College of American Pathologists
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  Speeding toward real time with POC glucoses


CAP Today


March 2008
Feature Story

Anne Ford

In this presidential election year, voters can expect no shortage of head-scratching political rhetoric. Just about every commander-in-chief has fallen prey to it over the years, from Calvin Coolidge (who purportedly said, "When a great many people are unable to find work, unemployment results") to George W. Bush ("I think we agree the past is over"). One of the most notable presidential verbal contortions, of course, comes courtesy of Bill Clinton, who insisted during the Lewinsky scandal that the truthfulness of one of his statements hinged on "what the meaning of the word 'is' is." That's splitting hairs awfully thin, no matter what your political leanings are.

But maybe some hairs deserve to be split. For example, in the case of wireless setups for point-of-care glucose testing, do results arrive in the electronic medical record in real time or "real time"? And how important is that distinction?

To back up a moment: As reported in the October 2007 issue of CAP TODAY ("Wireless Glucose Results-The Latest in Real-Time Data"), the University of North Carolina Hospitals, Chapel Hill, has implemented LifeScan's OneTouch DataLink system to greatly shorten the length of time it takes to obtain, view, and track point-of-care blood glucose results on clinical workstations, laboratory IT systems, and even physicians' PDAs. Other institutions are gradually following suit.

The LifeScan system speeds glucose result delivery by using a wireless unit to transmit data from Life­Scan's OneTouch Flexx meter into the electronic medical record rather than requiring point-of-care staff to take the meter to a docking station for upload. Here's what some consider the sticking point: The wireless unit is external, meaning the user must connect it to the meter with a serial cable before connectivity can be established. True, the LifeScan wireless unit is stored in the same carrying tote that holds the meter. But it's still an external solution.

"It's not real-time wireless," says James H. Nichols, PhD, DABCC, FACB, who, as a member of the Connectivity Industry Consortium, helped create the POCT1-A connectivity standard for point-of-care devices in 2001. Dr. Nichols is medi­cal director of chemi­stry at Baystate Health, Springfield, Mass., and associate professor of pathology at Tufts University School of Medicine, Boston. "It's a stepp­ing stone on the way to real time, but it's not there yet. It's not like you have the device in your hand, you push the button to scan the patient, and it communicates wirelessly with your server. It still has that limitation of intermittent transmitting."

Why does it matter? Because, Dr. Nichols says, the LifeScan setup doesn't eliminate the problem that he says plagues all point-of-care devices: "You do a test on a patient, and it remembers the results in connection with the date, the time, the meter you ran it on, who ran it, everything-and it could stay in that meter for a day, a month, all year long, if you never dock it.

"I have one of those Palm PDA phones," he continues, "and if I connect to the Internet, that thing stays connected until either my Internet connection drops or I walk out of range. And that would be how I would see these glucose meters ideally working."

LifeScan U.S. informatics marketing manager Jose Castanon is used to fielding questions about the real-time issue. "This is a common question. 'Is it truly real-time wireless?'" he says. "The testing can be performed in two ways. The OneTouch DataLink wireless unit can be connected to the OneTouch Flexx meter through a serial cable. When a test is performed with the wireless unit connected, results will download wirelessly as soon as testing is complete. Alternatively, the meter can be taken out of the tote [to test], and when it's returned, the user can conveniently initiate the download by plugging the cable in."

The technology to transmit data wirelessly with an embedded device does exist, he adds, but "there are design challenges, primarily with battery life. Wi-fi is a power-hungry solution. How manufacturers address the power management challenges will have implications to the charging process and the end-user. How long will the charge last? Will it require a charge every few hours or have a battery life that's too short to make it practical? LifeScan is working on solutions to overcome that." In the meantime, to the best of his knowledge, he says, "there isn't another wireless solution in the marketplace for point-of-care glucose."

The LifeScan device may not wirelessly transmit data in real time, says Jana P. Grayson, MPA, MT (ASCP), point-of-care coordinator at the University of Kentucky Hospital, Lexington, but nonetheless, "it really has improved the time that the results take to get to the electronic record. It has to have at least cut it in half." Before the LifeScan technology was implemented about a year ago, staff had to dock the glucose meters at a device that used the fax machine line. "We were having huge problems daily with the equipment," she says. "It was old technology, and they were removing a lot of those lines from the hospital, so that forced us to make a change." At about the same time, the hospital's tight glycemic control committee asked Grayson and her team to look for a way to get results into the electronic record in something at least approaching real time. "That was about the same time that Life­Scan came out with their wireless devices," she says. "We have about 98 glucometers and devices out on the floors now, and we have 25 waiting to be configured."

Implementing the new devices went more smoothly than Grayson expected. "There was a little bit of a learning curve in the beginning, but it really wasn't bad," she says. One big advantage: "It takes a lot less time to troubleshoot the upload problems." The staff will "at least try to troubleshoot the wireless devices," she says, whereas "with the docking stations, they would just call us to come and troubleshoot."

Good as Kentucky's experience with the LifeScan solution has been, there's still room for improvement. "The diabetes educators have come back to the nurse managers and indicated that they were still not getting the glucose results as quickly into the record as they would like," Grayson says. As it turns out, the staff in some areas were uploading data only "when they're forced to do it by the glucometer lockout. We requested that they upload periodically throughout the day. We're trying to correct that process so that the physicians can get a more real-time picture."

Another snag with the LifeScan setup has nothing to do with the vendor, she adds. "Our biggest problem is that this is a very old hospital facility, and as technology has increased, there is so much equipment they've tried to cram into these rooms. There's an electrical outlet shortage, and these devices have to be charged. Some areas just really don't have available outlets. They end up removing the wireless devices from the totes and just leaving them someplace to charge on a counter where there's an available outlet. Leaving the wireless devices out of the totes delays uploading of the patient results." Elaine Palm, PhD, enterprise network manager for the Lifespan integrated health care system in Providence, RI, characterizes her experience with LifeScan's wireless POC glucose setup as "very successful" and "something that I would recommend to other hospitals." The Life­Scan solution is just one of the pieces in the wireless technology array at her institution, which jumped into the wireless ring fairly early on, in 2001.

"We realized that the only way that we were going to succeed in bringing some of the newer technologies out to the nursing and physician staff was to allow them to go wireless," Dr. Palm says. "The technologies required increased use of computers, yet at the nursing units there was no more space for computers. In addition, they really needed to be able to work directly with the patient rather than being back in the nursing unit inputting data. With wireless carts, they were able to bring the technology right to the bedside. Everything just kind of grew from there. Today, all of our clinical areas are wirelessly enabled."

Since last summer, Lifespan has introduced the LifeScan wireless devices in two of its four hospitals and is now implementing them in a third. "We have had comments from physicians about how quickly the data is available to them in the system," she says, adding that the LifeScan devices allow doctors "to focus on patient care and not have to worry about technology steps that are really non-value-added."

"It's not seamlessly wireless," she says, "but it's certainly much better than the previous situation, where the nurse had to go back to a particular PC on the nursing unit and dock the device and then activate the upload. Imagine a unit with a lot of beds in a lot of rooms-docking may not occur until all of the rooms have been visited."

The University of Kentucky Hospital is planning to experiment with expanding wireless connectivity to another realm-thromboelastography. "We are going to try to set up a wireless remote viewing PC for that testing," Grayson says. "Hopefully it will happen within the next six months. I think we do have to move forward with wireless data transfer as the technology becomes more available."

Still, like Dr. Nichols, Grayson is looking forward to the day of true real-time wireless data transmission. "You still have the variable of the human in the way that it's set up now," she says. "You have to actually start the upload process. Like a cordless telephone when you set it in the cradle to charge-that's what I'd like it to be. If something similar was developed for the glucometer, so that when you put it back in its little tote, it would automatically wirelessly upload the results, it would be wonderful. But," she finishes optimistically, "they'll get there."

Anne Ford is a writer in Chicago.