uytfanghe K, De Grande LA, Thienpont LM. A
Harmonizing a greater number of clinical labora- “Step-Up” approach for harmonization. Clin Chim Acta
tory tests will contribute to improved healthcare 2014;432:62-7.
Page 36
Harmonization of clinical laboratory test results:

the role of the IVD industry
Dave Armbruster1, James Donnelly2
1
Director, Clinical Chemistry Scientific Leadership, Abbott Diagnostics
2
Chief Scientific Officer, Siemens Healthcare Diagnostics Inc.
Corresponding authors: At the start of the 21st century, a dramatic change oc-
Dave Armbruster
Director, Clinical Chemistry Scientific Leadership
curred in the clinical laboratory community. Concepts
Abbott Diagnostics from Metrology, the science of measurement, be-
E-mail: david.armbruster@abbott.com gan to be more carefully applied to the in vitro
James Donnelly diagnostic (IVD) community, that is, manufactur-
Chief Scientific Officer ers. A new appreciation of calibrator traceability
Siemens Healthcare Diagnostics Inc.
E-mail: james.g.donnely@siemens.com evolved. Although metrological traceability always
existed, it was less detailed and formal. The In
Key words: Vitro Diagnostics Directive (IVDD) of 2003 required
metrology, traceability,
standardization, harmonization manufacturers to provide traceability information,
proving assays were anchored to internationally ac-
Disclosure:
Dave Armbruster is an employee
cepted reference materials and/or reference meth-
of Abbott Diagnostics. ods. The intent is to ensure comparability of patient
test results, regardless of the analytical system
used to generate them. Results of equivalent qual-
ity allows for the practical use of electronic health
records (EHRs) capture a patient’s complete labo-
ratory test history and allow healthcare providers
to diagnose and treat patients, confident the test
results are suitable for correct interpretation, i.e.,
are “fit for purpose” and reflect a real change in a
patient’s condition and not just “analytical noise.”
The healthcare benefits are obvious but harmoni-
zation of test systems poses significant challenges
to the IVD Industry. Manufacturers must learn the
Page 37
Dave Armbruster, James Donnelly
theory of metrological traceability and apply methodology, stable analytical performance, etc.)
it in a practical manner to assay calibration so a significant change in concentration (de-
schemes. It’s difficult to effect such a practi- crease or increase) would signal a meaningful
cal application because clinical laboratories clinical change. In reality, patients are increas-
do not test purified analytes using reference ingly mobile and two or more laboratories may
measurement procedures but instead deal test their samples. If the tests performed by dif-
with complex patient samples, e.g., whole ferent laboratories are sufficiently harmonized
blood, serum, plasma, urine, etc., using “field so as to produce essentially equivalent results
methods.” Harmonization in the clinical labo- (not necessarily quantitatively equal, but clini-
ratory is worth the effort to achieve optimal cally equivalent), changes in concentration can
patient care. be correctly interpreted by a healthcare provid-
er. As explained by Gantzer and Miller “Clinical
 laboratory measurement results must be com-
parable among different measurement proce-
INTRODUCTION dures, different locations and different times in
order to be used appropriately for identifying
The world is experiencing globalization and the and managing disease conditions (4).”
clinical laboratory field is no exception. The goal
Harmonization is needed to use of electronic
is to provide optimal healthcare to the global
medical records/electronic health records
population and clinical laboratory practice is
(EMRs/EHRs) to capture all of a patient’s lab re-
inexorably moving towards harmonization. As
sults in an electronic file available to patients and
stated by Greenberg, “An increasingly important
healthcare providers. Clinical laboratory results
objective in laboratory medicine is ensuring the
typically account for much of the information in
equivalency of test results among different mea-
EMRS but the benefit is negated if the cumula-
surement procedures, different laboratories and tive values in EMR for the same analyte are not
health care systems, over time (1).” This requires comparable. Perhaps not a problem for trace-
harmonization and metrological traceability of able analytes, e.g., electrolytes and glucose, but
assays to provide equivalence of results derived very much an issue for immunoassays such as
from different analytical systems (2). This has thyroid and fertility hormones and cancer mark-
not been possible historically because assays ers. Interpretation of sequential values using
provided by Industry have not been sufficiently common reference intervals and medical deci-
comparable due to a lack of established refer- sion levels (MDLs) is difficult, if not impossible.
ence materials and methods to “anchor” tests. It’s been suggested laboratory data accounts for
As noted by Miller and Myers, “True and precise about 70% of clinical decisions. Hallworth has
routine measurements of quantities of clinical in- challenged that blanket statement but allows
terest are essential if results are to be optimally “The value of laboratory medicine in patient
interpreted for patient care. Additionally, results care is unquestioned (5). That value is greatly di-
produced by different measurement procedures minished without comparability of test results.
for the same measurand must be comparable if
Cholesterol is a prime example of successful
common diagnostic decision values and clinical harmonization. Creating a reference measure-
research values are to be broadly applied (3).” ment system (RMS) for this key lipid over about
A patient’s test history would be consistent if a 30 years (1970 – 2000) coincided with a major
single clinical lab performed all testing (i.e., same reduction in mortality rates for coronary heart
Page 38
disease (CHD) in the US and also achieved a METROLOGICAL TRACEABILITY

huge savings in healthcare dollars (1). The con-
The In Vitro Diagnostics Directive (IVDD) of
sequences of the lack of harmonization was
2003 applies to Europe for the purposes of the
demonstrated by an NIST report on calcium (Ca)
CE mark, but has global implications. It requires
that estimated the cost of a 0.1 mg/dL Ca bias
manufacturers to establish the metrological
can cost $8 - $31 for additional, but unneces-
sary, patient follow up testing (6). A bias of 0.5 traceability and uncertainty of kit calibrators.
mg/dL could results in an additional $34 - $89/ “Metrological traceability is defined in the VIM,
patient. On an annual basis, a 0.1 mg/dL bias clause 2.41 as the ‘property of a measurement
could translate into $60 - $199 million/year for result whereby the result can be related to a
about 3.55 million patients screened for Ca. reference (a standard) through a documented
unbroken chain of calibrations, each contribut-
HARMONIZATION VS. STANDARDIZATION ing to the measurement uncertainty. (1)” The
IVDD doesn’t provide specifics but ISO 17511
In this paper “harmonization” is used interchange- (Metrological traceability of values assigned to
ably with “standardization,” though there is a dis- calibrators and control materials) applies (7; see
tinction between the two (4). Standardization Fig 1.). It establishes a metrology infrastructure
means results are traceable to higher metro- for assays. The IVDD requirements are incorpo-
logical order reference materials and/or meth- rated in ISO 15189 (Medical laboratories- par-
ods and ideally can be reported using SI units. ticular requirements for quality and compe-
Harmonization means results are traceable to tence) (8).
some declared reference but accepted higher
order reference materials and/or methods are As White explains “Metrology, the science of
not available and SI units are not applicable. measurement, provides laboratory medicine
Harmonization ensures comparability of re- with a structured approach to the development
sults, enables application of clinical best prac- and terminology of reference measurement sys-
tice guidelines and reference intervals, increas- tems which, when implemented, improve the
es patient safety, and decreases medical care accuracy and comparability of patients’ results
costs. Harmonization requires the cooperation (9).” Metrological principles are a relatively new
of laboratories, academia, professional societ- in the clinical laboratory. For example, the Tietz
ies, metrological institutes, government agen- Textbook of Clinical Chemistry (third edition,
cies, EQA/PT providers, and industry. Two re- 1999) made no mention of “uncertainty” or
cent harmonization (actually, standardization) “commutability” (10). The fourth edition (2006)
success stories mediated by Industry are cre- mentioned uncertainty and commutability but
atinine and glycated hemoglobin (Hb A1c). Field only a definition of commutability was given
assays for both of these analytes feature com- (11). The fifth edition (2011) includes a discus-
plete traceability chains and are firmly anchored sion of uncertainty along with commutability
by reference measurement systems. That said, (12). As noted by De Bievre, “Discussions with
ironically results for both assays are still typi- analytical chemists have revealed that basic
cally reported in different units, creatinine in concepts in metrology, including ‘traceability,’
mg/dL (“conventional units”) and mmol/L (SI are generally not an integral part of university
units), and Hb A1c in % Hb A1c (NGSP units) and or college curricula and are not treated in most
mmol/mol (SI units). text books of analytical chemistry” (13).
Page 39
Figure 1 General metrological traceability diagram from ISO 17511, in vitro

diagnostic medical devices — Measurement of quantities in biological
samples — Metrological traceability of samples assigned to calibrators
and control materials, 2003
Abbreviations: ARML - Accredited reference measurement laboratory (such a laboratory may be an independent or
manufacturer’s laboratory); BIMP - International Bureau of Weights and Measures; CGMP - General Conference on
Weights and Measures; ML - Manufacturer’s laboratory; NMI - National Metrology Institute.
The symbol uc(y) stands for combined standard uncertainty of measurement.
Metrology must be adapted to the clinical lab- well-defined analytes in simple matrices but
oratory, but a practical approach is advisable clinical labs test complex, ill-defined analytes
due to differences between the disciplines. in challenging matrices (serum, plasma, urine,
For example, Metrology is a “pure science” etc.). Metrology estimates expanded uncertain-
contrasting with the mixed science of clinical ty (bias eliminated) while clinical labs focus on
chemistry (combines several diverse sciences/ Total Error Allowable (TEa = bias + imprecision).
technologies). National metrology institutes are Metrology seeks “absolute scientific truth” by
“ivory towers” in comparison to clinical labora- reference method analysis but clinical labs deal
tories (“the trenches”). Metrology tests pure, in “relative truth” by field method analysis.
Page 40
Good metrology does not necessarily equal good traceability chain not available). The JCTLM pro-
clinical laboratory science but the clinical labo- vides a list of higher order RMs and RMPs and
ratory field needs to adapt Metrology concepts reference laboratories (17).
and “translate” them for practical application. A requirement for harmonization is commut-
ability. Commutability is defined as a property
THE PILLARS OF HARMONIZATION of a reference material, demonstrated by the
In anticipation of the IVDD, the Joint Committee closeness of agreement between the relation
for Traceability in Laboratory Medicine (JCTLM) among the measurement results for a stated
was formed in 2002 (1). It established three pil- quantity in this material, obtained according to
lars of traceability: 1. reference measurement two given measurement procedures, and the
procedures (RMP), 2. reference materials (RM), relation obtained among the measurement re-
and 3. a network of reference measurement sults for other specified materials (4). In other
laboratories. The JCTLM maintains a search- words, fresh patient samples and materials
able database for all three on the International such as calibrators need to provide an identi-
Bureau of Weights and Measures (BIPM) web cal analytical response (see Fig. 2). Many sec-
site (14). The laboratory community has iden- ondary RMs are not commutable with native
tified three other “pillars” in response to har- clinical samples and have failed to accomplish
monization: 1. universal reference intervals the intended goal of achieving harmonized
and medical decision levels (MDLs), 2. accura- results (4). Commutability is not a universal
cy based grading EQA/PT programs to ensure property of reference materials and must be
traceability of field assays is maintained and proven with every field method. Well recog-
nized by Metrology, commutability is not so
analytical bias is minimized or meets estab-
widely appreciated in routine clinical laborato-
lished criteria (e.g., CAP PT requirement of +/-
ries. Historically, the commutability reference
6% of the NGSP target value for Hb A1c), and
materials and calibrators prepared from them
3. harmonization of clinical laboratory practice
or traceable to them has not routinely been
and the total testing process (TTP), e.g., stan-
established. Noncommutability results in sig-
dardized nomenclature/terminology, reporting
nificant biases with field assays due to matrix
units, EBLM, etc.
effects, use of non-human forms of analyte,
The JCTLM goal is comparability of patient test lack of antibody specificity, or other causes.
results from different methods to ensure ap- The JCTLM now requires a commutability as-
propriate medical decision-making and optimal sessment of reference materials to be listed in
healthcare (15, 16). The components of a refer- its database. CLSI EP30 (Characterization and
ence measurement system (RMS) are: 1. defi- qualification of commutable reference materi-
nition of the analyte, 2. RMP that specifically als for laboratory medicine) is a recent guide-
measures the analyte, 3. Primary and second- line (18). Metrology defines measurement
ary reference materials, and 4. reference mea- uncertainty, or simply uncertainty, as a non-
surement laboratories. Analytes fall into two negative parameter characterizing the disper-
categories: 1. Type A (well defined; concentra- sion of the quantity values being attributed to
tion in SI units; results not method dependent; a measurand, based on the information used
full traceability chain), and 2. Type B (not well (4). It is roughly equivalent to imprecision but
defined, heterogeneous, present in both bound ideally assay bias is eliminated prior to esti-
and free state, not traceable to SI , rigorous mating uncertainty. CLSI EP29 (Expression of
Page 41
Figure 2 Commutability is demonstrated if fresh patient samples and reference

materials, e.g., calibrators, demonstrate an equivalent analytical response
when tested by two methods
Commutable: same relationship for clinical samples and reference materials.
measurement uncertainty in laboratory medi- programs using commutable samples with ref-
cine) is another recent guideline (19). erence method target values allow accuracy
The fourth “pillar” of traceability- universal ref- based grading (20). Horowitz notes “Far too
erence intervals- cannot be erected without the many laboratories consider proficiency testing
just a necessary evil, little more than periodic
adoption of reference measurement systems
pass–fail exercises we perform solely to meet
and assay harmonization. Reference intervals
regulatory requirements. Even for central-lab-
for some analytes can be affected by various
oratory techniques, traditional PT suffers from
partitioning factors, e.g., age, gender, ethnic-
‘matrix effects,’ in that samples used for test-
ity, BMI (body mass index), and thus universal
ing often react differently from native patient
ranges may not be feasible. But such decisions
samples. Therefore, comparisons must be
can’t be made until harmonization has been
made only to peer groups, rather than to the
achieved.
‘true value.’ What if the peer group as a whole
To meet the IVDD traceability requirement is wrong? (20)” EQA/PT has typically been
for result trueness and comparability requires used to measure proficiency at performing a
the fifth “pillar:” validation of manufacturers’ test and not the trueness of the test method or
metrological traceability by EQA/PT. EQA/PT its performance relative to other method. For
Page 42
this reason, Miller concludes “Traditional PT test profiles and criteria for the interpretation of
materials are not suitable for field-based post- results (23).” Harmonization of reporting units
marketing assessments of a method’s trueness would seem easy to achieve but that’s not the case.
(21).” In one study, commutable serum-based “Even a change in the unit of hemoglobin (Hb)
material was assigned target values by refer- expression could potentially affect patient safe-
ence methods for six enzymes (ALT, AST, CK, ty. Findings in a recent survey conducted in the
GGT, LD, and amylase) and was tested by 70 UK revealed that 80% of laboratories were using
labs in Germany, Italy, and The Netherlands us- g/dL, although g/L is the recommended unit …
ing six field methods (22). Results were grad- (23).” Harmonization of basic terminology and
ed on accuracy based on biological variability units is necessary but the international clinical
targets. For ALT, results were deemed accept- laboratory community has yet to reach agree-
able for > 94% of the six commercial assays. ment. For examples of disharmony, see Table 1.
Performance for the other five enzymes was
variable and all methods demonstrated signifi- CHALLENGES FOR THE IVD INDUSTRY
cant bias for CK. “Overall, it appears clear that
Embracing metrological concepts and harmo-
method bias should be reduced by better cali- nization represents a paradigm shift for the in
bration to the internationally accepted refer- vitro diagnostics community. Manufacturers
ence systems (22).” traditionally sought to differentiate them-
The sixth harmonization “pillar” is the Total Testing selves from competitors (e.g., by claiming a
Process (TTP). Plebani observed “Although the greater dynamic range, lower LoD, better pre-
focus is mainly on the standardization of mea- cision, smaller sample size, etc.), and produc-
surement procedures, the scope of harmoniza- ing comparable patient results was not a prior-
tion goes beyond method and analytical results: ity. Lack of harmonization among field assays
it includes all other aspects of laboratory testing, is evident from review of EQA/PT data, often
including terminology and units, report formats, of necessity reported by peer group (as op-
reference intervals and decision limits, as well as posed to accuracy based grading). In an era of
Table 1 The necesity of reaching agreement over harmonization
of basic terminology and units in the international clinical laboratory
community: some examples of disharmony
Analyte “Conventional units” SI units*
ALT U/L mkat/L
Bilirubin mg/dL mmol/L
Cl mEq/L mmol/L
Glucose mg/dL mmol/L
Creatinine mg/dL mmol/L
Hb A1c % Hb A1c mmol/mol

* SI = International System of Units (Système International d’unités)
Page 43
harmonization, results from different systems An IFCC initiative is the Working Group on
should be comparable. Manufacturers are re- Allowable Error for Traceable Results (WG-
sponding by: providing calibrator traceabil- AETR). This group concluded “Although manu-
ity/uncertainty information, restandardizing facturers are compelled by the European IVD
assays, testing commutability, etc., and they Directive, 98/79/EC, to have traceability of the
work with many professional organizations values assigned to their calibrators if suitable
and each other to attain harmonization, but higher order reference materials and/or proce-
this is a new approach and challenge for the dures are available, there is still no equivalence
industry. Manufacturers have an integral role of results for many measurands determined in
in educating customers about harmonization clinical laboratories” (24). For some common
of assays, harmonization and clinical labora- analytes, such as sodium, current assays are too
tory practice in general. Of course the age old imprecise to meet TEa targets based on biologi-
cal variation. The aim of harmonization is equiv-
question remains: “Where do manufacturers’
alent results but unfortunately, due to cost and
obligations end and the obligations of lab di-
limited resources, IVD manufacturers don’t al-
rectors begin?” Manufacturers must provide
ways follow full traceability steps to value assign
“fit for purpose” tests, but labs must use the
every new calibrator lot but rely on value trans-
assays properly and effectively. When an as-
fer from an internally stored (“master”) calibra-
say “failure” occurs (and “failure” can apply tor material. In most cases, this procedure is
to myriad issues and causes) does the fault lie probably valid, but a common complaint is cali-
with the manufacturer or with the lab and its brator lot to lot variability. The WG-AETR noted
use of the test? that when there are two traceability paths for a
A major challenge for manufacturers is to measurand, calibrators from different manufac-
choose a total allowable error (TEa) goal from turers may both be derived from valid traceabil-
the many available options: CLIA requirements ity chains but produce non-equivalent results,
(U.S. specific); CAP; RCPA, RiliBÄK, or other EQA/ as illustrated by Fig. 3. Equivalent results from
PT provider specifications. A popular approach two systems may be possible by using a correc-
is to define TEa based on biological variability tion factor determined by a correlation study.
targets, but there are three targets from which The international clinical laboratory community
to choose: has embraced harmonization. A prime example
is the AACC’s ICHCLR (International Consortium
Minimum: for Harmonization of Clinical Laboratory Results)
2 2 ½
TE < 1.65(0.75 CV )+0.375(CV + CV ) (2). The ICHCLR prioritizes analytes globally for
a i i g
harmonization and development of RMs and
Desirable: RMPs for listing in the JCTLM database, which
TE <1.65(0.5 CV )+0.25(CV + CV )
2 2 ½
will allow for comparable results irrespective of
a i i g the laboratory, method, or the time when test-
Optimum: ing is performed. ICHCLR stakeholders include:
2 2 ½ clinical lab and medical professional societies,
TE < 1.65(0.25 CV )+0.125(CV +CV ) IVD manufacturers, metrology institutes, pub-
a i i g
lic health organizations, regulatory agencies,
CVi = individual biological variability; and standard-setting organizations. A similar
CVg = group biological variability initiative is Pathology Harmony in the UK (25).
Page 44
Figure 3 Manufacturers may prepare calibrators starting with traceability

to the same reference material and/or reference method, but the
calibrator manufacturing process may diverge at some point, resulting
in significantly different results for the same measurand in the same
patient sample if tested by the two field methods, despite metrologically
acceptable traceability for each assay’s calibrators
Pathology Harmony states: “as we move towards of Australasia) PITUS (Pathology Information
full electronic reporting of pathology results, we Terminology and Units Standardisation Project)
appreciate more fully that variations in things program that is dedicated to harmonization (26).
such as test names, reference intervals and units PITUS in particular focuses on the interoperabil-
of measurement associated with our results is ity of pathology test requesting and reporting.
something that hinders progress.’’ In Australia, These initiatives and others are all supported by
there is the RCPA (Royal College of Pathologists Industry.
Page 45
MANUFACTURERS’ ROLE contribute to the prioritization of projects, de-

IN THE 21ST CENTURY sign of experiment and contribute to the inputs
we would be assured changes requiring prod-
Industry support can be optimized when the
uct re-registration would be successful. This
harmonization initiatives are coordinated and
would also avoid unintentional competitive
prioritized. From the industry perspective there
are limitations, costs and tradeoffs which need imbalances.
to be considered. Device manufacturers all have A significant consideration is the traceability of
substantial product development priority lists the reference assay. Device manufacturer’s typi-
and development schedules and personnel and cally register products using a predicate device
financial resources are committed over long to demonstrate product acceptance. In such cas-
term periods to achieve strategic goals. The de- es proof of substantial equivalence is essential
velopment process for a new product can be to demonstrate the assay is safe and effective. If
measured over years in our highly regulated en- a reference assay is a laboratory developed test
vironment. Further, the cost for each project can the path to regulatory registration and the abil-
run into the millions of dollars. Reprioritization ity to commercialize the assay brings with it ad-
is possible and welcomed by industry when the ditional complications.
results will provide benefit to the clinician, pa-
tient and healthcare system. Stellar examples Lastly, a major consideration is whether the
such as creatinine, hemoglobin A1c and choles- harmonization initiative provides benefit to the
terol have been pointed out in this manuscript. public. While accuracy is important, there are
situations where existing assays may be rela-
The global drive for harmonization creates tively harmonized yet the reference method is
competing project priorities for companies. As very different from the commercialized assays.
manufacturers sign on to support harmoniza-
Under these special circumstances the cost of
tion projects, timelines that reflect develop-
harmonization which includes physician educa-
ment cycles (years) allow companies to reprior-
tion, patient safety and investment in product
itize resources while maintaining projects that
redevelopment must be carefully weighed to
drive innovation, product health and portfolio
understand the benefit of harmonization.
development.
Harmonization may also require worldwide re- REFERENCES
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25. Berg J, Lane V. Pathology Harmony; a pragmatic and
16. Braga F, Panteghini M. Verification of in vitro medical scientific approach to unfounded variation in the clinical
diagnostics (IVD) metrological traceability: Responsibili-
laboratory. Ann Clin Biochem 2011;48:195-7.
ties and strategies. Clin Chim Acta 2014;432:55-61.
17. Panteghini M. Traceability as a unique tool to improve 26. Legg M. Standardisation of test requesting and re-
standardization in laboratory medicine. Clin Biochem porting for the electronic health record. Clin Chim Acta
2009;42:236-40. 2014;432:148.
Page 47
Opinion paper: deriving harmonised reference

intervals – global activities
Jillian R. Tate1, Gus Koerbin2, Khosrow Adeli3
1
Pathology Queensland, Royal Brisbane and Women’s Hospital, Brisbane, QLD, Australia
2
NSW Health Pathology, Chatswood, NSW, Australia
3
Clinical Biochemistry, The Hospital for Sick Children, University of Toronto, ON, Canada
Corresponding author: Harmonisation of reference intervals (RIs) refers to

Jillian R. Tate
Department of Chemical Pathology
use of the same or common RI across different plat-
Pathology Queensland forms and /or assays for a specified analyte. It occurs
Royal Brisbane and Women’s Hospital optimally for those analytes where there is sound cal-
Herston, QLD 4029 ibration and traceability in place and evidence from a
Australia
Phone: 61-7-3646-0082 between-method comparison shows that bias would
E-mail: jill.tate@health.qld.gov.au not prevent the use of a common RI. The selection
of the RI will depend on various sources of informa-
Key words:
harmonisation, standardisation, reference tion including local formal RI studies, published stud-
intervals, transference, adult, paediatric ies from the literature, laboratory surveys, manufac-
turer’s product information, relevant guidelines, and
mining of databases. Pre-analytical and partitioning
issues, significant figures and flagging rates, are as-
sessed for each analyte.
Several countries and regions including the Nordic
countries, United Kingdom, Japan, Turkey, and
Australasia are using common RIs that have been de-
termined either by direct studies or by a consensus
process. In Canada, the Canadian Society of Clinical
Chemists Taskforce is assessing the feasibility of estab-
lishing common reference values using the CALIPER
(Canadian Laboratory Initiative on Pediatric Reference
Intervals) and CHMS (The Canadian Health Measures
Survey) databases as the basis. Development of
platform-specific common reference values for each
Page 48
Jillian R. Tate, Gus Koerbin, Khosrow Adeli
of the major analytical systems may be a more reference interval is also recommended as per
practical approach especially for the majority of CLSI guidelines.
analytes that are not standardised against a pri-

mary reference method and are not traceable to
a primary or secondary reference material. INTRODUCTION
We encourage laboratories to consider adopt- Despite studies having shown that the variation
ing reference intervals consistent with those in reference intervals (RIs) for chemistry ana-
used by other laboratories in your region lytes may be greater than the analytical inac-
where it is possible and appropriate for your lo- curacy of the measurement, differences in RIs
cal population. Local validation of the adopted persist between laboratories that use the same
Table 1 Sequence of events to derive and validate common reference intervals
(RIs) through an evidence-based approach and extensive data analysis
Identify problem
Agree to address common RIs
Identify relevant groups
Seek formal co-operation (if external bodies involved)
Form working group
Describe problem in detail
Allocate a budget and determine sources of funding
Gather information (surveys, RI studies, data mining, bias study, calibration traceability, RI
verification laboratory information, flagging rates)
Consider solutions
Produce discussion paper, etc.
Seek feedback from stakeholders
Revise recommendations
Obtain formal endorsement
Publish
Promote
Monitor introduction
Page 49
platforms and the same reagents (1-3). This has terminology are used, an individual patient’s re-
implications for result interpretation and pa- sults can then be amalgamated.
tient outcomes where the same values may be An organisational plan is required before setting
interpreted differently due to differences in RIs out on the sequence of practical processes that
or decision limits hence leading to inappropri- are required to achieve a major national change
ate over- or under-investigation or treatment of in pathology RIs. This is not a trivial matter and
the patient. the importance of a structured approach can-
One way to overcome this situation is to use not be overemphasised. Table 1 outlines the se-
the same interval. Harmonisation of RIs refers quence of steps required to derive and validate
common RIs that was used for the Australasian
to use of the same or common RI across dif-
RIs study (3). The four key areas are: 1) seeking
ferent platforms and /or assays for a specified
the evidence; 2) consultation; 3) verification;
analyte. Importantly, harmonisation of RIs oc-
and 4) implementation (Fig.1 A and 1B). The
curs optimally for those analytes where there Australasian Association of Clinical Biochemists
is sound calibration and traceability in place (AACB) and the Royal College of Pathologists
and evidence from a method comparison study of Australasia (RCPA) invited pathologists and
shows that bias would not prevent the use of medical scientists to harmonise RIs at the same
a common RI. The advantages of using a har- time as other RCPA initiatives for standardisa-
monised RI are less confusion and misinter- tion of pathology units, terminology, and report
pretation of results for both doctors and pa- formatting and flagging were being undertaken
tients. Irrespective of the pathology provider (4). The input by main stakeholders, i.e. patholo-
or the method, provided the same RI, unit and gists, scientists, clinical societies and government
Figure 1A Implementation plan for the introduction
of adult common reference intervals
Page 50
Figure 1B Implementation plan for the introduction

of paediatric common reference intervals
bodies, is central to the success of any harmoni- • data sources (literature, lab surveys, local RI
sation project and can provide helpful advice and studies, manufacturers’ product information)
guidance as was the case for the UK Pathology • data mining
Harmony RIs project (5,6).
• bias goal as quality criterion for acceptance
REQUIREMENTS FOR USE 6. Consider partitioning based on age, sex, etc.
OF HARMONISED REFERENCE INTERVALS 7. Define degree of rounding
Seeking the evidence is paramount to the 8. Consider the clinical implications of the RI
implementation of common RIs. One such ap-
9. Consider use of common RI
proach used in Australasia to assess the feasibil-
ity of using common RIs was an evidence-based 10. Document and implement
checklist approach. (7). It was based on the fol- An example of the checklist approach is shown
lowing criteria (8): for creatinine (Table 2).
1. Define analyte (measurand)
Assessment of method differences
2. Define assays used, accuracy base, analytical
specificity, any method-based bias Bias study
3. Consider important pre-analytical differenc- Any significant method bias will result in mis-
es, and actions in response to interference classification of too many patients. The expect-
ed information derived from the combination
4. Define the principle behind the RI of assay and RI must meet the appropriate
(e.g. central 95%) clinical sensitivity and specificity required for
5. Describe evidence for selection of common RIs each test. Hence a key requirement for the use
Page 51
Table 2 Checklist reference interval (RI) approach for creatinine
Analyte Creatinine (plasma and serum)
Based on healthy subjects not hospital patients.

Population RI
eGFR used for decision making.
Units µmol/L
ID-GC/MS and
ID-LC/MS (some methods require instrument factors).
JCTLM-listed traceability or preferred
method and reference material SRM 914 (pure creatinine).
SRM 909, 967 (human serum).
Pre-analytics
1. Serum/plasma 1. Interchangeable.
2. Sample collection 2. Increases with meat consumption.
3. Interferences
Analytical differences Analytically there are no differences.

Partitioning by
1. Gender 1. Gender differences.
2. Age 2. Age-related increases above 60 years not agreed by

Renal Physicians.
Reporting Interval 1 µmol/L
of common RIs is the effect of methodologi- were all within allowable limits for the tested
cal differences on bias and if this would affect measurement procedures (10). The allowable
the sharing of a common RI. Method differ- limits of performance or allowable error spec-
ences are best assessed for bias using com- ify that the imprecision and bias of a method
mutable patient-based samples. In the case of must be within stated limits. Of 27 tested ana-
the Australasian Harmonised RI study speci- lytes among eight platforms/assays, 19 gave ac-
fied performance limits based on biological ceptable bias for a common RI (11). Note that
variation were applied to determine whether where a RI is shared the analytical variation
bias would prevent the use of a common RI for more analysers in more laboratories using
by assessing if all results fell within the allow- more methods will be larger than a singly-de-
able limits of agreement and if regression lines rived interval, resulting in a wider RI (12).
Page 52
Calibration traceability the intervals on between-laboratory differenc-

An initial assessment of methodology and cali- es. For the majority of common chemistry ana-
bration traceability of laboratory assays to be lytes the between-laboratory variation in RIs is
used to establish the common RI is required. usually greater than the variation in results (15).
Laboratories need to assess the traceability These types of data can be used to support the
claims made by manufacturers including the use of common RIs for many analytes.
reference material and reference measurement
Published studies
procedures used to assign values to master
calibrators from which product calibrators are The Nordic Reference Interval Project (NORIP)
traceable in routine assays. Preliminary infor- established common RIs in apparently healthy
mation can be gathered from the manufactur- adult populations from five Nordic countries
er, external quality assurance (EQA) programs for 25 of the most common clinical chemistry
and other published data. If a laboratory uses analytes (16). Results were traceable to higher-
a method known to be biased compared with order reference measurement systems. More
the method used to set the RI, a common RI recently Nordic paediatric RIs have been deter-
cannot be used. Rather, for analytes with estab- mined for 21 common biochemistry analytes
lished traceability, traceable assays should be and intervals were suggested for combined age
used to both set and to use the interval (13). groups (17). In the United Kingdom, reference
Ideally, analytes should have a complete refer- limits have been established by a survey of RIs
ence measurement system or a reference mate- in use followed by an assessment of analytical
rial and/or a reference measurement procedure variability, any age and sex related variation,
listed on the Joint Committee for Traceability in or other variances in populations where these
Laboratory Medicine (JCTLM) website (14). were seen as relevant to the analyte (5,6). The
aim was to remove unnecessary variation that
Selection of reference intervals was demonstrated to lack scientific validity pri-
Various sources of information on RIs should be or to taking on new work to formally validate
searched including local formal RI studies, pub- the consensus RIs (6).
lished studies from the literature, laboratory
Global formal reference interval studies
surveys, manufacturer’s product information,
relevant guidelines, and mining of databases. The CALIPER Initiative
Pre-analytical and partitioning issues, signifi- The Canadian Laboratory Initiative on Pediatric
cant figures and flagging rates, which provide Reference Intervals (CALIPER) (18) was estab-
an indication of the clinical considerations of lished by a Canadian team of investigators to
the RI, should also be assessed for each analyte. develop a new database of biomarker refer-
ence values (stratified by age, sex and ethnic-
Common laboratory usage ity) determined from a large, healthy popula-
A survey of local laboratories ideally through tion of community children and adolescents.
the national EQA provider provides the op- The CALIPER project was initiated as a result
portunity for laboratories to compare their RIs of several detailed gap analyses evaluating the
with those from other laboratories using the availability of pediatric RIs in four clinical sub-
same and different methods. By linking RIs to specialties: bone markers (19), risk markers for
results from measurements on commutable cardiovascular disease and metabolic syndrome
samples, it is also possible to see the effect of (19,20), hormones of the thyroid and growth
Page 53
hormone axes (21), and markers of inborn er- were selected in a systematic manner to be rep-
rors of metabolism (22). These analyses re- resentative of 96.3% of the Canadian population.
vealed major gaps in data available to clinical Data from CHMS samples were then weighted
laboratories and paediatricians and highlighted to ensure that the study population was truly
the critical need for new initiatives. Since its representative of age, geographical distribu-
inception in 2009, the CALIPER program has tion and ethnic origin of the Canadian popula-
made considerable strides in establishing and tion. In a recent collaboration between CALIPER
publishing a new RI database for biochemical and CHMS, laboratory data from approximate-
markers (23-33), however, the reference values ly 12000 Canadian children and adults were
were initially established on a single analytical used to establish a comprehensive database of
system, the Abbott Architect assay system. To paediatric and adult reference intervals for 24
address this limitation, a series of transference chemistry (38), 13 endocrine/special chemistry
studies (34-37) have recently been completed (39), and 16 haematology markers (40). These
by the CALIPER program, allowing transference reference intervals provide a valuable descrip-
of paediatric reference values from the Abbott tion of the changes in key biochemical param-
database to four other major analytical systems eters within the Canadian population. The use
including Beckman, Ortho, Roche, and Siemens. of common patient selection, pre-analytical,
Additional transference studies are in progress analytical and post-analytical methods allowed
to complete transference of the entire CALIPER for assessment of fluctuations in ‘normal’ levels
RI database to all major chemistry assay systems over time and prevalence of disease risk factors.
allowing widespread application of CALIPER ref- Together, these studies provide a comprehen-
erence standards in clinical laboratories world- sive description of the changes in important
wide using any one of the five major biochemi- biomarkers within the Canadian population
cal assay systems. throughout the course of a lifetime, from child-
hood to adulthood to geriatrics.
Canadian Health Measures Survey (CHMS)
The CALIPER and CHMS initiatives also provide a
The Canadian Health Measures Survey (CHMS) unique opportunity to strive towards establish-
is the most comprehensive, direct health mea- ment of common RIs across Canada. A taskforce
sures survey ever conducted in Canada. The has recently been developed by the Canadian
study was launched in 2007 by Statistics Canada, Society of Clinical Chemists and discussions
in partnership with Health Canada and the have begun among a number of opinion leaders
Public Health Agency of Canada, to collect pop- across the country to assess the feasibility of es-
ulation-representative health information from tablishing common reference values using the
Canadians aged 3-79 years. An initial household CALIPER and CHMS databases as the basis. The
interview collected information about general Canadian common reference interval initiative
health including nutrition, smoking habits, al- is also examining the potential development of
cohol use, medical history, physical activity, and platform-specific common reference values for
socioeconomic variables. Respondents then vis- each of the major analytical systems. This may
ited a mobile examination centre, where direct be a more practical approach especially for the
physical measures of health were taken, such as majority of analytes that are not standardised
height, weight and blood pressure, and blood based on primary reference method and not
specimens were collected and analysed for bio- traceable to a primary or secondary reference
markers of health and disease (25). Individuals material.
Page 54
Asian Studies Normals formal RI study were in general simi-

Although not attempting to define population lar to those for the Australasian common RIs
reference intervals, Ichihara et al. (41) found study although somewhat tighter as they were
unexpectedly large variations between the re- determined using one platform only. However,
sults obtained from samples sourced from 6 γ-glutamyltransferase (GGT) upper reference
Asian cities (Hong Kong, Shanghai, Seoul, Kuala limits were notably higher in the Aussie Normals
Lumpur, Taipei and Tokyo) for the 13 analytes study which demonstrated BMI differences
tested suggesting that harmonised RIs would be with increasing age in men and women (44).
difficult between these countries that these cit- For the 18-<45y age group and BMI <25 kg/m2,
ies represent . GGT was 12-37 U/L for men and 9-38 U/L for
women. However, it is difficult to adopt RIs in
In contrast to the study by Ichihara, a Japanese association with BMI at this stage as this param-
multicentre study by Yamamoto et al. (42) in- eter is not routinely provided to the laboratory.
volving 105 laboratories across Japan and using
4 different chemistry platforms demonstrated Data mining
no regional differences and concluded that the Expert groups can provide RI information
RIs established in this study were also suitable through their data mining of millions of data
for adoption nationwide (Table 3). points from primary care patients. This method
Turkish Study: Similar to the Japanese study, has advantages over the direct RI validation pro-
a multi-centre study by Ozarda et al. (43) de- cess by providing large amounts of data on the
termining RIs for 25 commonly tested analyt- local population being tested and reflects the
es showed similar results between the seven actual analytical and pre-analytical conditions
Turkish geographical regions in 28 laboratories for the tested population. This approach is valid
where the samples were sourced. They con- only if there is a majority of results from the
cluded that the intervals determined by this primary care population such that the healthy
study using the same Architect 8000 analysers distribution of values can be clearly identified
were suitable for use in all Turkish clinical chem- in the midst of a smaller number of non-healthy
istry laboratories that used the same platforms values. Bhattacharya analysis to determine un-
(Table 3). derlying distributions in the presence of outli-
er results can be used to assess proposed RIs.
Australian Study For example, in Australasia data mining of over
The Aussie Normals study was a formal refer- 200,000 paediatric data points provided by 15
ence interval study of 1876 male and female laboratories for the main general chemistry an-
healthy adult Australians in the age group 18 to alytes from birth to 18 years of age was used for
95 years (44). Up to 91 biochemistry analytes establishing partitioned paediatric RIs (3).
were measured by Abbott Architect analysers.
Partitioning was done according to the effects Final selection of the common
of gender, age and body mass index (BMI) on reference interval
these RIs. For the most part these differences One approach to the setting of a common RI
were statistically small such as for lactate dehy- that was used in Australasia is described as fol-
drogenase and phosphate where they were less lows. The starting point to develop a common
than day to day biological variation. As shown RI was to do a national survey of laboratory RIs
in Table 3, reference intervals for the Aussie and determine the predominant RI in use. Then
Page 55
a method comparison study across the major Once RIs are agreed upon, the proposed ref-
chemistry platforms using commutable samples erence limits should be supported by flagging
from healthy subjects was used to assess if bias rates which provide an indication of the clini-
would prevent use of a common RI with accept- cal considerations of the RI. Excess flagging of
ability based on the specified allowable limits of results can lead to inappropriate testing due to
performance such as those based on biological decreased specificity of the RI. Horowitz sug-
variation for example (11). For analytes where gests that laboratories should be mindful of ex-
bias may prevent use of a common RI for one or cess partitioning which is due to minor changes
two main platforms, it may be possible for other
in physiology not to pathology (46). Hence lo-
platforms to share a common RI, e.g. lactate de-
cal laboratories should assess flagging rates
hydrogenase methods that use pyruvate to lac-
to determine if a change to historical RIs will
tate [P to L] rather than the IFCC-recommended
create higher flag rates. For example, the pre-
[L to P] method cannot be combined.
analytical effect of delayed sample transport
The next step involves gathering supportive would impact on potassium levels and hence
date for the proposed common RI using data for pragmatic reasons laboratories may choose
from formal local RI studies, if available, and
to have a higher upper reference limit (URL) of
from data mining. In Australia values from the
5.5 mmol/L rather than 5.2 mmol/L (Fig. 2A) (3).
Aussie Normals adult RI study were used to con-
firm the common RIs recommended for use in Final agreement by a majority of stakeholders
Australia and New Zealand (44). Note that ref- is required to support the selected common RI
erence intervals are wider for the common RIs and a laboratory’s intention to implement it, as
that have been established for eight platforms described in the next section. The consensus
compared with those obtained using the one process for deriving common RIs is not perfect
platform; inclusion of between-method varia- and there are limitations. As noted above, inter-
tion results in wider intervals than for a singly- vals are usually wider than for singly-derived RIs
derived RI (Table 3). Further mining of hun- obtained on the same platform, pre-analytical
dreds of thousands of data points from primary issues can cause elevated flagging rates, and
care patients who are relatively healthy was elevated BMI in the population is not factored
then employed to show the biochemical physi- into clinical interpretation by the routine labo-
ology from childhood to adulthood through to
ratory of GGT for example. Traceable analytes
geriatric age, according to age and gender (45).
with JCTLM-listed reference materials and ref-
In order to compare partitioning according to
erence measurement procedures are more
the continuous variables of age and pregnancy,
likely to share common RIs. However, countries
and whether merged or separate partitions will
affect clinical outcomes, there must be an un- may not be using IFCC recommended methods
derstanding of the physiological processes af- for enzymes as is the case in Australia where
fecting an analyte. Without the knowledge of non-pyridoxal-5’-phosphate (P5P) AST and ALT
clinical outcomes and their association with methods are predominantly in use (Table 3). A
partitioned RIs, the lesser approaches of clini- harmonised RI with non-P5P methods is better
cal opinion, statistics or laboratory consensus than no harmonised RI and a future goal is for
are used to determine the suitability of parti- Australian laboratories to use P5P methods for
tioning (45). AST and ALT.
Page 56
Table 3 Adult reference intervals (RIs) for chemistry analytes determined

by direct RI studies or by consensus
Australia44 Turkey43 Nordic United Japan42 Canada38 Austral

countries16 Kingdom5 asia3
Analyte Unit
Cat 2a Cat 2a Cat 2a Cat 4 Cat 2a Cat 2a Cat 4
Direct Direct Direct Consensus Direct Direct Consensus
Multiple Multiple 4 main 8 main

Architect Architect Architect
platforms platforms platforms platforms
16-49y:
mmol/L 136-145 137-144 137-145 133-146 137-144 135-145
137-142
Sodium
(M)
50-79y:
136-143
16-49y:
mmol/L 136-145 137-144 137-145 133-146 137-144 135-145
137-143
Sodium (F)
50-79y:
136-143
Potassium mmol/L 3.7-4.9 3.7-4.9 3.6-4.6 3.5-5.3 3.6-4.8 3.8-4.9 3.5-5.2
30-79y:
Chloride mmol/L 101-110 99-107 - 95-108 101-108 95-110
102-108
Bicarbonate mmol/L 20-29* - - 22-29 - 19-26 22-32
<75y: 16-79y:
µmol/L 59-92 60-100 60-100 57-94 60-110***
65-103 63-102
Creatinine
(M)
75+y:

47-120
<75y: 17-79y:
µmol/L 50-71 50-90 60-100 41-69 45-90***
54-83 49-85
Creatinine
(F)
75+y:

40-91
Page 57
2.2-2.6 20-39y:
mmol/L 2.19-2.56 2.15-2.47 2.15-2.51 2.2-2.5 2-10-2.60
Calcium (adjusted)** 2.28-2.60
(M) 40-79y:

2.24-2.56
2.2-2.6 20-39y:
mmol/L 2.19-2.56 2.15-2.47 2.15-2.51 2.2-2.5 2-10-2.60
(adjusted)** 2.24-2.53
Calcium (F)
40-79y:

2.24-2.56
Magnesium mmol/L 0.77-1.04 0.77-1.06 0.71-0.94 0.7-1.0 0.7-1.0 - 0.7-1.1
<50y: 16-47y:
mmol/L 0.83-1.36 0.80-1.40 0.8-1.5 - 0.75-1.50
Phosphate 0.75-1.65 0.95-1.52
(M) 50+y: 48-79y:

0.75-1.35 0.89-1.52
16-47y:
mmol/L 0.88-1.44 0.80-1.40 0.85-1.50 0.8-1.5 - 0.75-1.50
Phosphate 0.95-1.52
(F) 48-79y:

0.99-1.54
120-250
<70y: 124-226
U/L 130-230 126-220 - - (L-P
105-205 [JSCC]
LDH (M) [IFCC])
70+y:

115-255
120-250
<70y: 124-226
U/L 122-232 126-220 - - (L-P
105-205 [JSCC]
LDH (F) [IFCC])
70+y:

115-255
<45y: <50y: 61-257 <60y:

U/L 48-227 40-320 -
52-340 50-400 [JSCC] 45-250
45-65y: 50+y: 60+y:

CK (M)
55-357 40-280 40-200
65+y:

49-207
Page 58
<45y: 43-157
U/L 34-131 35-210 25-200 - 30-150
37-247 [JSCC]
CK (F) 45-65y:

39-230
65+y:

36-190
<75y: 122-330 16-21y:

U/L 43-116 35-105 30-130 30-110
43-112 [JSCC] 56-167
ALP (M)
75+y: 22-79y:

42-126 50-116
<45y: <50y: 104-299 16-29y:

U/L 35-105 30-130 30-110
32-96 34-97 [JSCC] 44-107
45-75y: 50+y: 30-79y:

ALP (F)
40-132 47-133 46-122
75+y:

44-146
<75y: 10-42 18-49y: 5-40

U/L 9-57 10-70
11-41 [JSCC] 18-78 (no P5P)
ALT (M)
75+y: 50-79y:

9-48 20-62
<75y: 7-27 12-49y: 5-35

U/L 7-28 10-45
9-35 [JSCC] 14-41 (no P5P)
ALT (F)
75+y: 50-79y:

8-33 16-44
<75y: 14-32 18-54y: 5-35

U/L 13-30 15-45
14-36 [JSCC] 18-54 (no P5P)
AST (M)
75+y: 55-79y:

14-34 18-39
<75y: 12-27 20-54y: 5-30

U/L 11-25 15-35
AST (F) 13-31 [JSCC] 18-34 (no P5P)
75+y: 55-79y:

14-35 18-39
Page 59
<45y: <40y: 12-65 20-35y:

U/L 11-69 5-50
9-63 10-80 [JSCC] 12-62
45-75y: 40+y: 36-79y:

GGT (M)
13-72 15-115 13-109
75+y:

15-78
<45y: <40y: 9-38 18-35y:

U/L 7-33 5-35
9-49 10-45 [JSCC] 12-38
45-75y: 40+y: 36-79y:

GGT (F)
9-55 10-75 10-54
75+y:

9-57
20-29y:
g/L 62-79 66-82 62-78 60-80 66-80 60-80
Total 65-83
Protein 30-79y:
65-78
16-48y:
µmol/L 5-20 3.8-24.1 5-25 <21 6.4-24.8 1-20
Total 3-18
Bilirubin (M) 49-79y:

2-20
16-48y:
Total µmol/L 5-21 2.7-15.9 5-25 <22 6.4-24.8 1-20
1-16
Bilirubin
(F) 49-79y:
1-17
* Bicarbonate measured prior to Abbott recalibration; ** Calcium is adjusted for albumin;
*** Creatinine has harmonised RIs for adults up to the age of 60 y.
ALP: alkaline phosphatase; ALT: alanine aminotransferase; AST: aspartate aminotransferase; Cat: category according
to Stockholm Hierarchy; CK: creatine kinase; GGT: γ-glutamyltransferase; IFCC: International Federation of Clinical
Chemistry and Laboratory Medicine; JSCC: Japan Society of Clinical Chemistry; LDH: lactate dehydrogenase; P5P: pyri-
doxal 5’-phosphate.
FINAL ACCEPTANCE, ADOPTION AND Laboratory acceptance should be sought at

IMPLEMENTATION OF HARMONISED a national level prior to introduction of com-
REFERENCE INTERVALS mon RIs. Various approaches can be used to
assess the likely adoption rates for the panel
Communication and discussion of RIs including a survey as to whether the
by all stakeholders laboratory is using the common RI already,
Page 60
would accept the RI, or ask for comments Validation of reference intervals
and their reason if they do not accept the by local laboratories
common RI. Representation is required from Responsibility for adoption of common RIs
the whole nation and from public and pri- lies with each laboratory. Advice on how to
vate pathology, small and large laboratories do this is found in guidelines from the Clinical
and networks if harmonised RIs are to have and Laboratory Standards Institute (CLSI) (47).
any chance of being implemented. National Key questions are: ‘Is this RI suitable for my
acceptance of a change to pathology RIs re- method and for my population?’ Validations
quires that there is an on-going discussion by of RIs may be by subjective assessment as-
all involved stakeholders especially those at suming the same method and the same pop-
the highest management level who are re- ulation are used or by a simple validation
sponsible for patient pathology results and using 20 normal subjects representing the
their interpretation. Harmonisation work- local population (47,48). Alternatively, you
shops provide a forum for presenting and can mine your laboratory’s existing data. The
discussing the evidence and reaching a con- most useful parameter is the midpoint of the
sensus decision. extracted data, which can be used to assess
Figure 2A Typical high flagging rates for the first measurement

in outpatient adults (18y – 60y) for sodium, potassium, chloride,
bicarbonate, creatinine (M), creatinine (F)
Reproduced from Tate et al. (3) with permission from the AACB.
Page 61
analytical or population bias by comparison Australasian common RIs project, a URL of

with the corresponding midpoint of the data 110 U/L for alkaline phosphatase may result
used to set the reference interval. Bhattacharya in a flag rate of 7-8% (3). However, the clini-
analysis can also be used to assess the pro- cal benefit of using the URL of 110 U/L is to
posed intervals (12). detect pathology in postmenopausal women.
Increasing the URL to 115 U/L did not have
Validation of flagging rates any significant impact due to the logarithmic
for local population distribution of reference values. In contrast,
Based on the principle of minimum, desir- the flag rate at the URL for sodium was 1%
able and optimal categories used to define indicating that hypernatraemia is uncommon
allowable bias limits, flag rates may range (Fig. 2A and 2B). Data mining of local popula-
from 1.0% to 1.8% for low flagging rates, and tion values also allows for an assessment of
5.7% to 3.3% for high flagging rates, respec- the expected number of results outside the
tively. Flag rates however, may be quite com- RI (12). The laboratory can then compare the
plex to interpret depending on the popula- expected flagging rates with their current
tion used to derive them. For example in the rates.
Figure 2B Typical high flagging rates for the first measurement
in outpatient adults (18y – 60y) for calcium, phosphate, magnesium,
lactate dehydrogenase, alkaline phosphatase, total protein
Reproduced from Tate et al. (3) with permission from the AACB.
Page 62
CLOSING THE HARMONISED CONCLUSION

REFERENCE INTERVAL LOOP
Consideration should be given by laboratories
Following the endorsement of common RIs by to adopting RIs consistent with those used by
pathologists and scientists, formal endorse- other laboratories in the region where it is pos-
ment by the profession is sought from the sible and appropriate for the local population.
National Pathology College and National Clinical These may be common RIs for use across sev-
Chemistry, Biochemistry or Laboratory Medicine eral major platforms in the region, e.g. United
Society. Support by the National Testing Kingdom, Nordic countries, Japan, Australasia,
Authorities for Laboratory Medicine, who should or for use with one specific platform, e.g.
be included in meetings on harmonisation, is via Canada, Asia, Turkey. Scientific evidence sup-
formal recommendations to laboratories that ports the use of common RIs for many gen-
they use these intervals, or if not, to provide eral chemistry analytes especially those with
supporting evidence for other references. sound calibration and traceability in place. For
other non-harmonised immunoassay analytes
Continuing work is required to produce and
where either there is currently no secondary
validate common RIs, to manage ongoing is- reference material or reference measurement
sues, e.g. problems with implementation of RIs procedure for value assignment, it seems logi-
by the local laboratory Information Technology cal to use platform-specific RIs and decision
unit into the Laboratory Information System. limits across regions, provided that labora-
These issues may be changes to reporting units, tories have acceptable assay precision, until
significant figures, rounding, report formatting, such time when methods become harmonised
etc. Consultation with clinical societies and ed- internationally.
ucation of local clinicians are imperative if the
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docrine and special chemistry biomarkers across pedi-
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hematologic markers across pediatric, adult, and geriatric
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Page 65
Critical risk results – an update

on international initiatives
Lam Q.1, Ajzner E.2, Campbell C.A.3, 4, Young A.5
1
Austin Pathology, Vic., Australia
2
Central Laboratory, Jósa Teaching Hospital of University of Debrecen Medical and Health Science Center,
Nyíregyháza, Hungary
3
Department of Clinical Chemistry and Endocrinology, South Eastern Area Laboratory Services, NSW Health
Pathology, Australia
4
Australian Institute of Health Innovation, Macquarie University, NSW, Australia
5
Quest Diagnostics, PA, U.S.A
Corresponding author: Direct communication of significant (often life-threat-

Dr. Que Lam
Austin Pathology, Austin Health
ening) results is a universally acknowledged role of the
Studley Rd., Heidelberg, Vic 3084 pathology laboratory, and an important contributor to
Australia patient safety. Amongst the findings of a recent survey
E-mail: que.lam@austin.org.au
of 871 laboratories from 30 countries by the European
Key words: Federation of Clinical Chemistry and Laboratory
harmonization, critical risk results, Medicine (EFLM), only 3 tests were noted to be com-
critical laboratory results, alert table,
alert threshold, critical laboratory notification mon to 90% of alert lists, and only 48% of laborato-
ries consulted clinicians in developing these alert lists
despite ISO15189 recommendations to do so. These
findings are similar to previous national surveys dem-
onstrating significant variation worldwide in how criti-
cal risk results are managed and also in how these pro-
tocols are developed. In order to promote “best
practice” and harmonization of critical risk re-
sults management, guidelines and recommendations
have been published, most recently by Clinical and
Laboratory Standards Institute (CLSI) and Australasian
Association of Clinical Biochemists (AACB). These
statements in particular have placed strong emphasis
on patient risk and risk assessment in the manage-
ment of critical risk results. This focus has resulted
in recommendations to adopt new terminology, the
Page 66
Lam Q., Ajzner E., Campbell C.A., Young A.
consideration of risk assessment when com- of best practice. The challenge is to define best
piling alert tables, consultative involvement of practice and to obtain the evidence required
laboratory users in setting up protocols, and the to support this. This review discusses the work
need for outcome-based evidence to support our currently being undertaken by a number of pro-
practices. With time it is expected that emerging fessional organisations worldwide to harmonize
evidence and technological improvements will and bring best practice to the management of
facilitate the advancement of laboratories down high risk results.
this path to harmonization, best practice, and
improve patient safety. WHAT IS THE CURRENT SITUATION?
Existing practices

Information on how laboratories manage high
INTRODUCTION risk results is largely provided by national sur-
veys 2-13, most of which have been questionnaire-
Direct communication of significant (often life- based with voluntary participation. Although
threatening) results which require timely clini- their findings are limited by the response rate
cal attention is a universally acknowledged role and potential selection bias inherent to this
of the pathology laboratory. Accreditation stan- method of data collection, these surveys re-
dards formalise the requirement for laborato- main the best source of information we have
ries to manage these “high risk results” but only on existing practices. In 2011, the Australasian
offer very general guidance on how this should Association of Clinical Biochemists (AACB) un-
be achieved. Not surprisingly, there is evidence dertook a survey of laboratories representing
of wide differences in practice between labora- a mixture of large private and public pathol-
tories both internationally and within the same ogy networks from key providers in the region,
country. These differences are seen in all as- servicing community and hospital patients2.
pects of high risk results management including Between September 2012 and March 2013,
the nomenclature and definitions used; which the European Federation of Clinical Chemistry
critical tests and thresholds are included in alert and Laboratory Medicine (ELFM) invited its
tables; specification of who can receive results members, affiliates and provisional member
and by what mode of communication; what in- countries to complete a modified version of the
formation should be conveyed with the result; Australasian survey, adapted for the European
how receipt of the result is acknowledged; es- professional environment. Eight hundred and
calation protocols for failed attempts at com- seventy one laboratories from 30 countries re-
munication; and how communication events sponded and these results3,4, in combination
are recorded. Lack of agreement is evident not with the Australasian findings, have provided a
only in what is contained in laboratory protocols comprehensive insight into international state-
but also in how these protocols are developed. of-the-art practice in this area.
It is now increasingly recognised that successful One finding common to all surveys has been
management of high risk results is an important the lack of uniformity in alert lists, both in their
contributor to patient safety1. As such, harmo- contents and how they are compiled. Only 41%
nization in this area cannot simply be a matter of Australasian and 48% of European laborato-
of shared definitions and procedures, but must ries consulted clinicians in this process despite
involve the determination and implementation the recommendation within ISO 15189 that
Page 67
clinical agreement be sought. However, this rate source (e.g. guidelines), rather than consensus
varied between nations with Norway and the regarding clinical risk. This can be seen amongst
Netherlands reporting high consultation rates laboratories measuring the drug carbamaze-
(72% and 88% respectively) comparable to the pine. In the Australasian survey, 22 out of 26
73% of U.S. laboratories previously described10. It laboratories reported a high critical threshold
is known from other national surveys that clinical for this drug, the median of which was 15 mg/L
consultation rates can be significantly lower12,13. (range 9-20). This same median high thresh-
Alert lists solely derived from the laboratory run old (15 mg/L) was found in a US survey of 36
the risk of being detached from clinical practice. internet-published alert lists for therapeutic
A Canadian laboratory found that when their drugs (range 11-20)16. Fifteen mg/L was also the
laboratory-derived alert lists were presented to mean high threshold (range 10-20) found in a
their hospital physicians, only 36% of adult and survey of UK laboratories6. In contrast, there is
61.5% of paediatric alert thresholds were con- little agreement with C-reactive protein thresh-
sidered acceptable and did not require modifi- olds in adults. Its inclusion in alert lists can be
cation14,15. “Published literature” is another com- seen in 28% of Australasian alert lists with a me-
monly cited source of critical thresholds (listed dian value of 100 mg/L (range 80-300) and in
by 59% of Australasian and 66% of European 30% and 43% of European adult and pediatric
laboratories) but what laboratories interpret this alert lists, respectively. Forty-three percent of
term to mean is often not explored. A previous Norwegian laboratories use CRP on their alert
survey of UK laboratories found that only 2 out lists17 with a median applied alert threshold of
of 94 laboratories actually quoted literature to 200 (10 and 90 percentiles; 50-200) mg/L. Of
support the thresholds in their alert table6. interest, only 35% of responding general practi-
Surveys have consistently highlighted variation tioners actually wanted to be alerted of CRP val-
in the content of alert lists. In Europe, only 3 ues above 120 mg/L (10 and 90 percentiles of
tests (potassium, glucose and sodium) were responses were 50 and 200mg/L, respectively).
common to the alert lists of more than 90% Further variation in alert list content has been
of survey respondents. In comparison, a U.S. described as a result of some laboratories using
report found 8 common tests (potassium, so- customized thresholds and modified policies
dium, calcium, platelets, hemoglobin, activated based on the patient age, location, individual
partial thromboplastin time, white blood count provider or practice group requesting the test,
and prothrombin time), again shared by more or the disease type where known7. Sixty-one
than 90% of the surveyed laboratories7. How percent of European laboratories use children-
many tests should we expect to be common on specific alert thresholds, and 19% apply unique
alert lists is not clear. The answer is likely to be thresholds for specialist wards.
complicated when considering the patient pop- Many surveys also described diversity in the
ulation serviced by individual laboratories, the communication policies around high risk re-
tests performed and whether there is evidence sults. Around 65% of European and 80% of
of clinical risk from outcome studies. Australasian laboratories would not actively
When the numerical alert thresholds used are communicate a critical risk result if it was not
compared between laboratories, the findings significantly different from a previously deliv-
are varied. Some analyte thresholds do show ered result for that patient. In U.S., only 36% lab-
harmonization probably as a consequence of oratories had a policy allowing for these repeat
the wide adoption of thresholds from a single critical results not to be called18. Furthermore, a
Page 68
College of Pathologist Q-Tracks study suggested literature. There has been disagreement on ter-
that reporting all critical values, including re- minology since the original phrase “panic val-
peat ones, was actually valuable as it may indi- ues” was first coined by Lundberg20. Commonly
cate a higher degree of vigilance in the critical used terms including “critical”, “significantly ab-
value reporting system19. normal”, “life-threatening” and “urgent” have
all been criticised because of their inability to
Where results are successfully conveyed by ver-
include all results that require timely notifica-
bal communication, the procedure of asking
tion, and because of the ambiguity caused by
recipients to “read-back” results to confirm suc-
their use in other areas of medicine and every-
cessful transmission was practiced inconsistent-
day language. Their generic use creates a prob-
ly between countries2,5,7,11 ; only 46 % of labora-
lem when these phrases are used as search
tories surveyed both in France and Australasia
terms; searching the NIH PubMed website (ac-
compared to 79% of U.K. laboratories. Rates at
cessed 4/11/2015) with “laboratory AND criti-
which this “read back” was formally document- cal AND results” yielded over 22,500 articles,
ed and records kept also varied between na- the top 50 of which were not relevant to our
tions; 10% of Australasian and 23% of European intention. Likewise, use of the term “value” it-
laboratories. self has also been discouraged as it seemingly
There is also diversity in escalation policies excludes semi-quantitative or non-quantitative
when a responsible clinician cannot be con- results such as microbiological cultures21.
tacted. Only 38% of responding laboratories Failure to distinguish “critical tests” from “criti-
in the European survey had an existing formal cal test result” also creates confusion. A “critical
protocol. Some laboratories contact the pa- test” is a laboratory test that influences clinically
tient either directly (64% of French and 23% of urgent patient management decisions irrespec-
Australasian laboratories) or via the police or tive of whether the result is normal, abnormal or
ambulance service (15% of Australasian labo- critical. Thus any result for a critical test should be
ratories). Thirty four percent of European and rapidly communicated. It is distinct from a “criti-
39% of Australasian laboratories formally docu- cal test result” which refers to a test result that
mented occurrences where delivery of a criti- requires timely communication only because it
cal result had to be abandoned. Information falls outside a pre-defined risk alert threshold. If
regarding the average time to abandonment of critical tests are not clearly defined, the lack of
communication attempts is sparse but has pre- associated thresholds to assist in their identifi-
viously been reported amongst U.S laboratories cation may lead to results being overlooked and
to be 20.2 minutes for inpatients and 46.3 min- therefore not communicated nor acted upon.
utes for outpatients10 . Recent discussion around the evidence re-
quired for alert list design has suggested that
Available evidence
alert thresholds should be considered “clinical
For patient safety, laboratories should follow decision limits” given that their purpose ex-
procedures that are considered best practice tends beyond merely indicating illness, but to
and based on high level evidence. However, trigger clinical action. A modified Stockholm
in most aspects of high risk results manage- Hierarchy has been proposed for clinical deci-
ment, the evidence required is often lacking. sion limits which assigns Level 1 evidence as
Contributing to this problem is the inconsis- “clinical outcomes in specific clinical settings”22.
tency in terminology and definitions used in the Such evidence is best attained with randomised
Page 69
control trials as they explicitly investigate the number of studies addressing clinical decision
relationship between an exposure (e.g., a criti- limits exist for many other analytes. This likely
cal risk result) and an outcome (e.g., mortality reflects the difficulty of studying analytes with
or serious morbidity) and enable calculation of assay-related variations in measurement and
the outcome risk specifically associated with where a clearly associated clinical outcome has
that exposure. However, even if it were pos- not been identified.
sible to induce a pathological state to generate
critical risk results within a random selection INITIATIVES
of subjects, it certainly would not be ethical.
Terminology
Consequently, the critical risk result outcome
studies reported in the literature are generally The need for harmonization and the implemen-
retrospective observational studies. The main, tation of best practice in high risk results man-
and often impossible, challenge in the design agement is now widely acknowledged and has
of such studies is separating the contribution provided a common goal for laboratories and
to the risk of adverse outcome posed by con- pathology organisations worldwide. Addressing
founding variables (characteristics of the study the variation in terminology has been an impor-
subjects other than the critical risk result) in or- tant first step. It is vital that the language used
der to assess the independent effect of the criti- must not only be common but it must correctly
cal risk result. convey the intention so that there is shared
understanding of the concepts underlying the
A further limitation of retrospective observa-
process.
tional studies is that they typically have not
been designed for the purpose of identifying Recently, the term “high-risk results” has been
the optimal alert threshold. A number of ret- proposed as an umbrella term to include “crit-
rospective observational studies published for ical-risk results”; results requiring immediate
serum potassium show relatively congruous medical attention and action because they in-
results with increased mortality risk observed dicate a high risk of imminent death or major
when potassium concentrations are below 3.0- patient harm, and “significant-risk results”; re-
4.1 mmol/L or above 4.3-4.5 mmol/L, despite sults that are not imminently life-threatening,
diverse study populations (general hospital, pa- but signify significant risk to patient well-being
tients with chronic kidney disease, acute myo- and therefore require medical attention and
cardial infarction, head trauma or on peritoneal follow-up action within a clinically justified time
dialysis) and varying timeframes observed for limit28. Emphasising the clinical risk to the pa-
mortality (during inpatient admission, 1 year tient rather than the timeframe required for
or longer term)23-27. However, these thresholds notification or the need to initiate clinical ac-
cross into commonly quoted reference intervals tion, is an important distinction. It underscores
for potassium and therefore would be impracti- the need for clinicians to assess and consider
cal for laboratory alert lists. While studies that the risk of harm in an individual patient with a
explore the continuous relationship between particular result, and to then decide on an ap-
test result values and outcome are important, propriate course of action. Although it might be
a decision must be made as to when the risk argued that this change in terminology is purely
of adverse outcome becomes unacceptable and cosmetic, it reminds us that critical values are
hence where clinical action should be taken. not “one-size-fits-all”; that results notification is
Unlike potassium (and sodium), only a small a trigger for clinical assessment. Common use
Page 70
of this terminology in clinical trials and publica- The CLSI guideline recommends that a labora-
tions would facilitate the transferability of find- tory or healthcare organization conduct local
ings as well as helping to collate evidence in a risk analysis to determine which laboratory re-
more systematic manner. sults should be defined as “critical-risk” or “sig-
nificant-risk”. In addition, risk analysis should
CLSI GUIDELINES determine the most reliable processes to com-
municate results to responsible caregivers, and
The terminology and concepts of “critical-risk” how to monitor these processes for effective-
and “significant-risk” have already been adopt- ness. The analysis should focus on the following
ed by some professional bodies in their guid- initial questions:
ance documents29,30. The Clinical and Laboratory 1. Do the laboratory results indicate a signifi-
Standards Institute (CLSI) in its recently released cant risk for adverse patient outcome?
guideline for management of laboratory results
2. Can the caregiver act on these results to sig-
that indicate risk for patient safety29 has intro-
nificantly reduce patient risk?
duced these terms to emphasize that the ap-
propriate steps for reporting a laboratory result 3. Will active communication from laboratory to
can be defined by the degree of risk for adverse caregiver reduce patient risk or promote bet-
patient outcome. Degree of risk in this context is ter care?
differentiated by immediacy, probability and/or To address these questions, organizations
severity of potential patient harm, as well as like- should consult with local laboratory and medi-
lihood of harm due to undetected breakdowns cal staff leadership, and review locally applicable
in communication. “Critical-risk” results signify regulations and accreditation standards. In ad-
probable, immediate risk of major adverse out- dition, the organization can refer to the growing
comes in the absence of urgent clinical evalu- number of international surveys on the report-
ation. The guidelines stress that such results ing of abnormal laboratory results. The surveys,
while revealing substantial practice variations,
should be actively communicated to responsible
have identified a core list of results that the
caregivers without delay, and that there should
majority of peer institutions define as “critical-
be documentation that the caregivers received
risk”; these results would likely be applicable
this information accurately. “Significant-risk” for the organization, with modification as need-
results indicate risk of important adverse out- ed based on local risk analysis or feedback from
comes that can be mitigated by timely clinical laboratory and medical staff. Examples of com-
evaluation (although the risks are not necessar- mon critical-risk results include very abnormal
ily immediate, highly probable or life-threaten- potassium or glucose concentrations in serum/
ing). Unless routine reporting systems have safe- plasma (See Figure 1), or cell counts in whole
guards against breakdowns in communication, blood.
significant-risk results should also be actively In contrast to critical-risk results, significant-risk
reported to responsible caregivers with docu- laboratory results are not specifically addressed
mentation of successful and accurate communi- in regulatory and accreditation standards, and
cation. However, the time frame(s) for reporting there are few published surveys for report-
such results do not need to be the same as for ing these results. Therefore, the organization’s
critical-risk results, as long as they permit appro- reporting procedure can be determined by lo-
priately timely clinical evaluation. cal risk analyses. To use a specific example,
Page 71
Figure 1 Alert thresholds of the two most frequent blood parameters

on adult alert lists in different surveys
K+ Low
3.5
3
2.5
2
1.5
1 2 3 4 5 6 7 8 9 10 11 12 13 14
K+ High
8
7
6
5
4
0 1 2 3 4 5 6 7 8 9 10 11 12 13 14
Glucose Low
4.00
3.00
2.00
1.00
0.00
0 1 2 3 4 5 6 7 8 9 10 11 12 13 14
Glucose High
60
50
40
30
20
10
0
0 1 2 3 4 5 6 7 8 9 10 11 12 13 14
Surveys included: 1. US 2002 Median (p10-p90), 2. UK 2003 Mean (range),3. US 2007 Median (p5-p95),4. Italy 2010
Median (p10-p90), 5.Spain 2010 Median (p10-p90),6. Thailand 2010 Mean (±SD), 7.Australia 2012 Median (range), 8.
China 2013 Median (p5-p95),9. Norway Median (range), 10. Norway GP’s Median (range),11. EU adult Median (p10-
p90),12. EU paediatrics Median (p10-p90), 13.EU dialysis Median (p10-p90),14. EU obstetrics Median (p10-p90).
Page 72
the organization might consider how to report accuracy and timeliness of the communication
unexpected, early-stage adenocarcinoma in a must remain appropriate for patient care.
routine appendectomy specimen. This result is 4. Reports of critical-risk and significant-risk re-
significant for prognosis and therapy, but does sults should be documented to identify the
not indicate immediate risk of severe adverse patient or patient’s sample, the laboratory
events, and does not require immediate clini- result, the reporter and recipient, the time
cal intervention for appropriate care. However,
of report, and verification of accurate com-
a delay in recognition and treatment could re-
munication. If intermediary personnel are
sult in a significantly worse outcome for the pa-
involved in the report, each leg of communi-
tient. Therefore, this result might meet criteria
cation should be documented.
for “significant-risk” depending on an organiza-
tional risk analysis. If routine pathology reports 5. The reporting of critical-risk and significant-risk
cannot be verified for receipt and acknowledg- results should be continually monitored for ef-
ment, the organization should classify the unex- fectiveness. Root cause analyses should be
pected finding of malignancy as a significant-risk conducted if performance targets are not met,
result, and require the pathology laboratory to in order to identify potential sources of risk.
actively notify caregivers in a clinically appropri-
ate time frame (for example, within 24 hours). AUSTRALASIAN RECOMMENDATIONS
On the other hand, if routine pathology reports A guidance document on the communication
are monitored to verify acknowledgment by re-
and management of high risk results has also
sponsible caregivers within an appropriate time
been recently published by the AACB in con-
frame, the organization might choose to rely on
junction with the Royal College of Pathologists
standard reporting in this situation.
of Australasia (RCPA)30. It contains recommen-
Policies and procedures for reporting critical- dations which reflect “best practice” based,
risk and significant-risk laboratory results should where possible, on available literature but ul-
include the following: timately reflects the consensus view of a spe-
1. The definition of critical-risk and significant- cifically formed working party comprising of
risk results, and timeframes for reporting. pathologists and laboratory scientists with in-
These should be established through con- terest and expertise in this area. The statement
sensus between laboratory, medical and ad- has been written in a general manner so as to
ministrative personnel. be able to be applied to all disciplines within pa-
thology. Before publication, an open invitation
2. The laboratory should identify personnel re-
to comment on the draft was sent to the wider
sponsible for reporting critical-risk and signif-
laboratory community, clinicians and patient
icant-risk results.
interest groups. This wide consultative process
3. The organization should identify caregivers au- acknowledged the importance of agreement
thorized to receive reports of critical-risk and amongst these three groups in order for the
significant-risk results. Final recipients should successful management of high risk results.
be responsible clinicians who can direct pa-
tient care based on the laboratory results. It The document features 8 key recommendations
may be reasonable for the laboratory to report for laboratories, namely to:
results to intermediaries, who relay the re- 1. compile an alert list(s) in consultation with
port to the responsible clinician. However, the its users;
Page 73
2. have procedures to ensure that high risk re- laboratories see the management of high risk
sults are reliably identified; results as a dynamic process requiring monitor-
3. specify, in agreement with its users, the modes ing and updating in light of changing circum-
of transmission for the communication of high stances and technology.
risk results; These recommendations are an initial step to-
4. specify, in agreement with its users, who is au- wards harmonization. The working party hopes
thorised to receive high risk results; to compile a “starter” alert list with thresholds
based on outcome studies and expert opinion,
5. define what data needs to be communicated
framed by the risk assessment model proposed
to the recipients of high risk results;
by the CSLI. Laboratories could expect to use
6. develop a system for the acknowledgement this list as a foundation for discussion with their
of the receipt of high risk results to confirm clinical users.
that results were accurately and effectively
communicated; FUTURE DIRECTIONS
7. ensure that every high risk result notification Future directions in the area of high risk results
is appropriately documented; management will be influenced by emerging
8. have procedures that involve its users in evidence and advances in technology. There is
maintaining and monitoring the outcomes of a clear need for more outcome studies. These
its high risk result management practices. studies should use consensus terminology and
Further details of how each recommendation be designed to not only demonstrate where the
should be achieved, including some examples, risk of harm to patients starts but also deter-
are explored within the body of the paper. mine the threshold level(s) where clinical action
can eliminate or diminish this risk. With stron-
The consensus statement aims to incorporate a ger evidence will come harmonization of alert
number of important concepts for harmoniza-
thresholds and protocols for laboratories and
tion and best practice. Laboratories are encour-
their users. Studies should also look at specific
aged to adopt the newly proposed international
populations or scenarios to allow for alert lists to
terminology and are also encouraged not to
better cater for individuals thus generating less
develop their procedures in isolation but in-
false positive clinical notifications. While having
stead to collaborate with their laboratory users
more exceptions or rules seems unmanageable
(that is, medical practitioners, nurses and other
today, it is reasonable to expect improvements
health care professionals directly involved in
in technology that will assist the way we iden-
patient care). Although the guidance document
tify and communicate high risk results.
represents what is considered best practice, it
recognises that individual laboratories, due to Laboratories will also need to adapt their pro-
unique circumstances, may struggle with some cedures and protocols as new opportunities are
recommendations. To address this, the terms presented by improving technology. Already,
“needs to”, “should” and “may” are purposely the use of electronic text messaging as an al-
used to give an indication of the strength of ternative form of communication to the tra-
each recommendation, providing laboratories ditional phone call has been described with
with an understanding of which recommenda- success31,32. Further advances in the way labora-
tions must be adhered to, and which can be tories identify high risk results and notify clini-
viewed as suggestions. It is also important that cians are certain. However, it is important that
Page 74
the underlying principles of best practice re- Alert threshold: The upper and/or lower thresh-
main, so that in the example of text messaging, old of a test result or the magnitude of change
receipt of the result must be acknowledged and (delta) in a test result within a clinically signifi-
documented and where this does not occur, an cant time period, beyond which the finding is
escalation procedure implemented. considered to be a medical priority warranting
timely action.
CONCLUSION Alert list: A list of critical tests and tests with alert
High risk results management is recognised as thresholds for high risk results ideally reflecting
an important contributor to patient safety. Wide an agreed policy between the laboratory and its
variation in laboratory practices worldwide has users for rapid communication within a pre-spec-
been identified, and the need for harmoniza- ified time frame and according to a procedure.
tion is universally acknowledged. Recent initia- Escalation procedure: An ordered list of alter-
tives towards harmonization have focussed on native steps to be followed when the appropri-
patient risk and risk assessment. This approach ate recipient(s) of a high risk result cannot be
has framed proposed new terminology, dis- reached in a clinically appropriate time frame.
cussions around the design of alert tables, the
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Page 76
Analytical challenges in the genetic diagnosis
of Lynch syndrome – difficult detection
of germ-line mutations in sequences surrounding
homopolymers
Castillejo M.I., Castillejo A., Barbera V.M., Soto J.L.
Molecular Genetics Laboratory, Elche University Hospital, Elche, Spain
Corresponding author: A genetic diagnosis is essential in families with a suspi-

José Luis Soto
Molecular Genetics Laboratory
cion of Lynch syndrome, as it allows the use of proper
Elche University Hospital and specific surveillance programs for high-risk indi-
Camino Almazara nº 11 viduals who carry a pathogenic mutation. The predic-
03203 Elche. Spain
Phone: (+34) 966 616185
tion and prevention schemes reduce the impact of
E-mail: soto_jos@gva.es cancer in high-risk families in a cost-effective manner.
Genetic tests for LS are well standardized and broadly
Key words:
diagnosis, Lynch syndrome, analytical challenges used, although there remain some specific difficulties
that need to be addressed to reach an optimal diag-
Competing interests:
The authors declare no competing interests. nosis. In this report, we addressed the problem raised
by the detection of mutations at intronic-splicing con-
Ackowledgements: sensus sites located near mononucleotide repeats. A
We thank the Hereditary Cancer
Program of the Valencian Region. standard procedure was applied for LS diagnosis in
all cases. PCR and Sanger sequencing results of the
whole coding sequences and intron–exon boundar-
ies of the MSH2 gene were analyzed. Moreover, we
designed quality-control procedures to verify the at-
tainment of the intended quality of results regarding
sequences located in complex contexts. We found
eight families with point mutations at intron 5 of the
MSH2 gene located near the BAT26 mononucleotide
marker, which could be missed in a regular diagnostic
process. Four families had the c.942+2T>A mutation,
and the remaining four families had the c.942+3A>T
mutation. In conclusion, the detection of pathogenic
Page 77
Lynch syndrome diagnosis: detection of germ-line mutations in sequences surrounding homopolymers
mutations located near microsatellite sequenc- homology with several pseudogenes, or the de-
es is especially difficult and requires the imple- tection of variants located in the proximity of a
mentation of specific quality controls to opti- homopolymer sequence in the MMR genes.
mize diagnostic methods. In this report, we addressed the problem raised
by the detection of mutations located at intron-

ic-splicing consensus sites, near mononucleo-
tide repeats. In this particular sequence context,
INTRODUCTION
the detection of mutations is a real analytical
Lynch syndrome (LS) (MIN No: 120435) is an challenge.
autosomal dominant hereditary condition that
predisposes to colorectal, endometrial, and oth- METHODS
er tumors. The syndrome is caused by germ-line
Our laboratory performs genetic testing for the
mutations in one of the mismatch repair (MMR)
diagnosis of LS covering a population of over
genes: MLH1, MLH2, MSH6, or PMS21. A genetic
five million people in the southeast of Spain.
diagnosis is essential in families with a suspicion
These genetic tests are requested from the five
of having LS, as it allows the use of proper and
genetic counseling units of the Public Health
specific surveillance programs for high-risk indi-
Hereditary Cancer Program of the Comunidad
viduals who carry a pathogenic mutation. Thus,
Valenciana3.
high risk individuals are advised to stay with-
in the normal weight range and refrain from The present study was conducted in compliance
smoking since a high BMI and smoking increase with the ethical principles for medical research
the risk of developing adenomas and colorectal involving human subjects of the Declaration of
cancer in Lynch syndrome. Regular colonoscopy Helsinki. Informed consent was obtained from
leads to a reduction of colorectal cancer-related all subjects, and the study received the approval
mortality. Hysterectomy and bilateral oopho- of the Ethics Committee of the Elche University
rectomy largely prevents the development of Hospital.
endometrial and ovarian cancer and is an op- A standard procedure was applied for the di-
tion to be discussed with mutation carriers who agnosis of LS in all cases. Fulfillment of the re-
have completed their families especially after vised Bethesda Guidelines or loss of expression
the age of 40 years2. of MMR genes during universal screening for
The prediction and prevention schemes reduce colorectal and endometrial tumors is required
the impact of cancer in high-risk families in a for referral to the Genetic Counseling in Cancer
cost-effective manner. Units4,5. Before gene mutation analysis, the tu-
In general, genetic tests for LS are well stan- mors of the probands were studied for micro-
dardized and broadly used, although there satellite instability and MMR protein expression
remain some specific difficulties that need to (MLH1, MSH2, MSH6, and PMS2), to confirm
be addressed to reach an optimal diagnosis. MMR implication and select the target gene/s
In addition to the postanalytical limitations in for mutation analysis.
the interpretation of the clinical significance of Mutation testing using the probands’ blood DNA
some genetic variants, there are other analyti- was then performed to assess the causative
cal challenges, such as the difficult study of the germ-line mutation in their families. PCR and
PMS2 gene because of the high number and Sanger sequencing results of the whole coding
Page 78
sequences and intron–exon boundaries of the received the corresponding genetic counseling
MSH2 gene were analyzed. The PCR primers and and genetic predictive tests were offered to at-
conditions used were reported by Wahlberg et risk relatives. Genetic predictive tests are usually
al.5. The suspicious genetic variants detected performed using PCR and sequencing of both
were confirmed by an independent sequence strands of the amplicon that contains the muta-
analysis of both DNA strands. The clinical signifi- tion detected in the family.
cance of the variants was assessed according to
the InSiGHT Variant Interpretation Committee: RESULTS AND DISCUSSION
Mismatch Repair Gene Variant Classification
Criteria, Version 1.9 August 2013 (http://insight- After 10 years of testing experience of genetic
group.org/criteria/)7. Pathogenic mutations and diagnosis for LS, we have found eight families
variants of unknown clinical significance were with mutations in homopolymer surrounding
deposited in the InSiGHT database (International sequences. All tumors analyzed in these families
Society for Gastrointestinal Hereditary Tumors: showed high microsatellite instability with posi-
http://www.insight-group.org). Once a caus- tive results for the five mononucleotide markers
ative mutation of LS was detected, the patient analyzed, as well as loss of inmunohistochemical
Figure 1 Microsatellite Instability analysis and loss of expression of MSH2 protein

by Immunohistochemistry in colorectal tumors
a) WT Microsatellite stable tumor with normal expression of MSH2 protein
b) c.942+2T>A Microsatellite Instability with loss of MSH2 protein expression
c) c.942+3A>T Microsatellite Instability with loss of MSH2 protein expression
NR27
NR2 NR21
NR2 NR24
NR2 BAT25 BAT26
a) wild-type control, b) and c) cases with c.942+2T>A and c.942+3A>T mutations, respectively. NR27, NR21, NR24,
BAT25 and BAT26: microsatellite markers.
Page 79
Table 1 Clinical data of probands and families with pathogenic mutations

located near the BAT26 marker
Proband´s Relatives*
Id. Sex FH Variant Protein Ages
neoplasms +/-
1 F AM II EC, CRC 41, 43 6/13
2 F BG CRC 33 5/0
c.942+2T>A
3 F BG OC 45 3/2
4 M AM II CRC 51 0/12
p.Val265_Gln314del
5 F AM II EC 42 0/2
6 F BG CRC, GC 50, 50 0/2

c.942+3A>T
7 F AM I CRC, BC 48, 49 0/0
8 M BG CRC 47 0/2
*Relatives: number of predictive tests performed to date in the family with positive/negative results.
Sex: F, female; M, male.
FH, family history; AM II, Amsterdam Criteria II; AM I, Amsterdam Criteria I; BG, Bethesda Guidelines.
Neoplasms: BC, breast cancer; CRC, colorectal cancer; EC, endometrial cancer; GC, gastric cancer; OC, ovarian cancer.
In bold italic letters: tumors in which microsatellite instability and MMR protein immunohistochemistry were detected.
expression of the MSH2 and MSH6 proteins all point mutations detected in the four MMR
(Figure 1, Table 1). genes. In addition, and to date, 47 at-risk rela-
Four of these families had the c.942+2T>A mu- tives from these families have also been tested,
tation, whereas the remaining four families had which led to the identification of 14 mutation-
the c.942+3A>T mutation. Both at intron 5 of carrier individuals. These high-risk individuals
MSH2 gene just by BAT26 mononucleotide mark- are currently benefiting from a specific surveil-
er [(A)26] (Figure 2, Table 1). These mutations had lance and monitoring program aimed at mini-
the same effect at the protein level, i.e., exon 5 mizing the impact of cancer2.
skipping (p.Val265_Gln314del). Consequently, Up to nine intronic large homopolymer se-
important functional domains of the protein quences (over 10mer long) are located in the
were affected, such as MutS II and III, which are proximity of exons and around splice sites in
connector and lever domains, respectively. These the MMR genes. To date, pathogenic mutations
domains play different roles in holding the DNA at eight out of these nine sites have been de-
that is to be repaired. Therefore, both mutations scribed in the InSiGHT database (Table 2). The
were pathogenic and causative of LS. splice sites are conserved and essential for exon
The special sequence context of these muta- definition and appropriate splicing. Mutations
tions hampers their detection. In our series, in those consensus positions generate aberrant
these mutations represent about 18% (8/45) transcripts and loss of protein function and are,
of MSH2 point mutations and 5% (8/148) of consequently, pathogenic.
Page 80
Figure 2 igure forward sequence of the MSH2 gene: Ex05–i05 boundary

Sanger
a)
WT
MSH2 Ex05 i05

b)
c.942+2T>A
MSH2 Ex05 i05

c)
c.942+3A>T
a) wild-type sequence, b) c.942+2T>A mutation, and c) c.942+3A>T mutation
Page 81
Table 2 Mononucleotide repeats (>10mer long) located in the proximity

of consensus splicing sites of the MMR genes and mutations
detected at those sites
Intron-exon Homo # families # families

Gene Mutation Class*
boundaries polymer Our Lab InSiGHT
c.1039-2A>G 4 0 2
MLH1 i04-E05 (T)21 c.1039-2A>T 4 0 1
c.1039-1G>A 5 0 4
c.212-2A>G 4 0 2
i01-E02 (T)13
c.212-2A>G 5 0 7
MSH2
c.942+2T>A 5 4 6
E05-i05 (A)26
c.942+3A>T 5 4 161
MSH6 i06-E07 (T)13 c.3556+3_3556+13del 3 0 2
PMS2 i04-E05 (T)13 None - - -

*Class: variant classification according to their clinical significance (InSiGHT database): 5, pathogenic; 4, probably
pathogenic; 3, unknown.
It is important to note that mutations that oc- are mandatory. For the analysis of probands
cur in the proximity of a large mononucleotide by Sanger sequencing, validated PCR and se-
repeat can be detected only by sequencing of quencing conditions for all amplicons that are
the DNA chain that contains the variant in the needed to cover the regions of interest are re-
5′ side to the repeat. Confirmation by sequenc- quired. The use of visual inspection, in addition
ing of the complementary chain is unfeasible; to the bioinformatics tools used for sequencing
for this reason, special care is needed to detect
analysis, is highly recommended. When there is
and confirm these variants.
reason to suspect the presence of mutations, a
Currently, the vast majority of tests used for double check by a second experienced observer
the genetic diagnosis of hereditary cancer syn- and a confirmatory analysis using the same DNA
dromes in Europe are laboratory-developed
sample are required. A positive-control sample
tests (LDT). As stated by the international stan-
should also be tested in parallel. When next-
dard ISO 15189:2012(E) (Medical laboratories,
requirements for quality and competence), the generation sequencing (NGS) platforms are
laboratory should design quality-control proce- used for non-validated diagnostic testing, con-
dures that verify the attainment of the intended firmation by Sanger sequencing is compulsory.
quality of the results. Standard operating proce- Furthermore, for predictive testing of at-risk in-
dures that include the approaches that are nec- dividuals, at least two independent PCR-Sanger
essary to overcome these specific difficulties sequencing experiments that include positive
Page 82
and negative controls of the genetic variants in Valencian Community (Eastern Spain). Fam Cancer. 2014,
13(2): p. 301-9.
question are recommended.
4. Umar A, et al. Revised Bethesda Guidelines for heredi-
In conclusion, the detection of pathogenic mu- tary nonpolyposis colorectal cancer (Lynch syndrome)
tations located near microsatellite sequences is and microsatellite instability. J Natl Cancer Inst. 2004,
especially difficult and requires the implemen- 18;96(4): p. 261-8.
tation of specific quality controls to optimize di- 5. Pérez-Carbonell L, et al. Comparison between univer-
sal molecular screening for Lynch syndrome and revised
agnostic methods. Bethesda guidelines in a large population-based cohort
of patients with colorectal cancer. Gut. 2012, 61(6): p.
REFERENCES 865-72.
1. Rustgi AK. The genetics of hereditary colon cancer. 6. Wahlberg SS, et al. Evaluation of microsatellite insta-
Genes Dev. 2007, 15;21(20): p. 2525-38. bility and Immunohistochemistry for the prediction of
germ-line MSH2 and MLH1 mutations in hereditary non-
2. Vasen HF, et al. Revised guidelines for the clinical man- polyposis colon cancer families. Cancer Research 2002,
agement of Lynch syndrome (HNPCC): recommenda- 62: p. 3485-92.
tions by a group of European experts.Gut. 2013,62(6): p.
812-23. 7. Thompson BA, et al. Application of a 5-tiered scheme
for standardized classification of 2,360 unique mismatch
3. Cuevas-Cuerda D, Salas-Trejo D. Evaluation after five repair gene variants in the InSiGHT locus-specific data-
years of the cancer genetic counselling programme of base. Nat Genet. 2014, 46(2): p. 107-15.
Page 83
The first green diagnostic centre and laboratory
building in Indonesia
Joseph B. Lopez1, Endang Hoyaranda2, Ivan Priatman3
1
Immediate Past President, APFCB, Kuala Lumpur, Malaysia
2
Secretary, APFCB; Prodia, Jakarta, Indonesia
3
ARCHIMETRIC, Surabaya, Indonesia
Corresponding author: Like every human activity, clinical laboratories pro-

Joseph B. Lopez
17 Jalan SS 21/46, Damansara Utama duce a carbon foot-print which they have a societal
47400 Petaling Jaya obligation to reduce. The renovation or construc-
Malaysia
E-mail: jblopez2611@gmail.com tion of a new laboratory provides an opportunity to
achieve this. A new, environmentally-friendly diag-
nostic centre in the city of Surabaya, Indonesia, was
recently constructed under the supervision of a LEED
(Leadership in Energy and Environmental Design) -
certified architect incorporating the three basic te-
nets of good environmental practices, i.e. to reduce,
reuse and recycle. Sustainable practices that were ad-
opted in the construction of the building involved its
architectural features, the location and the construc-
tion materials used. The building has been designed
for energy and water conservation in the long-term.
The cost for these green features was an additional
30% compared to that of a conventional building. It is
expected that this extra cost will be recouped in the
long run through cost-savings.
Page 84
Joseph B. Lopez, Endang Hoyaranda, Ivan Priatman
INTRODUCTION The building was designed and constructed un-

der the supervision of a LEED-certified archi-
All human activity consumes resources, leaves a
tect. LEED accreditation for the building is being
carbon footprint and produces waste. The clini-
sought. The three fundamental tenets of good
cal laboratory is no exception to this rule and it environmental practices, namely, to reduce,
impacts the environment in several ways. They reuse and recycle, underscored its design and
therefore have a societal obligation to reduce construction. The building has also been de-
their environmental impact. Laboratories may signed to make the internal environment men-
do so by adopting policies and activities that tally conducive for the staff.
are sustainable and environmentally friendly.
The sustainable practices that were adopted for
The construction of a new laboratory building
this building have involved consideration of the
or renovation of an existing one provides an ex-
following aspects:
cellent opportunity to make it environmentally-
friendly with regard to the utilization of building • The location and features of the building;
materials and recurrent resources such as en- • The construction materials used;
ergy and water and waste production. (1)
• Energy conservation;
LEED or Leadership in Energy and Environmental
• Water conservation.
Design, is a green-building certification program
that recognizes best-in-class building strategies The incorporation of green features to the build-
and practices. It is the most widely recognized ing has resulted in a 30% increase to the overall
and used green-building program across the cost compared to that without these features.
globe (2). The first green laboratory and diag-
nostic-centre building in Indonesia , the Grha LOCATION, BUILDING FEATURES
Prodia, was opened on 14th March 2015 in the The key features of the building are stated in
city of Surabaya. This centre performs an av- Table 1. The building has a recycling facility.
erage of about 60,000 tests a month of which Initially this will be for paper and plastics. It is
clinical chemistry, including urinalysis, accounts located in one of the main arteries of Surabaya
for about 43,000. close to amenities such as banks, schools and
Table 1 Building parameters
Feature Parameter
Main orientation north-south
External dimensions 18.75 by 56.45 metres
Floors (including ground floor) 11
Total gross square footage / gross floor area 4406.577 sqm
Total parking floor area 1.027,601 sqm
Total floor space (include basement parking) 5434.178 sqm
Page 85
other facilities. This will enable the approxi- both thermal and sound insulation. The steel
mately 213 staff members to use these facili- and aluminum used has recycled content; the
ties without having to travel long distances and latter was produced very close to the building.
thereby reduce their carbon footprint. In ad- Fly-ash was used in the construction of the con-
dition clients and suppliers will also have easy crete structure. It is a recycled material com-
access to the building. The parking lots are re- posed of the fine particles which is one of the
served for staff who car-pool. There are bicycle residues generated by coal combustion. Care
racks and three showers for staff who commute was taken to ensure that the paint used had low
by bicycle. volatile organic compounds (VOC) since organic
compounds used in conventional paint have
Orientation and space VOCs that are carcinogenic.  
The main axis of the building has an east-west The waste materials generated during construc-
orientation to reduce the heat from the sun. tion were glass, ferrous metals, non-ferrous
This means that most of the external surface metals, gypsum, concrete, wood, cardboard
area faces the north-south axis and is not direct- and plumbing fixtures. They were kept in sepa-
ly exposed to the heat from the tropical sun. To rate bins and sold for recycling.
further reduce the heat inside, the building has
been constructed with sun-shading horizontal Floor covering
fins made from aluminum panels. The floor spaces that are carpeted use square
The building occupies 50% of the land area be- tiles (50 x 50 cm) to permit replacement of the
longing to it. Of the remaining area surrounding tiles in the event of damage or wear and tear.
the building, 41% has been turned into garden The tiles were made of 100% recycled materi-
space, which is 3 m wide. This contrasts with the als. In areas where linoleum is used as in the
city requirement of 10% for green space for pub- laboratories, it is made from linseed oil. This is
lic buildings. The local species of grass and trees a rapidly renewable material that can be har-
that make up the garden requires minimal main- vested and put to use for manufacturing in less
tenance. In addition, there is a roof top garden. than 10 years from planting. Both the linoleum
and carpet tiles were imported.
Indoor environmental quality
The building has been designed such that 95% ENERGY CONSERVATION FEATURES
of all spaces that are regularly occupied have Natural lighting
a view of the outside. This is important for
The rooms have been designed to maximize the
eye and mental health, which should yield the
use of natural light. The windows are adequately
consequent benefit of improved work perfor-
sized to allow the maximum amount of natural
mance. The top floor where meetings are held
light to enter a room. All rooms in the building
has glass walls on 3 sides with a view of the city.
have windows with a view of the outside. The
building is insulated with double-glass windows
BULIDING MATERIALS USED
which have high-performance low-emissivity
Recycled materials were used in the construc- glass on the inside and tinted glass on the out-
tion of the building. Most of the materials were side. With a window height of 3 meters, it is cal-
manufactured in nearby regions. The envelope culated that light can penetrate 6 meters into the
of the building contains rock-wool that provides space.
Page 86
Lighting plant. The water salvaged from the plant is used

The building uses light-emitting diode (LED) light- for the toilets and for watering plants.
ing with motion sensors in every room which au- Toilets
tomatically switch off the lights when the rooms
are not occupied. LED lighting is approximately 3 All toilets have a dual-flow capability which use
times more expensive than conventional lighting. 4.5 and 3 L of water, respectively, per flush as
against single-flow conventional toilets that use
Air-conditioning 6 L. The urinals in the building are of two types:
waterless urinals for the staff and low-flow uri-
The temperature inside the building is set by
nals for the public who may not be familiar with
thermostat at 24° C. The air-conditioning uses
the former. All faucets have sensors that pro-
a Variable Refrigerant Volume® (VRV) system
vide the same flow for less water. These water-
from Daikin (Japan), a concept that is similar
saving devices are approximately 150% more
to inverter air-conditioners that are commonly expensive than the conventional ones but use
available. The amount of cool air that is pro- 43 % less water.
duced will depend on the number of persons in
the room. The VRV system is 3 to 4 times more CONCLUSION
expensive compared to conventional air-condi-
tioning systems. The construction of this green facility is recog-
nition of the need for sustainable practices by
WATER CONSERVATION MEASURES laboratories. It is a visible act of corporate so-
cial responsibility that should yield intangible
The city of Surabaya faces a water-shortage in rewards in the future. It is expected that the
the dry season and receives excessive rain that additional cost of the building will be eventu-
results in floods during the wet season. The ally recovered through lower energy costs and
building expects to obtain 42% of its water re- other sustainable practices.
quirements from processed sewage and rain-
water and will depend on the city for only 58% REFERENCES
water supply. Rain-water will be harvested from 1. Lopez JB and Badrick T. Proposals for the mitigation
the roof and stored in a tank with a 11,000-li- of the environmental impact of clinical laboratories. Clin
tre capacity which is located in the basement Chem Lab Med 2012. 50: 1559-1564.
floor. The building contains a sewage treatment 2. http://www.usgbc.org/about. Accessed 25 August 2015.
Page 87
Editor-in-chief
Gábor L. Kovács
Institute of Laboratory Medicine, Faculty of Medicine, University of Pécs, Hungary
Assistant Editor
Harjit Pal Bhattoa
Department of Laboratory Medicine, University of Debrecen, Hungary
Editorial Board
Khosrow Adeli, The Hospital for Sick Children, University of Toronto, Canada
Borut Božič, University Medical Center, Lubljana, Slovenia
Rajiv Erasmus, Dept. of Chemical Pathology, Tygerberg, South Africa
Nilda E. Fink, Universidad Nacional de La Plata, La Plata, Argentina
Mike Hallworth, Shrewsbury, United Kingdom
Ellis Jacobs, Alere Inc., New York, USA
Bruce Jordan, Roche Diagnostics, Rotkreuz, Switzerland
Evelyn Koay, National University, Singapore
Maria D. Pasic, Laboratory Medicine and Pathobiology, University of Toronto, Canada
Oliver Racz, University of Kosice, Slovakia
Rosa Sierra Amor, Laboratorio Laquims, Veracruz, Mexico
Sanja Stankovic, Institute of Medical Biochemistry, Clinical Center of Serbia, Belgrade, Serbia
Danyal Syed, Ryancenter, New York, USA
Grazyna Sypniewska, Collegium Medicum, NC University, Bydgoszcz, Poland
Peter Vervaart, LabMed Consulting, Australia
Stacy E. Walz, Arkansas State University, USA
Publisher: IFCC Communications and Publications Division (IFCC-CPD)
Copyright © 2016 IFCC. All rights reserved.
The eJIFCC is a member of the Committee on Publication Ethics (COPE).
The eJIFCC (Journal of the International Federation of Clinical Chemistry)

is an electronic journal with frequent updates on its home page. Our
articles, debates, reviews and editorials are addressed to clinical
laboratorians. Besides offering original scientific thought in our featured
columns, we provide pointers to quality resources on the World Wide Web.
Contents may not be reproduced without the prior permission

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February 2016 ISSN 1650-3414

Communications and Publications Division (CPD) of the IFCC

Foreword of the editor

Analytical challenges in the genetic diagnosis of Lynch syndrome

The first green diagnostic centre and laboratory building in Indonesia

Foreword of the editor

Harmonization of clinical laboratory test results

ARTICLE INFO EDITORIAL

Corresponding author: Clinical laboratory testing is now a global activity with

What is the status of harmonization of promising harmonization initiatives among

TTP International and national

Post- 1. Standardization of reporting units 1. IFCC C-NPU, IUPAC, IFCC WG-HbA1c,

2. Standardization of reporting 2. Pathology Harmony (UK), RCPA PITUS

3. Harmonization of calculated parameters 3. ACB Albumin-adjusted calcium, AACB

4. Common reference intervals (RIs) 4. IFCC C-RIDL, Nordic countries (NORIP),

5. Platform-specific RIs and decision limits 5. AACB Harmonisation Committee

6. Standardization of report formatting 6. RCPA PITUS (Australia)

7. Critical laboratory results (CLR) – 7. EFLM, CLSI, AACB-RCPA WP-CLR

8. Interpretative commenting 8. IFCC WG-Harmonisation

9. Biological variation – harmonized 9. EFLM WG-BV

Post-post 1. Promotion of clinical and laboratory 1. IFCC Taskforces, AACC Strategic

AACB: Australasian Association of Clinical Biochemists;

RCPA: Royal College of Pathologists of Australasia;

CONCLUSIONS 8. Beastall GH. Adding value to laboratory medicine: a

Harmonization of clinical laboratory

ARTICLE INFO ABSTRACT

Corresponding author: According to a patient-centered viewpoint, the me-

Chemistry and Laboratory Medicine (IFCC) has HARMONIZATION: CURRENT PROJECTS

1. Define analyte (measurand)

Quality indicators FUTURE STRATEGIES

Harmonization initiatives in Europe

ARTICLE INFO ABSTRACT

Corresponding author: Introduction: Modern medicine is more and more

Figure 1 Papers in PubMed with the word “harmonization” or “harmonisation”

The Working Group on the “Harmonisation of EFLM SURVEY ON HARMONIZATION

Questions on harmonization of sharing easily the documents within Europe.

The International Consortium for Harmonization

ARTICLE INFO ABSTRACT

Corresponding author: Results from clinical laboratory measurement proce-

THE PROBLEM: INTRODUCTION ACHIEVING HARMONIZED

Figure 1 Traceability scheme

Source: ISO 17511

WHAT TO DO unmet needs for harmonization of clinical labo-

International Consortium for

Governance, Harmonization Operations

manufacturers, professional societies, standard- given measurand. If an organization, such as the

Figure 3 Harmonization website resources page

Harmonization of clinical laboratory test results:

ARTICLE INFO ABSTRACT

disease (CHD) in the US and also achieved a METROLOGICAL TRACEABILITY

Figure 1 General metrological traceability diagram from ISO 17511, in vitro

Figure 2 Commutability is demonstrated if fresh patient samples and reference

Commutable: same relationship for clinical samples and reference materials.

Analyte “Conventional units” SI units*

ALT U/L mkat/L

Bilirubin mg/dL mmol/L

Glucose mg/dL mmol/L

CONCLUSIONS 8. Beastall GH. Adding value to laboratory medicine: a

Australia44 Turkey43 Nordic United Japan42 Canada38 Austral