College of American Pathologists
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  When POC connects the data, everyone wins





cap today



April 2006
Feature Story

Sue Parham

The story of point-of-care connectivity is quickly becoming one of laboratory medicine’s twice-told tales: POC setups have come a long way, and hospitals are reaping the benefits.

For Debra Norkett, MT (ASCP), education coordinator for the laboratory and point-of-care coordinator at NorthEast Medical Center, a 457-bed hospital in Concord, NC, incorporating POC test data into an electronic patient record system is the ultimate goal. “Our hospital is working toward having electronic patient records, and theoretically, point-of-care connectivity has been set up to support such a system,” she says.

NorthEast Medical Center implemented POC connectivity about three years ago, beginning with the installation of a positive patient identification system that uses bar-coded patient wristbands in conjunction with bar-coded POC instrument operator badges to capture the data from each encounter that involves a POC test. “The success of our POC connectivity is tied into our bar-code system. The bar-coded wristbands and badges have enabled us to reduce patient misidentification errors, as well as automate POC test ordering and result reporting,” Norkett says. Since bar coding became part of the POC process at NorthEast, patient identification errors have dropped to below one percent.

Because NorthEast installed its vendor-neutral Rals-Plus POC data-management system at the same time it implemented its positive patient identification system, POC connectivity has always been enabled by the bar-code system. “I took the job of POC coordinator a few years before we implemented POC connectivity. Then, we had about 30 glucose meters and I would carry a laptop from unit to unit and actually download the information,” Norkett recalls. “At the time, it took so long to gather the data that report generation was always about a month after the fact.”

Now, the center has more than 70 glucose meters and 17 i-Stats. At the point of care, certified personnel perform rapid strep testing, rapid pregnancy testing, activated clotting time, electrolytes, blood gases, urine dipsticks, Hemoccults, Gastroccults, and prothrombin time tests in various locations throughout the hospital. Influenza testing was recently added to the menu of POC tests performed by NorthEast’s emergency department, but has not yet become part of the POC connectivity solution. “We’re waiting for the documentation piece of the software to be available so that the ED can also enter the influenza test results at the bedside,” Norkett explains. “Right now, they are entering them into our Misys laboratory information system, and it takes a gatekeeper to make sure they’re done properly.”

When searching for a data-management system, Norkett quickly concluded that a vendor-neutral system was essential since NorthEast uses several POC instruments—Roche’s Accu-Chek Inform glucose meters, Abbott Laboratories’ i-Stats, Medtronic’s HepCon analyzers, and HemoCue’s hemoglobin test system. “Using Rals-Plus allows us to have one interface to connect all of our different instruments, and gives me the flexibility to add new instruments as needed,” Norkett says. Only the Medtronic and Hemocue instruments are not connected now to the LIS through Rals-Plus, though there are plans to add interfaces for both instruments.

Tracking noncompliance is where POC connectivity has had the biggest impact, Norkett says. “I can see through the interface if users are putting in an incorrect ID number when they perform a test. Just this morning, I had a glucose that came up in the system as having an invalid patient ID. It was run at 9 AM. I called the unit and asked for a confirmation on the patient since the ID did not exist.” Further investigation showed that the patient ID for this particular glucose test had been entered manually, which is still done in some locations in the hospital, and operator error was the problem.

Connectivity’s effect on billing for POC tests is also noticeable. “We do not bill for glucose—except for outpatient glucose. Hemoccults are the same way. We do bill for other tests, though,” Norkett says. When the medical center was able to capture data on urine pregnancy tests performed in the emergency department, a longstanding budget deficit was erased. “For years, we had a 15 percent deficit in the ED because people would not document the use of pregnancy tests on our manual log system,” Norkett says. In addition, they were not able to get the results entered into the computer system in a timely manner. “However, connectivity, combined with having a pregnancy test available on our glucose meter, has allowed us to correct for that 15 percent billing deficit,” she says.

Connectivity also supports competency checks for everyone who operates a POC device, Norkett notes. “Because the operator is locked out if he or she is no longer certified, it drives users to be accountable to get recertified and to meet their competency validation on an annual basis.”

Wireless technology, which makes it possible to transfer POC test information instantly to a data-management system without having to dock the instrument and download the data, is on Norkett’s wish list. “Wireless is our next step,” she says, “and I think it may be available to our labs sooner than anyone might think.” For now, she’s enjoying the Web-based applications of the Rals-Plus system, which were implemented at NorthEast a few years ago. “I can go on the Web and actually check to see what the problem is with an instrument if an operator can’t get in, and can even troubleshoot somewhat from my home.”

To prepare for NorthEast’s move to electronic patient records, Norkett has begun to add certain functions to POC instruments. “In planning for the electronic patient record, I’ve set up our instruments so that users can enter comment codes and things of that nature. I’m sure that as we implement the electronic records, though, we’ll have to tweak what we are doing in terms of POC connectivity.” She hopes that because they’ve been working toward the electronic patient record all along, when it’s implemented, the changes to the POC program “won’t be too drastic.”

Randel Roy, MT(ASCP), clinical coordinator at Affiliated Laboratory Inc., Bangor, Me., is familiar with how POC connectivity works in a system that has an electronic patient record. Affiliated Laboratory provides laboratory services to Eastern Maine Medical Center and other hospitals and health care providers that are part of the Eastern Maine Healthcare Systems. “We’re the last large medical center on Interstate 95 until you get to Canada, so we provide a lot of services to all of the northern, eastern, and central Maine hospitals,” Roy says.

At one point, the laboratory was a hospital laboratory in a large medical center that had begun to build its test volume by performing tests for clients outside of the hospital. Affiliated Laboratory became an independent, for-profit reference laboratory a number of years ago when the Eastern Maine Healthcare Systems began to ally itself with other smaller hospitals in the region. “To provide the type of services we needed, including toxicology and hormone testing, we had to have a top-notch laboratory so that we could avoid the four- and five-day turnaround times for send-out tests that we experienced before we became our own entity,” Roy explains.

Affiliated Laboratory began eight years ago implementing POC connectivity in the Eastern Maine Medical Center. After exploring vendor-based and vendor-neutral solutions, Roy chose to implement a prototype of Abbott Laboratories’ POC connectivity solution. “Although the vendor-neutral systems do an excellent job, having a vendor-neutral software company come in and provide our connectivity solution was not financially feasible for us,” he explains. The Abbott prototype was appealing because it could be connected using the Web-based hospital electronic medical record system that Eastern Maine already had in place. “We were able to connect right into it, and at the time, there wasn’t anybody available that could do any of that,” Roy says.

Eastern Maine has been a beta site for Abbott’s Web-based connectivity solution ever since, and has offered the solution to other hospitals in the Eastern Maine Healthcare Systems. “When the hospital system was created, all we needed to do to bring connectivity to the sites that joined us was to establish a connection. In most cases, the connection was already there because the hospital—in its desire to become a health care system—invited other hospitals to join us and adopt our communications systems,” Roy says.

Because the Abbott solution was Web-based, Roy was able to offer it as a value-added service to every hospital that was a part of the Eastern Maine Healthcare Systems. “If I heard we were getting a new member, I would approach the hospital lab manager and ask if the hospital would like to have the Abbott data-management system,” Roy says. Using the Abbott system, Roy would connect the outside hospital lab to Eastern Maine’s server, and would give the outside hospital all the privileges it needed to access its data. “Consequently, a nurse on the eighth floor of Eastern Maine Medical Center downloading results from an instrument sees no difference in service than the nurse who is downloading results in our member hospitals and clinics, which may be more than 100 miles from here,” he says.

Though all of the POC data come to Eastern Maine’s server first, the data are fed back to the laboratory in the hospital where they originated. “Everything is absolutely autonomous to the hospital where the data were created. They run the system the way they want to run it, and they set it up the way they want to set it up. The only thing we share is the server,” Roy says.

Most of the hospitals in the health care system are now using only the Abbott Precision PCx for glucose testing, though Eastern Maine Medical Center is using both the PCx and i-Stat system. “In most cases, the smaller hospitals in our system really only need glucose for their bedside point-of-care testing,” Roy says.

Like Norkett’s medical center, Eastern Maine has a bar-coding system for positive patient identification, and Roy says he “wouldn’t have done anything with connectivity unless we had bar coding.” He, too, finds that connectivity in conjunction with the bar-code system fosters CLIA compliance. “Positive patient identification is probably one of the hallmarks of our bar-coding capabilities because the scanner is going to get it right, whereas the human being may not,” he says. Patient identification error rates at Eastern Maine are now well below one percent.

“With our system,” Roy says, “we can now produce reports on our instrument operators that provide information on their certification status. If they are not certified, we can lock them out. We can also lock out operators that bring in test strips from outside of our hospital, and likewise, test strips can’t leave our hospitals because they can’t be used on outside instruments.”

Christine Cursio, MLT, manager of client services and point-of-care testing at Toronto Medical Laboratories, understands the advantages of implementing POC connectivity in a health system. Toronto Medical Laboratories provides laboratory services to the three hospitals that compose the University Health Network, or UHN—Toronto General, Toronto Western, and Princess Margaret—and to a number of other contract hospitals. Its largest client, however, is the UHN.

“The point-of-care testing program at UHN is fairly extensive,” Cursio says. Six programs are in place now. They have 170 to 180 bedside glucose meters in use in the three UHN hospitals, an extensive point-of-care blood gas testing program at Toronto General, urinalysis and pregnancy screening in various units throughout the UHN, activated clotting times in the operating rooms and catheterization labs at Toronto General, and POC hemoglobin in Toronto Western’s autologous blood donation program.

Electronic patient records are an important part of the UHN’s information management strategy, and the POC programs support that strategy, Cursio says. Toronto Medical Laboratories has two different vendor-based data-management systems that allow POC connectivity for two programs—the DataCare system from Roche, which processes the data from the UHN’s glucose meters, and Bayer Diagnostics’ Rapidlink, which manages the POC blood gas testing data.

The results derived from the UHN’s blood gas analyzers are now a part of the electronic record. “Because our blood gas program is fully interfaced to our HIS, when a sample is run on a blood gas analyzer, all of the information related to the test passes through the network to our LIS, through our data-management system, and then out to our HIS,” Cursio says. Staff must place an order for the blood gas test in the hospital information system before performing it. In this way, the data are captured. “When the instrument operators order the test in our electronic medical record system, they get a bar-coded label, and then they are able to scan that label and we can push the information on the test associated with the label through to the electronic patient record,” Cursio explains.

With Roche’s DataCare system, glucose results are captured but not downloaded into the electronic record. The UHN now performs 260,000 to 300,000 bedside glucose tests per year, and one of its primary goals over the next few years is to get all of its glucose test results into the electronic record. “We’ve noticed over the last couple of years,” Cursio says, “that there is a lot of support for getting our glucose results into the electronic patient record because of the incidence of diabetes and the importance of having a complete diabetic record.” They’re moving toward their goal, and they hope to be able to achieve it with a vendor-neutral connectivity system.

The drawback of having two data-management systems is that both must be maintained at all times, Cursio says. In addition, if a unique system is used for each POC program, the cost of interfaces becomes very expensive. “Purchasing six different interfaces for our programs is something we want to avoid if at all possible,” she says.

Bar-coded armbands may also make it easier to capture glucose test results in the electronic record. “At this point in time, glucose test results are manually recorded on the patient’s record, but we may go to a system of bar-coded patient armbands in the future to help our cause,” Cursio says. The glucose meters are attached now to UHN-networked PCs, and all results are sent to the centralized data-management system in the lab once the device is docked.

UHN isn’t alone in wanting to push POC glucose results through to an electronic record. With more and more clinicians recognizing that tight glycemic control in critically ill patients reduces morbidity and mortality, demand grows for POC connectivity tools that make executing tight control possible. LifeScan’s DataLink is one such tool. It has a bidirectional interface that allows remote transfer of data between SureStep Pro and Flexx blood glucose bedside units and a central PC workstation. It’s a vendor-based system, but LifeScan has alliances with Medical Automation Systems, for integrating DataLink with Rals-Plus, and with Telcor, for integrating DataLink with Quick Multi-Linc. Thus, users can manage all their POC data with DataLink integration. POC connectivity should become even less cumbersome as more manufacturers use the POCT1-A Standard from the Clinical and Laboratory Standards Institute. The standard was completed by CLSI (then NCCLS) several years ago, and, says Kirk Harmon, a senior staff software engineer at LifeScan in Milpitas, Calif., many POC device manufacturers are making every effort to develop systems that meet the standard. “The problem is that some existing systems could not be adapted to meet the standard, and hopefully, companies that are working on their next-generation instruments will attempt to meet POCT1-A,” he says. LifeScan’s next-generation glucose meter will be POCT1-A-compliant.

Whether the standard, particularly the part of it that relates to the device interface, could be improved has been discussed informally, Harmon says, but he knows of no effort underway to change it. “Right now, the goal is to continue to support the standard and to keep it in the minds of those who are developing tomorrow’s POC connectivity solutions,” he says.

Sue Parham is a writer in Edgewater, Md.