College of American Pathologists
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How one lab tossed paper, squelched noise, set rules

September 2001
Eric Skjei

Six years ago, when the University of Illinois at Chicago Medical Center decided to replace its paper-based medical record system with an electronic system, the clinicians there rallied for better, faster access to lab data. They got their wish.

Today that system (known as Gemini), developed by UICMC in collaboration with Cerner Corp., has paid off in many ways. Order-entry errors have been reduced, diagnostic test results are available more quickly, clinicians can track the progress of orders online, and automated guidance for clinicians, in the form of rules-based alerts and filters, is now available.

From the start, says Joy Keeler, chief information officer at UICMC, Gemini was intended to be a way to supply clinicians with current, integrated, reliable clinical information. "When we started this project," she explains, "our first priority was to focus on clinicians, to shape the system in ways that would help them meet the challenges of their work."

"The first thing we did," says Keeler, "was to populate the central data repository with general lab results, AP, blood bank, and microbiology." That, she adds, was a big hit.

It was also important to UICMC to make clinical information available throughout the institution. Today, with 3,000 workstations and all inpatient departments served by Gemini, that goal largely has been met.

Reducing noise

Ask Samuel Levin, PhD, to explain how the Gemini system benefits laboratories, and you’ll get a surprising response. "The most apparent benefit is a decreased noise level in the laboratory," says Dr. Levin, who is director of chemical pathology in the Department of Pathology at UICMC.

"In a paper-based system," explains Dr. Levin, "when the record is unavailable, the physician is likely to pick up the phone and call the lab." Before Gemini, the phones in Dr. Levin’s lab rang constantly, and the questions he was asked weren’t always easy to answer. "A physician might call and say, ’I want the lab results from two weeks ago on Maria Gonzales,’" he says. "Do you have any idea how many Maria Gonzaleses there are? Or how often two weeks turns out to really be two months?"

Since implementing Gemini, Dr. Levin says, the number of phone calls to his lab has dropped, and the laboratory is much quieter—and more efficient. Not only do physicians and nurses enter test orders in Gemini, they also track them as they move from order to collection to analysis to report. "Once a lab order is placed, the physician or nurse can access a series of status screens, starting with one that says ’Ordered, Physician or Nurse to Draw,’" explains Dr. Levin. "As soon as the sample is drawn and the record is updated in Gemini, the status changes to ’Collected, in Lab.’ Within seconds after we complete the work, the word ’Completed’ appears."

The UICMC lab also uses a Sunquest laboratory information system. "Having an extremely robust and sophisticated LIS means that on those rare occasions when Gemini goes down, we can still operate," says Dr. Levin. "The lab can still achieve its objective, which is to accept a specimen, do the testing, and get the results back to the clinician.

"Since we have no need to interact with Gemini," he adds, "only a handful of lab personnel have been trained to use it, and only about half of that group access it on a regular basis."

Improving orders

Automating the order-entry process has helped the UICMC lab minimize other problems inherent in paper-based record systems, such as deciphering illegible handwriting. "Because the electronic order process in effect imposes a template on the process," says Dr. Levin, "there’s usually no question as to such basic information as when the order is entered, who the ordering doctor or nurse is, which tests they want to order, and what the admitting diagnosis is."

Gemini also has the ability to help clinicians screen for inappropriate, ineffective, potentially dangerous, or unnecessary tests. "For example, if a doctor orders a CBC on a patient with a fractured toe, it’s safe to say the carrier is likely to disallow the test," says Dr. Levin. "Gemini can screen for that type of conflict and will present the ordering clinician with a prompt that questions the order before it is submitted."

UICMC implemented its first rules—a kind of automated decision-making guidance process—when it went live with its order-entry system in November 1999, says Keeler. "The first rule required physicians to indicate whether the patient had allergies or not before entering a medication order."

Today, says Dr. Levin, the system can incorporate rules pertaining to most, if not all, medications—for example, digoxin, commonly prescribed for patients with heart disease. Giving digoxin to patients with very high or very low potassium in their blood, Dr. Levin explains, can cause problems. "The only way for a physician to check for this potential problem is to access patients’ lab data, look at the potassium result, then place the order," he says. But once the Cerner Discern Rules functionality in Gemini has been deployed, and a physician places an order for digoxin, the system will be able to automatically check the patient’s potassium data and, if necessary, alert the physician to potential problems. Conversely, the system can alert the physician that an abnormal lab value may be the result of test interference due to a medication the patient is taking.

The rules functionality in Gemini also cuts costs by reducing unnecessary testing. "How does one judge whether a test is unnecessary?" asks Dr. Levin. "If a CBC was done for an outpatient within the last 48 hours, for example, then it’s fair to ask if a second one needs to be ordered so soon." Gemini guides this decision. "It allows you to set up time windows within which physicians can check to see if the test they are ordering has already been ordered or will be ordered soon, so they can cancel a test if they see it isn’t needed," he explains.

Moving forward

Since the inception of Gemini, Keeler and her staff have managed a series of additional rollouts. "After lab, the next ancillary results we brought up were radiology interpretations," she says. "The next phase included support for direct note entry and an interface to the transcription vendor for progress notes, operative reports, discharge summaries, and so forth."

With the automation of these documents came electronic authentication and other functions designed to enhance clinician communication across departments. "If I’m a primary care physician and I want to refer my patient to you—a specialist—I can very easily forward my progress notes to your inbox. These notes appear in the appropriate folder of the receiving physican’s inbox, along with all clinical information on the patient. You do your documentation and send it back to my inbox," Keeler explains. "Information no longer disappears into a black hole, turnaround is very fast, virtually the same day, and physicians find that improved communication facilitates better patient care."

What’s left? "Today," says Keeler, "we are focused on bringing nursing and the other ancillary departments into the system to finish the process."

Eric Skjei is a freelance writer in Stinson Beach, Calif.