Feature Story

Bringing LIS technology converts into the fold

May 2004
Karen Southwick

Integration. Integration. Integration. When it comes to laboratory information technology, it’s perhaps no surprise that this is the chief challenge for multiple-hospital health care systems.

Although integrating technology—particularly using a common laboratory information system or lab portal—gets most of the attention in spending and strategic planning decisions, cultural and political factors can be stumbling blocks too.

Jane E. Carroll, operations director for LabNet of Ohio in Columbus, an administrative office that oversees laboratory work for 19 area hospitals, voices a typical plaint. "LabNet drives no compliance," she says. LabNet offers technology and support. Then it’s a matter of marketing to the hospitals—all of whom have their own lab IT priorities—and persuading them to adopt the desired technologies.

Six integrated delivery network laboratories interviewed by CAP TODAY are all grappling with the general problem of how to move their member hospitals to either a common LIS or a common front end for accessing the LIS. And all are wrestling with the related problem of making online order entry a reality.

Memorial Hermann Healthcare System, Houston, will upgrade its laboratory information system from Cerner Classic to Millennium over the next couple of years, reports Jim Faucett, vice president of laboratory and oncology services.

Memorial Hermann’s laboratory service organization serves the organization’s nine hospitals. It operates comprehensive core laboratories in two locations, which allows the other community-based hospitals to offer an essential services menu of about 50 to 60 tests.

Most of the hospitals were using separate lab information systems and were gradually unified on one of two Classic systems, Faucett says. The next step is unifying all of the labs on Millennium. In preparation, Memorial Hermann has begun standardizing reference ranges, clinical values, and interpretive data.

"Memorial Hermann also uses Millennium for its other clinical systems," Faucett says, "which will allow for an enterprise-wide electronic medical record." The basic system was implemented last year and is being used for order entry, results reporting and storage, and clinical documentation. Additional clinical information documentation and medication administration are scheduled to be implemented in the next 12 months.

Sacramento, Calif.-based Sutter Health, which operates 27 hospitals, is in the process of standardizing on Misys, says Stephanie Olivier, manager of clinical systems and integration.

The advantages of using one system are obvious: It’s more convenient and cost-effective, and there are economies of scale in being able to buy as a group. But "we don’t come in and tell our hospitals what you’re going to do and when," Olivier says. As with LabNet, it takes persuading and demonstrating.

So far, 15 of Sutter’s hospitals are on Misys; another half-dozen are expected to convert this year. Because the larger hospitals converted first, by the end of this year "we will have 90 percent of our lab tests processed through Misys," she says, compared with about 75 to 80 percent last year.

"Our goal is standardized systems and standardized data," she says. "We want results that can be viewed consistently regardless of where in the system they came from."

Sutter helps defray the conversion costs and provides information support to member hospitals. It maintains centralized services for the laboratories along with a centralized support team. The local hospitals purchase needed PCs and software licenses. "As we’re able to put products out there like a physician portal to allow them to view the information, it incents hospitals to convert because they get better quality and turnaround," Olivier says.

Fairview Health Services, a seven-hospital system based in Minneapolis, has likewise standardized its LIS on Misys and its pathology on CoPath. "We’re in the midst of bringing our seventh hospital live on Misys," says Pat Berger, corporate director for clinical systems.

Before hospitals began to merge into integrated delivery networks, LIS decisions were left to the individual facilities. Today, a stand-alone lab system is a rarity, Berger adds, but the transition to the unified system requires "a tremendous amount of work to win acceptance and change workflow."

TriCore Reference Laboratories, Albuquerque, NM, also chose Misys. "Our core lab and one of our hospitals were already using Misys," explains Shirley Arellano, director of computer applications. It took about two years to complete the conversion for TriCore’s five hospitals. "We recently did a version update," she says, "that once again proved to us the value of using a single standard system. Updates are predictable, reliable, and rapid."

Manhasset, NY-based North Shore-Long Island Jewish Health System, with 18 hospitals and numerous tertiary facilities including a 50,000-square-foot central laboratory, is in the process of standardizing, though the decision hasn’t quite been finalized, reports Zachariah S. Johnson, director of IS. He says North Shore-LIJ uses primarily Cerner Classic for its LIS, but the central repository for information is on Cerner Millennium. "We standardized our instrumentation and centralized our database on Millennium, and we’re now looking to move to Millennium for the LIS, but we’re still in the review process," he says.

Timing is the sticking point. "The hospital laboratories have so many priorities in keeping up with today’s inpatient care demands. This, coupled with the push to compete in today’s aggressive outreach market, makes scheduling a successful information technology upgrade a process of strategic timing and efficient management," Johnson says. He hopes to have every hospital on Millennium by 2006.

LabNet handles the reference work for 19 hospitals in Ohio and has not sought to get all those hospitals to standardize on a single LIS, Carroll says. Rather, it has used Atlas LabWorks as a front-end portal to give a common look and feel across all hospitals.

"We just went live in March with our nine sending hospitals," she says, who have about half a dozen LISs between them. "We have to do the customization to get the interface [with LabWorks] to work." Once that’s accomplished, each hospital can view results through a terminal.

The biggest personnel issues the integrated delivery network labs face are finding IT employees who have health care experience and, at the same time, avoiding the temptation to raid their medical technologist ranks by converting them to LIS experts. Because of better pay and growth prospects, many technologists are eager to move into the IT field, compounding shortages in the laboratory, several hospitals report.

Berger says most of Fairview’s laboratory IT team came from the medical technologist ranks. "What we’ve done to mitigate that movement is to make entry salaries in medical technology on par with lab IT," she says. Of course, she adds, "if you stay in IT your salary tends to surpass that of a med tech."

At North Shore-LIJ, about half of the laboratory IT staff came from the medical technology ranks. "I’ve been told I can’t take any more med techs," Johnson says.

By mid-year, Memorial Hermann Healthcare System expects to make online order entry available to its physicians through Cerner’s PowerChart. But "we’re not requiring our physicians to do computerized order entry," Faucett says. "The goal is to be paperless. Over the next five years we’ll get there."

"You’ve got to get physicians involved in the planning" of IT upgrades, Faucett adds. "That way, you develop champions for use of the technology."

Also on the table is a virtual ICU—a way to manage intensive care patients throughout the system from a single location by means of an electronic medical record, including monitoring of lab results via point-of-care entries. To do that across multiple hospitals means all the instruments must be correlated with "lab ranges consistent across the system," Faucett says.

To improve communication with patients, Memorial Hermann will establish a portal over the next year or two where patients will be able to view their own results and even their electronic medical records. "That will be the physician’s choice: how much to move over to the patient portal," he says. "The physicians always will have to use their judgment."

He expects his biggest test in the next couple of years will be establishing a systemwide EMR. Eventually, aggregate data on conditions such as cancer, heart disease, and diabetes can be used to strengthen individual care, Faucett says.

Sutter Health already has a live virtual ICU, or "eICU," Olivier says. "For the past year, we’ve been monitoring patient beds 24/7 in the Sacramento area from a remote location. Last week we went live with interfaced lab results that are available real-time for physicians." Ranges vary by method, instrument, and hospital, but physicians can see the reference ranges by clicking on the result. "We’re also working to standardize ranges where possible," she says.

Online medication order entry is operational in one of Sutter’s hospitals, "and several more are interested," Olivier says. "We’re working through our strategy, taking it slow, with physicians participating every step of the way."

Offering online order entry within the hospitals presents different challenges than offering it for outreach, where physician offices will need a front-end portal for access, she says. In the hospital, "order entry can be done in an EMR system," one that allows also for viewing of results.

For its inpatient EMR, Sutter is using technology from Eclipsys and, for its outpatient EMR, EpicCare from Epic Systems. "We have an internal interface team working on developing interfaces between patient information and the lab system," Olivier says. The ideal is to offer the physician a unified look at all of a patient’s data via a physician portal.

Like Memorial Hermann, Sutter wants to develop a clinical data repository to identify best practices in using and interpreting laboratory results. It’s another place where LIS standardization can help.

Fairview is using a setup similar to Sutter’s: Eclipsys for inpatient online ordering and Epic for outpatient. And it uses Allscripts for e-prescribing in its clinics, so "we have orders from three different electronic records that come into Misys," Berger says.

Online order entry can be done within the hospital. For two years "we’ve been getting [our system for] results and orders perfected," Berger says. Now the system will be extended to physicians. "We wanted to work out all the bugs before having our physicians use it."

To get physicians to move to the new technology, the adoption strategy will target "super users" and provide on-site training and support. The hope is that they’ll spread the word, Berger says. There will also be a "roving clinical support team" that will provide training at doctors’ offices. If necessary, she adds, "we’ll set a date by which our physicians must be doing online ordering," but she hopes that successful training will take care of most of them.

Fairview, too, is considering how to implement an outreach laboratory solution by which clients "can order and get results through our portal." She hopes to get administration approval and "get something live for results by the end of the year." Because of competitive pressure, she says, "we really need that capability."

North Shore-LIJ offers a Web-based application to view lab results called ePathLink, from its LIS technology partner Cerner. "Our [outreach] clients don’t realize we have a commingled architecture of LIS systems because all they see is the unified portal," Johnson says.

In addition, North Shore-LIJ is signing up clients to use ePathLink for online ordering and has been successful in getting about 60 physician offices to do so—out of about 2,000 clients currently serviced by the North Shore-LIJ core lab. "Everyone was afraid of order entry," Johnson says, "but it’s beginning to take off as our clients are now recognizing the benefits of technology in the office place." It allows for improved specimen tracking, simplifies billing, and improves turnaround times and accuracy.

He says there’s no "drop dead date" set for ordering online, but he hopes to get the 350 physician offices that do the majority of the volume of tests onto ePathLink by year’s end.

North Shore-LIJ is in the process of analyzing a move to an integrated information platform. "We have a single hospital information system on the inpatient side and a single virtual LIS, with a large number of ancillary systems. Our long-term plan is to integrate the entire system on a single EMR," Johnson says. The success with Cerner products in the lab "has made them [Cerner] a natural candidate, but North Shore-LIJ is not yet near a decision," he says. The administration "is impressed with what we have built with the LIS and recognizes it as a strong foundation to build on."

Further out, North Shore-LIJ wants to continue to move its laboratory instrumentation toward more automation. As Johnson works to schedule a replacement of instrumentation that’s five to seven years old, he believes "automation is the way to go." It not only cuts the cost per test but also helps to solve the medical technologist and technician shortage, he says.

TriCore, which manages reference laboratory services for its member hospitals, is using two products for online order retrieval: Misys’ Encompass and Atlas’ LabWorks. "Most of our clients run on our lab system," Arellano says, and use Encompass as a portal to view results.

LabWorks is intended to be the order entry product that supports clinics and hospitals requiring an on-site PC and practice management interface. "We found that physicians have very little interest in doing order entry unless it’s interfaced with their practice management system," Arellano says. TriCore is using a third party to import information from the physician office systems into LabWorks for patient registration.

Once that process is complete, Arellano hopes more physician offices will move to online order entry. Her goal over the next year or so is to get an additional 30 to 50 of TriCore’s higher-volume clients to use the order entry function as well as results reporting.

Carroll says LabNet of Ohio has gotten its member hospitals to obtain results online and use online order entry. In March, the system started using LabWorks, "which was a newly developed bidirectional interface," she says, meaning LabNet had to ask Atlas to do a lot of the customization between various lab information systems.

LabNet and its member hospitals are negotiating an action plan that will accommodate the interfaces each sending facility wants. LabNet provides "the interface, workstation, and 100 percent support," she says. LabNet also will help the hospitals get LabWorks functioning for their outreach clients, an incentive to help them increase that business. "We want to support their outreach because this allows our members to retain that business," she says.

Once LabWorks and the interface are installed, training takes only about 15 minutes, Carroll reports. "Administratively, rolling out the product has been bumpy, but it’s very smooth sailing from the user end."

Complicating the process has been the fact that LabNet may change its outside reference lab. "We’re looking at other vendors to see where we are in the market," Carroll says.

Although LabNet’s structure differs from that of many other integrated delivery networks, it shares the same challenges in nudging members toward compliance. And it’s not really a matter of technology. "What I have observed is incredible frustration in coordinating efforts and schedules," Carroll says.

Karen Southwick is a writer in San Francisco.