May 2000
Cover Story
Mark Uehling
LABORATORY tests are now being ordered and results delivered via the Internet, a development that could bring a few seismic shocks to the world of laboratory medicine. Not long ago, in a pilot project, an Arkansas-based physician ordered an HIV-related test. The doctor happened to be traveling in California when the results came in. He obtained the laboratory report not from his staff, or even from his e-mail inbox, but from a small handheld device like the Palm Pilot, which can easily connect with the Internet and other computer networks. The physician consulted the patient immediately and adjusted the patient’s medication. On a Sunday.
Laboratories and the Internet are about to be joined in technological matrimony. Test results—images, data, and hyperlinks to the latest peer-reviewed research—will be delivered not using the expensive, proprietary hardware and software of yore, but via the same generic Internet protocols that have revolutionized the airlines, publishing, and other businesses. And the cost of legacy laboratory information systems is being marked down to lower-than-imagined levels.
As with other industries rocked by the World Wide Web, it’s too early to say whether the electronically linked laboratory will be cheaper or better—but it is coming. "The Net for laboratories will level the playing field in terms of tools," says Tim Rich, CEO of Antrim, a division of Sunquest. "Now the very small laboratories can afford to have the same information management tools Quest has. The three-year cost of ownership may be 50 to 70 percent less expensive than traditional ownership."
At this stage, it’s tricky to say which approaches to unite the Internet and the laboratory will prevail. But Net--related infiltration of the laboratory landscape holds out the potential of improved accuracy and faster turnaround times, which could make the technology pervasive. "It’s going to be the standard of practice in the next year or two," says Advanced Health Technologies president Robert J. Alger. "Electronic results will just be an expected part of the lab experience."
That experience will vary. At its most basic, the Internet-enabled laboratory might take orders via the World Wide Web and report results in the same way. The Web pages presenting those results might or might not have supplementary information about abnormal values or diagnostic criteria. All such services to laboratories might be packaged under the auspices of a traditional laboratory brand name (The Cleveland Clinic, for example, or Tulane University) or by less established dot.com names (Healtheon or Medscape).
Because the nuances of laboratories and the Internet are complicated, some vendors and laboratories are excited about another way to combine them—the application service provider, which uses the Internet to deliver applications. Thanks to high-speed fiberoptic cables lacing the nation, using the ASP approach is indistinguishable from having a powerful computer on the premises. In theory, ASPs can do any information-related chore a laboratory already does and eliminate most of the costs attendant with computers and the people who maintain them.
For proof of what the future holds, one need look no farther than Specialty Laboratories, Santa Monica, Calif. "If you’re not on the Internet, if you don’t have a plan to be on the Internet, you’re going to be left behind," says Dan Angress, vice president of marketing. "The revolution for hospitals and laboratories is clear: Recognize the limitations of the laboratory information system in outreach, and develop strategies to use the Internet. That’s where the change is going to happen."
Angress is quick to point out—as the major LIS vendors themselves concede-that the LIS originated in an era of less—powerful and less-connected computers. In today’s networked environment, Angress notes, the proprietary and quirky interfaces of the LIS may seem somewhat outdated. "They’re not going to go out of business," he says of LIS vendors. "The [Internet] technology has gotten so superior that the need for an LIS in-house is going to be limited."
His own company, he reports, began aggressively adapting its ordering and result reporting in 1997. Its Data-PassportMD was first conceived as something for the physicians who ordered low volumes of tests. But demand was high. Today, more than 1,000 hospitals and physicians can order Specialty Laboratories’ tests online and see the results using a browser like Microsoft Internet Explorer. Eighty-five percent of the company’s tests are ordered electronically, Angress says.
The biggest selling point: accuracy. Electronically selecting tests eliminates accessioning errors, handwriting headaches, and other data entry problems. That allows the company to turn results around more quickly. What’s more, the system creates a trove of data that makes it possible for administrators to analyze physician test-ordering patterns, even to the point of delivering raw data that bean-counters can plug into their own spreadsheets.
Specialty Laboratories has 12 full-time support staffers who work with customers to make sure the software works properly. "We’re in a unique position to make this robust," Angress says, "because we’ve had the product up and running for more than two years. We are continually issuing upgrades. We are now on version 3.0."
Neither Angress nor anyone else in the information technology industry is certain how all the new gadgets will alter the habits of hundreds of thousands of physicians. Angress is willing to predict, for now, that physicians will continue to scrawl prescriptions as they have since time immemorial. Ballyhooed efforts to unite the disparate parts of a patient’s record are also lagging. "The doctor will still move around with a notebook or clipboard. He will still write in a chart."
Where there may be genuine change afoot, Angress says, is in the portability of laboratory result delivery. Angress says his company is finding that physicians do want to be able to see and read laboratory results anywhere, 24 hours a day, seven days a week. To Angress, there is nothing futuristic about the tale of the Arkansas physician getting laboratory results on a handheld device. That was a test project of Specialty Laboratories and one not regarded as particularly impressive from a technologic standpoint.
For Angress, the needs of the future might be more mundane. He’d like to help hospitals analyze their existing test data more effectively. "Hospitals have valuable data that are difficult to manipulate," Angress notes. "We are looking at what we can build that would help our clientele." Routine tasks like billing and reporting need to be simplified, but even Angress says such products and services may be a couple of years away.
OTHERS believe that day is closer. The Chicago-based Advanced Health Technologies is a leader in helping integrated delivery networks use the Internet. President Robert Alger notes that network connections cost roughly one-third as much as a laboratory results teleprinter. "Tele-printers cost between $100 and $150 a month," he says. "That includes the printer, the maintenance, the supplies, the paper, the phone line, the whole thing. You can give someone access to the Internet for substantially less. Maybe a third of that amount."
Alger continues: "What previously was seen as premium service, which would only be given to your very best customers, has the ability to generate a lower cost for the lab." And while there is naturally trepidation associated with computer--related decisions, Alger believes action of some sort needs to be taken quickly. His thinking, in brief, seems to be that the Internet will enable once--distant competitors to electronically eat your lunch. Says Alger: "The biggest message: You’ve got to start experimenting with this."
No matter which direction the world of technology takes, Alger suggests, there are basic steps every laboratory manager should consider. "Your LIS is going to need to talk to the Internet regardless of what you do. So let’s figure out how to spend $50,000 over a limited period of time to get going. Not how you’re going to spend $2 million. Get a little piece of the budget every year. Your organization really needs this. Your customers need this."
Longer term, Alger says, Internet-enabled laboratory systems have the potential to affect clinical practice as well as the cost of testing. "Say you have someone looking at a lipid panel, and you have a button saying ’For diagnostic help, click this link.’ Now you’re letting the doctor control the level [of detail], which is very important. But you’re also putting very important and powerful information right at their fingertips, right when they need it."
Advanced Health, as Alger explains it, is an intermediary. It is working with laboratories that want to provide additional services to clients and with third parties who prepare the content that appears when a lab report Internet link is clicked. That content creation is still in flux, he says. It may be written by drug companies, by instrument companies, by major academic medical centers-or all of the above.
One potential endpoint, Alger hypothesizes, is a change in how the role of the pathologist and other laboratory professionals is perceived. "The pathologist has been disenfranchised because the value they add isn’t really seen by the consumer. The ultimate value of the Internet technologies is to increase the amount of useful information that’s being provided by the laboratorians to increase perceived value."
ANOTHER specialist in bringing Web solutions to laboratory information services is the Canadian software company Triple G. It already has 175 customers operating 360 laboratories in eight countries, including the United States-and it is taking its application service provider offerings global. As an ASP, Triple G is an example of the new animal in the laboratory industry.
The term ASP is not tightly defined, but generally implies that rather than buying a soon-to-be-outdated computer for your office, you can get the benefit of the same services over the Internet for a smaller monthly fee. The idea is a red-hot fad on the Internet, with ASPs springing up in many industries. Some seers believe that such basic software programs as Microsoft Word might ultimately be provided not on one’s own computer, in other words, but a thousand miles away.
Although considered new, this model is a rebirth of a remote computing model served up by Medi-tech, Shared Medical Systems, and others decades ago. Use of the Internet, as opposed to private networks, is what sets application service pro-viders apart from their predecessors.
Triple G CEO Lee Green is betting that many laboratories will not want to fuss with the nitty-gritty of setting up and maintaining laboratory systems, portals, and networks. As he and others in the industry concede, attracting the necessary personnel is no easy task. Hospital information systems departments are, and will always be, at a disadvantage in a fast-growing technological industry where 900,000 jobs go unfilled every year.
"It can be difficult to compete with higher-paying information technology companies," says Green. "It’s tough for any company to attract employees in this field." But "private companies have the advantage of being able to offer their employees stock options and interesting development projects."
Triple G offers its customers something equally valuable: their own brand names. Rather than surrender a national brand name like that of the Mayo Clinic or a regionally respected academic medical center, Triple G customers remain in the spotlight. Internet companies, in contrast, propose to handle or subcontract laboratory tests under their own names in exchange for providing a hospital or physician with other information services. Triple G’s work, technologically speaking, is backstage. "We will allow our clients to own their own brands," says Green.
Companies like Triple G are simply taking the next logical step, but one that may make some administrators uneasy. "The ownership of the data always resides with the laboratory and hospital," Green says, "but the data itself is stored remotely."
SURPRISINGLY, there are already solid case histories in the field that suggest the union of laboratories and the Internet will be a happy one. Clinicians at the University of Minnesota did not need special training to get Web-based laboratory results when the lab introduced that capability in late 1994, says Donald Connelly, MD, PhD, a member of the CAP Informatics Committee. Even many of the older physicians immediately understood the service, delivered by Web browser. Why? They had been using it at home. So when a yellow box came up in a Netscape window, indicating a physician had ordered a test not covered by Medicare, the physician was not flummoxed. She knew-from visiting Yahoo! or Travelocity or Amazon.com—how to fill in a patient—specific form to keep the medical paperwork moving.
Based on this positive experience with physicians and the Web, Dr. Connelly and others founded Abaton.com, a company focused on bringing Web-based technologies to clinics. Within 120 days of signing its first contract, in February 1998, Abaton.com began ASP service to Allina Laboratories in Minneapolis. "The laboratory wanted to strengthen its outreach capabilities to physician offices throughout the Allina health system," Dr. Connelly says.
"Abaton.com’s product does not replace the workhorse elements of an LIS that are so important to the efficient internal operations of a laboratory," Dr. Connelly continues. Rather, "it puts a shell of friendliness around the LIS so that those outside the laboratory can order tests, review results, and get reports via a browser interface that is less cryptic than what a typical LIS presents to external users." To this Web-based shell, Abaton.com adds services that the LIS may not have, such as real-time medical necessity checking as orders are placed, detailed pickup lists for specimen couriers, and specimen tracking. Three laboratory organizations are now using Abaton.com’s ASP services.
As professor of laboratory medicine at the University of Minnesota and an employee of Abaton, Dr. Connelly reports that clinicians are increasingly accepting of Web-based services as they become more comfortable with the Internet. One factor driving the process: physicians who revise their understanding of the me-ta-physical "location" of the laboratory information they need. "For the integrated delivery system, that information has to be accessible throughout the health system, not buried in one clinic’s chart locked away in a medical records room when the patient appears in one of the system’s emergency rooms in the middle of the night," Dr. Connelly says. "With Web-based access, that lab result can be gotten when and where it’s needed with little effort." Lab results can now be simultaneously available via the health system’s intranet to those authorized to access those results.
Dr. Connelly is heartened that medicine can finally take advantage of technological advances developed in other industries. "Health care is going to take advantage of the technologic progress and standards of the much wider business community," he says, and thereby gain the affordability and connectivity advantages that Internet technologies offer everyone.
NATURALLY, the established LIS vendors have not been standing still. At Cerner, for example, one of the company’s foun-d-ers has returned to lead the charge into providing Cerner’s services on an ASP basis. That is, bill a monthly subscription, not a huge one-time fee, and use the Internet to avoid installing a big mainframe altogether.
"We are running ASPs today," says Paul N. Gorup, vice president for application and data services. "We are supplying a Cerner application where all of the IT-related activity and risk is being taken away and offered as a subscription service. Cerner is aggressively trying to proceed in this direction."
Peace of mind is part of the package, he says. "The machine they would have bought, which would have been obsolete by the time they got it up and running, is now no longer a risk," he notes. He adds that Cerner now has three ASP clients—in North Carolina, New York, and Missouri—and in each case they were customers who "specifically did not want, long term, to maintain the IT infrastructure."
A key feature distinguishing Cerner’s offerings, Gorup proposes, is that it is not a generic ASP, but potentially as customizable as what the company has always done with its largest installations. "A lot of people hear ASP and think, ’It’s like a Ford Model T; you can get any color you want, as long as it’s black.’ That’s not what we’re trying to do."
Instead, he says, the idea is to have a spectrum of options and prices to accommodate the traditional large laboratory or hospital as well as smaller clinics. To accomplish that, Cerner is working to ensure the ASP telecommunications links will be as solid as the ground beneath our feet.
In concrete language, Cerner wants to know that its worst-case scenario-a worker in a hardhat driving a backhoe cuts AT&T service east of the Mississippi-will not be a problem. The company has backup plans for backup plans, networks on top of networks. "If one goes down, the other picks up," he says, launching into a 10-minute digression of every possible contingency. "We spend a lot of time making sure we can provide a service level that’s very high."
At Sunquest, the mission is equally clear. Tim Rich says the company is slowly facing some of the problems presented by large, aging mainframe-based LISs-how to reduce cost of ownership so more laboratories can enjoy the benefits of more products. The Texas-based Rich says he was able to hire engineers from Sabre, a former American Airlines subsidiary in Dallas that pioneered the technology needed to allow 150,000 travel agents to make reservations online. Rich has formed a Sunquest team, not unlike the Saturn project within General Motors, to rethink laboratory information services from the bottom up. Their main product: e-Suite.
If it all works, Rich believes, he will be able to use cheap informational capacity on the Internet, or bandwidth, to revitalize gray-haired mainframes. He’s targeting the smaller laboratories for now, partly to preserve the company’s revenue stream, but he admits just about every segment of the LIS market is asking about ASP options.
"Later this year," Rich predicts, "we are going to launch a high-end commercial lab ASP and use that market as a way to validate the high-end ASP delivery and sales process." All customers, he concedes, are essentially wondering if they still need to own and manage computers themselves.
"Our big mainframes were expensive and time-consuming to deploy and sell," Rich allows. "The customers had a really high cost of ownership; therefore I was only selling to the ’high’ end of the market." The rapidity of the change seems to surprise even a farsighted technovisionary like Rich: "The Web has allowed us to go from very laborious 1,800-hour installations to 200-hour installations where we never make a site visit. We had our customers, even in beta trials, up and running in 90 days."
In keeping with the nonproprietary nature of the Internet, Rich makes a somewhat unorthodox admission. "The method I am using to deploy software over the Internet would work with anybody’s software. You do not have to modify software to provide remote Internet access. What you see on the screen, running inside of Internet Explorer, is a cell that emulates, giving you both system access and Internet access in the same view." Thus the cost of ownership, and likelihood of computer-related migraines, should be radically lower.
Vendors who provide laboratory services centrally through an ASP model will be able to implement improvements—for example, Health Insurance Portability and Accountability Act compliance as regulations are finalized. Says Rich: "We believe we’re compliant today. The underlying computer software code was already HIPAA compliant. We’ve read the regs, and if they go out the way they’re written today, we feel very comfortable about compliance."
No new gizmo to come along would faze Rich. His programming gurus are already working with the paging company SkyTel to develop a system in which laboratory results could be transmitted from a mainframe to an individual physician’s belt.
The savings in frustration become more apparent when Rich imagines a world in which laboratory couriers and office managers are similarly interconnected. Within the window of a standard browser, like Netscape, Rich suggests, an office manager might click on a link for a particular courier, and that company would automatically dispatch someone for a particular specimen. No telephone call, no typing. As Rich says, "Information and communication portability will change the way labs do business."
SOME of the largest changes, however, may far transcend technology. As Bruce Friedman, MD, of the University of Michigan, explains, some pathologists may not appreciate the magnitude of what the Internet ultimately means for laboratories. Like an officer on one of Christopher Columbus’ ships, Dr. Friedman has figuratively returned from the New World to tell the Spanish royalty about something big. Trouble is, the Spanish court can scarcely comprehend the message.
But Dr. Friedman ploughs ahead anyway. "There are going to be huge changes on a two- to five-year horizon," says Dr. Friedman, who oversees information technology for his department in Ann Arbor. "The practice of pathology and laboratory medicine will be radically transformed on a five-year horizon."
For starters, he takes it as a given that paper-based test ordering will go the way of the passenger pigeon. Electronic ordering, he insists, is not a fad or a largely unrealized dream like telepathology. "It will be the dominant way to order tests going forward," Dr. Friedman says. "Docs in their offices or mobile docs will bring up a Web page to order. That will be the way everybody orders tests. Result reporting will take place in the same way."
Virtually every health care Internet startup has the potential to affect laboratory medicine, from the smallest company handling esoteric laboratory work to the biggest kahuna at this time, Healtheon/Web MD, Dr. Friedman believes.
| An overview of the Web-related options and opportunities for clinical laboratories:
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Healtheon, as readers of the business magazines know, has used its own stock like Monopoly money, embarking on a $15 billion acquisition binge. With so many components, Healtheon now faces skepticism on whether it can be a focused company. But one of the things it wants to be is the first place that physicians ordering laboratory tests click on when viewing their computer screens.
It is by no means clear that any medical center will allow Healtheon to have that sort of access to physicians, Dr. Friedman says. But it is not too early for pathologists to consider whether they want to let go of the medical record that Internet startups are already squabbling over.
"We’ve always been the custodian for the laboratory portion of the medical record," says Dr. Friedman. "The larger question is whether physicians in general will control the clinical record or whether they will turf it to nonphysicians."
Some of what Dr. Friedman is talking about is already here. Internet appliances, or souped-up cellular phones, are offered now by Sprint and Qualcomm. But new connections are needed between laboratory tests and information that help nonpathologists interpret laboratory tests. In his scenario, a cardiologist might walk into the hospital room of Patient X, stare at his superphone, note results just posted by the laboratory, and touch the part of the screen that represents his favorite pathologist.
The pathologist, though not in at the moment, picks up the phone for a brief conversation about Patient X. (He, too, sees the latest lab results.) The cardiologist hangs up, taps a few more buttons, and orders another panel of tests before moving on to the next room.
The content of reports will evolve as dramatically as the means of delivery. Pathologists of the future will be mixing their own observations with prewritten blocks of text. "The pathologist will be dealing with templates, some of which he may create himself, some of which he may license from commercial sources or academic centers," Dr. Friedman predicts.
"You’ll have a Hashimoto’s template. You’ll have a well-differentiated lymphocytic lymphoma template," he adds. "The pathologist will drop into that his diagnosis and description. But in addition there will be a series of Web URLs to direct the receiving clinician to additional reading on that lesion, particularly obscure lesions. So going from a dull report with a diagnosis, you go to a mini-textbook. There will be hotlinks and he can read on the National Cancer Institute or go to controlled clinical trials. The physician will see images with annotations, which he can use to achieve better communication with the patient."
Dr. Friedman would be the first to admit his vision will not be easy to execute. "It’s going to be very messy," he says. "It’s a different model. It’s a model with better access to information on the part of physicians and patients." But there will be a downside to it. An example: If the physician with a superphone is working at 11:00 PM or 4:00 AM, so will a pathologist.
He speaks of a glass curtain between the laboratory and the clinician which has protected the pathologist. "I’m not sure the majority of pathologists and laboratory scientists want that curtain to be shattered because we’ve been in a very comfortable place with a sort of 8 to 5 job," Dr. Friedman says. That will not be true five years from now for pathologists at large medical centers. "The consulting talent has to be willing to be available 7 by 24."
PART of the future he describes is already here. An emerging company in suburban Chicago, Netsteps, has figured out ways to sidestep the issue of what to do with ancient mainframes grinding away in the basement. Netsteps allows physicians to access the same data from old LISs and HISs using a Web browsing software like Netscape or Internet Explorer.
To Netsteps, it does not matter which LIS the customer has used or whether the data are stored on Windows or Unix computers. Its software can handle just about anything; the company has no special allegiance to any LIS vendor. "That independence is a real selling feature," says Alan Gornik, director of sales and marketing.
To quote the Netsteps case study of one client: "In contrast to existing delivery channels via phone, fax, and local courier service, the new delivery method must allow a physician to get his or her patient lab results at any time from any place in a real-time, highly secure, and cost-effective manner."
Gornik continues: "Mid-size hospitals are very open to what we do. The cost of what we do is relatively modest. We integrate legacy information systems so that physicians can see the information they need over the Web in one view."
A completely new system, Gornik adds, may cost millions of dollars and take a year to install. His company’s fee is far less. "We can get up and running in 90 days. Speed is a real advantage."
Netsteps tries to give customers the software equivalent of a reliable car. "We have a robust technology that is proven and it works. We design [our product] to have a low cost of ownership and main-tenance," Gornik says. "We do not want it to add a burden to the information systems people." Typically, the company tells a hospital that one half of a full-time equivalent will usually suffice to maintain Netsteps’ solution, which also includes Web-enabled admission/discharge/transfer information and dictated reports.
The return on the investment is hard to calculate, Gornik says, but the anecdotal evidence is that physicians loathe pulling an entire chart just to glean one fact buried in a hospital’s computers but inaccessible to anyone without an advanced degree in mathematics. Administrators, Gornik says, tell him physicians are clamoring for an easy, one-screen, Internet-based view of a patient’s laboratory results.
"Doctors want results, and they want them now," says Gornik, noting that one of the first benefits of Netsteps will be to reduce the percentage of tests that are needlessly reordered simply because the results were not available at the moment of need. With the Internet, of course, the point of need could be the patient’s bedside or a doctor’s laptop anywhere on the planet.
Another advantage is privacy. Gornik concedes there is concern when potential clients hear that such sensitive information is available on the Internet. "There is a perception that records are more available because they’re on the Internet," says Gornik. The reality is different: Every record is scrambled in accordance with the current standard for online commerce.
Gornik suggests test results protected by Netsteps’ system are more secure than traditional paper records. With Netsteps software, and its built-in HIPAA compliance, an audit trail of every medical record is maintained. An inquiry about a VIP patient may even cause the system to issue a special alert, warning a user that his or her access of Senator McGuffin’s toxicology screen is about to be recorded for posterity.
Netsteps customer Dennis Coon is more than satisfied. "It’s not vaporware. It’s been a major boost. They delivered what they said they’d deliver and a lot more," says Coon, associate director for laboratory services at Central DuPage Hospital, Winfield, Ill. The laboratory at Central DuPage, operating out of five locations, handles each year 1.5 million billable procedures generated by the hospital and a reference laboratory business of 100 clients in the vicinity of the hospital.
"When we started," Coon recalls, "we weren’t sure what the final product would look like. We just knew we had to do a better job of getting the information to physicians." The hospital’s own information systems people were deeply skeptical of Netsteps’ claim of being up and running in 90 days. But Netsteps lived up to its promise.
Now the system is so popular that even departments or personnel with their own computer systems—nurses, for example, or even the laboratory—use Netsteps software to look at their own data through an Internet browser. Physicians who used the system in early testing had no trouble with it, Coon says, because they were familiar with how to browse the Internet. That cuts the training and handholding that can accompany the installation of less intuitive, and more proprietary, computer systems.
One of the novel benefits, he says, is in record keeping. With paper, it is inevitable that a critical laboratory report will be misplaced or misfiled. Netsteps allows him to retrieve that record far more easily and cheaply.
Physicians who use the Central DuPage laboratory will soon be able to access the laboratory’s test catalog on the Internet and any other notices—payment and procedural changes, for example-the lab wants them to have. "I have not found any other vehicle that comes close to the Internet in delivering what we need to deliver to physicians," Coon says.
The future, apparently, is here a bit sooner than expected.
Mark Uehling is a freelance writer in Chicago.