|
From the February 2003 Issue |
LIS and the Enterprise Lab information systems play a pivotal role in patient care, and IT systems have evolved to meet current-day users’ needs. By Richard R. Rogoski
Aware of the challenges faced by lab managers, doctors and nurses, and chief information officers, laboratory information system (LIS) vendors are exploring a number of options to make their products more user-friendly and utilitarian. They are also keeping a watchful eye on healthcare trends that eventually will impact laboratory systems. It’s no surprise that Microsoft Windows and Web-based systems have already streamlined much of the work in hospitals and clinics, but because laboratories are essentially data-centric, systems integration has been a stumbling block. Plus, the amount of data compiled in labs is predicted to grow as patients take more active roles in their own healthcare decisions. Needful Users
Hauck says the emphasis now being placed on electronic medical records (EMRs) will require the collection of vast amounts of information. Too often, this information—including laboratory test results—is stored in several places and never entered into a central database. “There have been no standards for the capture and storage of this information,” he notes. One solution is to create a relational database, which is a feature of both Cerner’s LIS, called PathNet Millennium, and Orchard Software Corp.’s LIS, called Orchard Harvest. But Mike Breedlove, Cerner’s former enterprise vice president of laboratory medicine, points out that there are some who still balk at adopting technologies in the lab that could pull all this information together. He says the dividing line is between “those stuck in the way it used to be and those who see the advances in technology.” Also, there are those who would readily adopt newer technologies if they had the infrastructure to accommodate those technologies, says Rob Bush, president of Orchard Software Corp. in Carmel, IN. Bush’s 9½-year-old private company targets hospitals with 50 to 100 beds and small clinics that often need to interface with larger hospitals. While he admits that most laboratory information systems, including his own, now provide online order entry and real-time access to test results, he says that in some geographic areas, “Not every doctor has a computer.” Concerns about security and misconceptions surrounding Web-based networks also pose challenges to vendors according to Bob Sage, founder and president of Milford, MA-based Psyche Systems Corp. Sage’s 27-year-old private company shifted its focus in 1995 when it redesigned its LIS, called LabWeb, and moved away from providing turnkey solutions to become an application service provider (ASP). Even though the company’s target market includes hospitals from fewer than 100 beds to 2,000 beds, health maintenance organizations, state and commercial labs, and physician practice groups, Sage says, “The majority of the market is not ready for an ASP.” Those who have embraced an ASP model, he explains, are early adopters who have faith in the underlying technology, or those with limited resources who need to outsource some mission-critical applications. But there is also a third group—those who have had a bad experience with servers. “They crashed. They were underconfigured or they became obsolete,” he says. Evolving Systems
Breedlove says Cerner’s original LIS suite of software, called Classic, had been text- and procedures-based. But when the company launched Millennium four years ago, it incorporated a GUI front end. Not only is the architecture more like those of other widely used applications, but Breedlove says, “I can’t think of an HIS we haven’t interfaced to.” And interfacing is becoming more important, says Bush. “Everybody in our market wants integration,” he says. Like Cerner, both Orchard Software and Psyche Systems use a Windows platform that provides more flexibility and scalability than text-based systems. While the push toward integration continues, Bush cautions those looking to replace an old LIS with a new system to explore interfaces, both the industry standard and custom interfaces to billing, reference labs and medical record applications. One way to facilitate systems integration and keep pace with changes is to purchase LIS software written in an object-oriented programming environment, he says. Smarter Systems The need to get results out of the lab faster also is driving development of “smarter systems,” says Sage. He says users want systems that can “think” for them, and streamline and condense workflow. “Instruments today are processing information faster and with less intervention,” he says, so a smart system needs to be a rules-based system that can set up specific rules per physician and enter comments based on values, rather than being just a recording system. Orchard’s Bush also acknowledges the need for rules-based technology—at the front end, in the middle and at the back end. At the front end, he says, there need to be rules for ordering tests so that all the information needed for specific tests is there for anyone who is ordering. As an example, he cites the ordering of a creatinine clearance test. “The nurse orders it, but she needs the height and weight of the patient and the volume of his urine output. If the nurse doesn’t know what information needs to be included, how can she order the test correctly?” The further away from the lab tests are moved—like making order entry part of an electronic medical record—the more rules need to be added so that testing is done accurately for the right factors, he says. Tests and EMRs Bush cites another example to prove his point. “EMRs are trying to address the needs of physicians and staff,” he says. Yet when it comes to phlebotomy, for example, most EMRs come up short. By incorporating specific front-end rules, Bush says his system is able to manage all the necessary information. “We know what the codes are. We know what tubes are required for each test. We know the handling instructions for each sample. All those rules are areas we address.” With an interface to an EMR, those ordering specific tests receive on-screen prompts as to what each order entails. But there is more at stake than just the clinical aspects of test ordering, Bush says. There also need to be front-end rules for financial issues like medical necessity-checking for Medicare so that the lab can perform its work and the organization can get paid. Breedlove adds, “Integrated delivery networks, whether for-profit or not-for-profit, have certain services that generate revenue. The percentage of reimbursement and the amount labs are getting reimbursed is important to them. They need to increase revenue and decrease the amount written off.” Sage agrees that reimbursement is currently a hot issue in the laboratory—so big, in fact, that Psyche Systems has added a medical necessity-checking module so that rules can be set up for only those tests covered by Medicare. As for mid-level rule sets in the lab, Bush says these are necessary to speed up the testing process and to auto-validate results for accuracy. On the back end, rules-based technology determines how and where the lab report should be sent—whether to the emergency department, for example, or to a specific doctor. Interestingly, many emergency rooms still like getting lab results in a paper format that comes through a printer. But Breedlove says that in many automated emergency departments, patients are tracked and test results are posted on computer monitors. With the advent of the Internet and secure corporate intranets, Cerner introduced ePathLink to provide a real-time link to the LIS. “As soon as a lab test is verified, the results become available—instantaneously,” he says. “We’re pushing those results right to the physician.” Information Overload
“For years, what we have done is provide data for test requests,” he notes. “It’s either high, low or normal. We haven’t done enough to provide context to personalize the report. The more knowledge we can add to the data, the more we can improve patient care and reduce medical errors.” Hauck agrees. He says genetic information, which can show a predisposition to certain diseases or alter prescribed therapies, should also be included. “In many cases, the information is already there in the databases,” he says. But it is seldom stored in one place. If databases are relational, “we know what lab tests the patient has had before and what medications he is on. Everything is related to this one person.” Bush, too, sees the value in compiling genetic information, but he says insurance companies will be reluctant to pay for such tests. “If you’re going to do genetic testing, you’re going to have to pay for it yourself,” he predicts. The role of the patient also is increasing, Breedlove says. Many patients already have their own personal Web page or their Web medical records section online with their providers, and they expect to be able to get real-time access to information about their lab tests. However, he predicts a future with more filtering to quantify what information patients will be able to access. Some states have passed laws making it possible for patients to purchase laboratory tests from a lab without a doctor’s order and then provide their physicians with the results of these tests. New York now allows 152 of these tests, and California, eight. Among the direct access tests allowed in New York is the PSA test used to screen for prostate cancer. Breedlove says, “This is where the consumer is driving us.” ASP Nation? With Web access becoming an integral part of healthcare and patient empowerment, it’s not surprising that Psyche Systems is staking its future on the ASP model. According to Sage, Psyche Systems’ LabWeb creates “pages” of information that can contain text, images, motion pictures and sound—all of which is easily accessible through a graphical browser. In addition, there are several different button/tool configurations designed to provide a specific set of operations only to those who need them, giving the system an additional layer of security. But one of the biggest benefits, Sage says, is that hospitals with a limited IT staff and small labs no longer have to maintain their own in-house servers, since LabWeb resides on Psyche Systems’ ASP server. Control, he adds, is not as big an issue as it once was. Not everyone agrees. “Laboratorians are a pretty conservative bunch,” says Bush. “They like to have control of that information.” Sage counters by saying that his contracts with customers guarantee that “they will have access to their data and that they get backup tapes.” While Sage admits that some customers are reluctant to use Web-based technologies because of perceived security risks, he points out that user PCs are connected to Psyche Systems’ ASP server via a private wide area network that uses frame relay technology, and adds that his company also will allow the use of virtual private networks as an option.
“Any workstation can access the information,” he says. “A network is a network. Our ASP is just a secure node on their network, and their network is just a secure node on our network.” Cerner also offers a by-subscription ASP model as well as a remote hosting service, and Breedlove sees these capabilities playing a significant role for laboratories in the future. No matter which way the future of laboratory information systems unfolds, laboratorians can count on smarter systems, automated workflows, activated patients and interfaces to EMRs being part of their everyday life—starting now. Richard R. Rogoski is a free-lance writer and a contributing editor to HMT. Contact him at rogoski@aol.com. HMTFor more information about PathNet from Cerner Corp., www.rsleads.com/302ht-200 For more information about Orchard Harvest from Orchard Software Corp., www.rsleads.com/302ht-201 For more information about LabWeb from Psyche Systems Corp., www.rsleads.com/302ht-202 © 2003 Nelson Publishing, Inc |
With more information to gather and store,
and with increased demand by clinicians for faster turnaround times between ordering tests and getting results, laboratories are demanding more from their information systems.
Collecting, storing and pushing all that data out to those who need it demands a more robust solution, says Art Hauck, M.D., the new enterprise medical officer for laboratory medicine at Kansas City, MO-based Cerner Corp. “Medicine has been a cottage industry, and doctors’ offices have been largely paper-based,” he says. “There hasn’t been a concerted effort to bring all the information together into one place.”
Given the nature of the data collected, labs traditionally have relied on text-based “green screens” with the look and feel of DOS-based systems. But the need to integrate lab systems with other hospital information systems has led to an evolution of systems and a general acceptance of a graphical user interface (GUI).
The move toward EMRs and greater patient involvement puts pressure on labs to store and access more and more information. But by using a relational database and data mining software, labs can provide clinicians with real information rather than just data and lab results, Breedlove says.
Sage asserts that with the price of bandwidth decreasing rapidly, with newer encryption technologies in place and with zero downtime, ASP solutions are more attractive and are virtually indistinguishable from running an LIS on your own server. “People who are running ASP don’t know they’re running ASP. It’s just as fast as an in-house system, and there are several ways to interface with an HIS.