Ups and downs of bringing in Beaker AP LIS

Charna Albert

August 2019—Having an enterprisewide health care platform can put laboratories in a stronger decision-making position for enterprisewide IT, whereas in most other circumstances, “we are relatively isolated,” said Raj C. Dash, MD, in a talk he gave at this year’s Executive War College.

Dr. Dash, vice chair of pathology IT at Duke University Medical Center, shared what he called the blessings and curses of his department’s move in 2014 to a lab information system that’s fully integrated with the electronic medical record. His focus was Beaker’s AP-LIS module.

On a technology hype curve, he said, “I think there is still a trough of disillusionment but it’s getting better for Beaker, and I’m here to, I hope, reset some of the expectations.” It’s about understanding what you have to put into the product, he said, to get what you want out of it.

After evaluating the 2010 and 2012 versions of Epic’s Beaker and installing the 2012 version at one of Duke’s two community hospitals, the laboratory decided to delay a systemwide implementation until Beaker’s 2014 version release. Beaker’s 2012 version, Dr. Dash said, “wasn’t even as good as a glorified word processor.”

The 2014 version, however, included rich text formatting, a maturing CP module, workable microbiology and AP modules, and “solid” cancer synoptic implementation.

Duke University went live with Epic EMR in 2013. Duke’s laboratories, having moved to an enterprisewide system, have “never been closer” with IT, said Dr. Dash, who is also medical director of laboratory information systems, Duke Health. In pre-Beaker days, Duke had only one director in the labs who worked with the LIS team. Now, 60 Beaker super-users meet monthly, and LIS analysts meet on site in all the laboratories. “They have gotten to learn Epic Beaker together,” he said, “and it’s a very collegial relationship.”

Before Beaker, when Duke implemented a new CPOE system, pathology was involved only from an interfacing perspective and not in designing decision support rules. “We were happy to just manage our area,” Dr. Dash said. “And I didn’t recognize the potential benefits or the potential workload of getting involved at the enterprise level.”

Standardizing lab test order names was tough as Duke prepared to transition to Epic EMR.

Before implementing Epic EMR, Duke’s three hospitals each used a different system—Meditech, Siemens, and a homegrown EMR—and a McKesson CPOE. “And we did not have the same names for most of our most commonly ordered tests,” he said. The version of Meditech the hospital used had a 12-character limit for lab order names.

“Twelve characters for over 8,000 order [names]? You can imagine the series of letter combinations we had,” he said.

At the time, Duke had a laboratory orders team operating as part of an EMR and independently of pathology. “And they started building things based on this interface.” The ambulatory systems were sending orders to the lab’s Cerner system and a mapping occurred. “We could just use the Cerner names in our laboratory, so it didn’t affect the lab directly.” As the lab moved to Beaker, “it became an imperative to own laboratory orders because we were the recipients of the build.” Thus, even before selecting a new LIS, the pathology department spent several years harmonizing lab order names across the three hospitals.

“But what we should have done is taken ownership of laboratory orders right from the beginning,” in the pre-Beaker days, “and it would have simplified a lot of our downstream efforts,” said Dr. Dash.

There are many ways to use Beaker’s features in the wrong way and few “guardrails” to help, Dr. Dash said. Beaker’s virtual laboratories can be designed with a “department” structure or a “section” structure. The department structure, he explained, allows for highly granular specimen tracking as specimens enter or leave a department. Epic asked: “Do you want to be able to track your specimens with the highest level of granularity and in the most robust way?” And that’s using packing lists to transfer. “We said sure. Who wouldn’t want the most robust tracking mechanism? Little did we realize that meant a lot of work, even if you’re moving something from a lab that’s one counter over.”

They learned from other users that virtual labs called departments or sections should be designed based on physical location. The packing lists should be used only when specimens are traveling a distance and there is a relatively high chance of their being misdirected. “It’s a very configurable system,” Dr. Dash said of Beaker, “but there are not a lot of guardrails that keep you moving on the right path. You can go sideways and someplace you don’t want to go.”