Lab Links to Patient Safety

From the March 2005 Issue

Pushing lab results to clinicians and enabling Web access gets timely information into the hands of decision-makers for this West Coast health system.

By Ellie Krock, D.L.M., C.L.S., and Ann Tozier, C.L.S.

Because a large majority of clinical decisions are based on the results generated by clinical laboratory departments, many labs are evaluating new ways to efficiently get information into the hands of clinicians while minimizing the potential for errors.

These issues prompted the laboratory department at the Sansum – Santa Barbara Medical Foundation Clinic in California, a nonprofit organization, to be proactive in its efforts by upgrading its laboratory information system (LIS) in early 2004. Although Sansum was satisfied with the fundamental capabilities of its existing LIS, new features within the upgrade addressed several lab-related patient safety concerns as well as improved internal laboratory productivity and turnaround. These features included improved clinician notification of critical results, the automated entry of results from outside reference labs, and overall improved access to information for decision-making.

In addition, the upgrade transitioned us from a character-based system to a browser-based LIS using native browser technology, which reduced the total cost of ownership with less desktop administration and requirements, and made it easier for users to learn and navigate. Because we were already satisfied with our current LIS vendor, the upgrade made sense, considering that a new vendor selection process would take a year or more to complete, and then the organization would have to create new databases and interfaces during the implementation period.

Links to the EMR
Sansum – Santa Barbara Medical Foundation Clinic has more than 150 staff physicians practicing more than 30 specialties at its clinics and branch offices from Carpinteria to Lompoc. The organization is the result of an October 1998 merger between Sansum Medical Clinic and Santa Barbara Medical Foundation Clinic.

Before the merger, both organizations were users of the CyberLAB LIS offered by CCA (Creative Computer Applications Inc.), Calabasas, Calif. The Santa Barbara Medical Foundation Clinic has been using CyberLAB since 1990, and the Sansum Medical Clinic implemented CyberLAB in 1996. Following the merger, the process of centralizing lab operations was greatly eased because both organizations used the same LIS. Now, the combined lab at Sansum – Santa Barbara performs more than 2 million lab tests every year.

In the coming year, results from CyberLAB will automatically populate the enterprisewide electronic medical records (EMRs) solution that is currently being implemented at the organization. According to Kurt N. Ransohoff, M.D., Sansum’s CEO, president and medical director, “A concurrent phase of our efforts includes implementing an IDX management solution along with an Allscripts EMR, which will enable our organization to have a seamless flow of clinical information. Future efforts include integrating our radiology and pharmacy systems with the IDX solution.”

Web Deployment Eases IT Burden
We completed the upgrade to the browser-based CyberLAB 7.0 in April 2004, and within six days of the go-live date, the laboratory was fully functional. The lab did not experience any loss of productivity, and clinical report distribution was not disrupted. All of Sansum’s 150 physicians were already securely accessing the system’s WebGateway for online lab results query from their offices using a standard Web browser. This continued without a hitch.

In addition, use of standard browser technology has eliminated the need for IT staff to deploy the solution on users’ desktop systems. All users accessing the online system have unique IDs and passwords to ensure patient confidentiality and security.

Donovan Wade, Sansum’s manager of technical services, says the system’s architecture greatly decreased the IT staff’s workload during deployment of the upgrade. That allows the IT staff to push forward with other objectives. “We’re now working on providing remote physician offices—ones that are not part of Sansum—with secure access to lab results for their patients. This is particularly helpful when a Sansum physician refers a patient to a specialist outside of Sansum, or a physician refers a patient to Sansum for tests. The system gives us the ability to set up access by physician groups, so an entire group practice can have access to the results for their patients who had tests performed at Sansum.”

The lab system and the clinic’s own policy and procedure manuals support online user documentation. The clinic’s online manuals are frequently accessed to provide patients with information on test requirements, such as fasting before tests, or for technicians to look up specimen collection and packaging procedures, such as whether the specimen should be refrigerated, frozen or at an ambient temperature when sent to a reference lab. The laboratory will continue to convert the remaining policies and procedures to the online format.

Financial Benefits
Following the upgrade, lab-generated revenue increased by 15 percent, while the lab department’s workload increased by only 7 percent—an unexpected but favorable result. We attributed this to CyberLAB’s increased reporting capabilities, one of which enabled lab administrators to search for missing or invalid ICD-9 codes. Once detected, the errors can be corrected prior to bill generation.

The system’s medical necessity rules also contribute to financial gain. They alert users when a test is ordered that is not covered by Medicare for a specific diagnosis. Users are prompted to have patients sign an advance beneficiary notice (ABN), informing them of their financial responsibility, rather than having the lab absorb the cost. The system’s remote entry function even allows ABN collection to occur at remote Sansum – Santa Barbara phlebotomy sites.

The CyberLAB LIS and its SQL Gateway facilitate the use of reporting tools to track high-risk patients by diagnosis or by the medications that they use. This is particularly helpful for tracking diabetic patients or running reports to analyze all patients having positive hemoccult results, which may indicate a cancerous condition. In fact, a quarterly positive hemoccult report is created and distributed to the medical director and the physicians within Sansum to ensure that the results are not mistakenly overlooked, misread or inadvertently misrouted.

Coronary heart disease and diabetic patients are tracked as well by creating reports based on the lab test usage by these patients. We voluntarily report the resulting information to the various insurance plans that contract with us on a pay-for-performance arrangement. The clinic’s research and patient education departments also use the SQL reporting tool to select and monitor patients in their programs.

“The lab system’s open architecture allowed us to port the LIS data into a repository that includes lab, pharmacy, claim and encounter data. With the lab information, we have been able to feed back data to our physicians about how they are managing their diabetic patients and acute cardiac patients,” says Marjorie Newman, M.D., Sansum’s assistant medical director. “The lab system helps us show that we do a good job in managing our diabetics. Eighty-five percent of our diabetics had a HgbA1c level drawn within the calendar year, which, though not perfect, was among the highest of the groups in California.”

Distributing Results
For Sansum physicians, test results are distributed various ways, depending on the urgency of the tests or results, and the desires of the clinician. All test results are available for viewing over the Web via CCA’s WebGateway solution. In addition, test results are sent out to physician offices via automated print-at-location capability, distributed manually or autofaxed directly from the LIS. For example, a physician office can set its preferences to receive reports at a specific time of day, and the system automatically prints a batch of results on the printer or via fax machine in the physician office at the specified time.

Stat tests and results with critical values generate an alert within the LIS, notifying the clinical laboratory scientists (CLSs) that the physician office should be called immediately with the results. The CLSs can make the calls themselves, but have the option to electronically send the alert to administrative staff within the lab department to make the call, which minimizes interruptions to the workflow. All calls are internally documented within the LIS for historical review and accountability tracking.

Inbound calls to Sansum’s lab to check results have been infrequent for quite some time, since for years we have used CCA’s WebGateway for viewing and printing Web-based results. Until recently, however, clinicians would call to get results on tests that were sent out to reference labs.

These calls were virtually eliminated in January when Sansum implemented an interface between CyberLAB and the reference lab that it uses for outsourced tests. Previously, we had to manually distribute the reference lab results; they were not entered in the LIS system because of the potential for data entry errors. Now, results are automatically uploaded into the system via the interface between CCA and the reference lab. Results are disseminated via distributed printing, or clinicians can access them via the WebGateway along with the in-house test results.

Ellie Krock, D.L.M., C.L.S., is Sansum’s director of laboratory services. Contact her at ekrock@sansumclinic.org. Ann Tozier, C.L.S., is Sansum’s LIS administrator. Contact her at atozier@sansumclinic.org.