Stand-Alone Applications: Filling the LIS Functionality Gaps

Liron Pantanowitz, MD

Associate Professor of Pathology & Biomedical Informatics University of Pittsburgh Medical Center

Conflict of Interest

None

Stand-Alone Apps

Laboratory information system (LIS) at the core of most lab operations

Legacy LIS as newer technology becomes available to perform tasks

Add-on modules (SLAMs) & upgrades can extend/enhance a legacy LIS

Supplemental solutions fill growing functionality gaps

◦ Enable labs to perform tasks not currently possible with existing hardware/software

◦ Tools often easy to use, maintain and many are plug-&-play (seamlessly connect to LIS)

◦ Provide increased efficiency, better patient care & ROI (e.g. save FTE time)

Solutions may include:

◦ IT tools from middleware or lab instrument vendors

◦ Vendors cater to all size/type of labs (e.g. POLs)

◦ Expert services & training provided by consulting firms

New user friendly & helpful solutions are constantly being designed

Stand-alone applications provide inexpensive solutions for

labs struggling with several problems:

Staff shortages (med techs)

Increased test volumes

More complex instruments

More complex lab operations

EMRs demanding connectivity

Trend toward ensuring quality of care

Demand Drivers

IMPROVEMENTS

Operations (Management)

Workflow (Processes)

Productivity (Services)

Quality (Safety & Compliance)

Revenues (Billing)

Operation Improvements

3rd-party software components that support LIS operations – separate install recommended by LIS vendors (e.g. MS Word, AccuSoft, Excel, Crystal Reports)

Data transmission (e.g. Forward Advantage manages faxes, LabDE automates capture & transfer of data in lab reports)

Storage solutions (e.g. HP StorageWorks EVA8000, Mesa Corp)

Support for virtual applications, legacy apps & web-based cloud management (e.g. VMWare, Citrix)

User connectivity (e.g. remote login, password control)

Electronic change control process (e.g. SharePoint)

Automated testing software helps lab test new/changes to software (e.g. Software Testing Solution)

Management of personnel & trainees (e.g. human resources packages, resident evaluation systems)

Workflow Improvements

Need: Inefficient current processes

Answer: Optimize workflow process

Several solutions: ◦ Instrument connectivity & maintenance

◦ Automation (e.g. autoverification)

◦ Continuous (vs. batch) workflow (e.g. Lean tools)

◦ Tracking solutions (barcodes, RFID)

◦ Remote system monitoring (real-time, web-based)

◦ Scheduling (according to staff availability/subspecialty, work distribution & workload demands)

◦ Inventory management (supplies, reagents, equipment)

Middleware “Plumbing - Stuck in the Middle”

Hardware & software that acts as an intermediary between instruments & LIS (connect legacy to newer systems)

Allows data exchange or performs data management tasks the LIS can’t handle

3 types of middleware solutions: ◦ Instrument level: Instrument data management

◦ Work area level: Work area management (WAM)

◦ Lab level: Lab production management

e.g. Instrument Manager, Laboratory Production Manager, Remisol Advance, Sysmex WAM, TD-Harmony, Roche Middlware Solutions, JavLin interfaces, JResultNet, IM2, AgilityEngine

LIS-Middleware Relationship

LIS WAM

Inventory

Autoverification

Automatic review & release (verification) of results received from a lab instrument without technologist review

Application of rule-based logic allows communication between a lab instrument & LIS to generate an action (pass/fail) based upon pre-defined rules/algorithms

Greatest benefit obtained with frequently ordered tests (e.g., automated chemistry assays, routine hematology tests)

Systems enabled through the lab instrument, middleware, or LIS

Apps for Automation

Pre-Analytical Phase ◦ Courier services to optimize fleets, routes, special

situations like stat specimens, tracking & call center coordination (e.g. Gajema, Logitrac, Elite)

◦ Pneumatic tubing systems (incl. carrier tracking)

◦ Specimen collection (e.g. scheduling)

Analytical Phase ◦ Lab automation systems (robotic sub-systems, process

control software)

◦ Sample processing, transportation & queuing

Post-Analytical Phase ◦ Storage & retrieval systems (e.g. add-on testing)

Schematic IT hierarchical infrastructure of a laboratory automation system (LAS)

Advantages of Automation

Increased productivity

Offset staff shortages

Economic gains

Error reduction

Improved turnaround time

Avoid operator exposure to hazards (e.g. blood)

Avoid operator exposure to injury (e.g. repetitive tasks)

Continuous Processes Improvement

Lean & Six Sigma IT tool kits e.g. LeanKit Kanban

Value stream mapping (draw, analyze & design workflows)

Dashboards (real-time monitors of performance/metrics)

LEA

N S

IX

SIG

MA

Asset Management

Tracking solution benefits: ◦ Automate, standardize & timestamp data collection process

◦ Facilitate Lean manufacturing process (e.g. JIT technique & reduce turnaround time)

◦ Drive workflow at point of contact (e.g. barcode driven protocols)

◦ Error reduction (improve quality/patient safety) ◦ Provide measurable metrics to enhance processes (detect workflow bottlenecks)

◦ e.g. Vantage (Ventana)

Quality Improvements

Need: Standardize QC/QA processes & continuously monitor compliance

Answer: Single electronic database & current documentation

Several solutions: ◦ Positive patient ID solutions (e.g. wCareCollect, BD.id,

Identi-Match, MedPoint, CareChek)

◦ Statistics & method validation tools (e.g. GraphPad Prism, EP evaluator, Altosoft)

◦ Lab staff competency (web-based systems)

◦ Reporting & tracking of HR issues

QA Data Tools

Notable LIS weakness:

(collect, manipulate & display data)

Utilize QA data outside LIS

Automatic continuous updates (“real time”)

User friendly (easy wizard approach)

Better data management (impressive analytical capabilities & metrics)

Superior displays (graphs, dashboards)

Web-based solutions available

Access varied database formats (Excel, SQL, Oracle)

Document Management

Paperless environment

Scan documents, requisitions & reference lab reports

Easy document access, retrieval & data extraction

Standardize electronic policy & procedure creation, review & approval

e.g. SoftTech, policyTech, Mesa, Zequel, Policy IQ, Vignette, PolicyMedical, OnBase, Extract Systems, Scantron

Service Improvements

Need: Client & patient services

Answer: Enhanced productivity, client satisfaction & better access to information

Several solutions: ◦ Patient services (access to information & convenience)

◦ Client services (easy connectivity & tracking)

◦ Practice management systems

Patient Service Tools

Access to lab results ◦ Online patient portals

◦ Maintain HIPAA compliance

◦ (e.g. eClinicalWorks, CureMD, e-telmed)

Scheduling ◦ Automated appointment

management

◦ (e.g. Q-nomy, Quest)

Client Service Tools

Outreach LIS-EMR connectivity ◦ Several EHR integration solutions ◦ e.g. Lifepoint, Atlas, Initiate exchange platform, 4Medica,

Halfpenny, CareEvolve, Blue Iris eLaborate, JResultNet

Lab portals ◦ Lab orders, test results, schedule pick-up, inquiries, specimen

tracking, & determine status ◦ Electronic lab manuals (catalogs with test menu & user guide)

Physician Office-Lab Links (POLL) ◦ Bidirectional connectivity between instruments & EMR ◦ e.g. Fflex eLink, Atlas LabWorks, ePathLink

Help desk software ◦ Customer management & support (e.g. sample collection supplies,

coordinate issues, follow up outstanding issues) ◦ Automatic call triage & recording ◦ e.g. TrackIT, CRMdesk, Request tracker, H2Desk

LIS-EMR Connectivity using SaaS Pantanowitz et al. J Pathol Inform 2010; 26:1

Data managed & routed using vendor server & software

EMR Integration Issues

LIS-EMR interface projects can be lengthy, unpredictable & costly to implement and maintain

Solutions utilize innovative SaaS-based hub technology

Bidirectional flow of data (orders match test results) ◦ Support CPOE from many EMRs ◦ Handle complexities (e.g. add-ons, cancels, reflex tests) ◦ Result delivery with appropriate downstream display

Support mobile devices (on-the-go orders/ready-to-view results)

Meet requirements for Meaningful Use certification Behind-the-scenes business rules tailored to match unique

workflows, flexible test menus, coding & billing

Specific CP Apps

Microbiology ◦ Infection & antibiogram surveillance

Transfusion Medicine ◦ Transfusion safety (e.g. Final Check LIS codes)

◦ Virtual blood banking & remote refrigeration management

◦ Blood donor systems with computer-assisted scheduling & interviewing

Specific AP Apps

Dictation & transcription management

◦ (e.g. Winscribe, Voicebrook, Nuance)

Synoptic reporting

◦ (e.g. mTuitive)

FS diagnosis communication

◦ (e.g. FSLink @ Yale)

Automated e-reporting to cancer registries

◦ (e.g. e-Path)

Tissue banking

◦ e.g. BIGR from Healthcare IT, Daedalus

Autopsy

◦ (e.g. UPMC remains tracker)

Digital Pathology Solutions

Image acquisition (e.g. gross & microscope capture workstations)

Image management (e.g. Aperio Spectrum, Apollo PathPACS)

Image workflow (e.g. Omnyx workstation)

Telepathology (e.g. Zeiss robotic microscopy, CellaVision, web-based portals)

Automation (e.g. Pap test screening)

Image analysis (e.g. Ventana VIAS, CellSens, HistoRx, Farsight, Genie, TissueStudio, Inform)

Point-of-Care Testing

Interface managers ◦ Interface with multiple vendor devices (open connectivity)

◦ Provide a single result feed to LIS (simplified compliance)

◦ Compliant with connectivity standards

◦ Support wireless connectivity

◦ e.g. Telcor

Database management systems ◦ Flexible, web-based, centralized control

◦ Added features (e.g. QA, HR links to update staff updates, competency tools)

◦ e.g. Abbott PrecisionWeb

Electronic data flow from point of care to EMR

Revenue Improvements

Need: Maximize profits

Answer: Good business solutions

Several solutions: ◦ Revenue cycle management tools - automate large

volumes of transactions

Features: LIS interface capability, server or browser based, management & marketing reports, compliance (e.g. HIPAA & coding such as LOINC)

◦ Outsourcing with consultants ◦ e.g. Boston WorkStation, Costflex, Peachtree, Lab Outreach Business

Pro, PSA Billing & Collection Services, Chi Solutions

Practical Take Home Points

Labs have limited resources (IT skills, finances, time)

Middleware installation often easier than LIS upgrade

One-size-does-not-fit all (customization)

Beware of rapidly retired vogue solutions

Flexible homegrown systems require IT skills

Closed system architecture - middleware specific to vendor instruments may constrain the level of automation that can be achieved (e.g. inability to swap or add devices)

Open system architecture – middleware can interface with several vendor instruments & information systems

Plan ahead & avoid middleware “band-aid” solutions that create more work (e.g. additional training, maintenance & troubleshooting)