College of American Pathologists
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cap today

Special Delivery

April 2002
Eric Skjei

Laboratories that adopt Web-based outreach systems to give physicians and others access to lab data are making slow but steady progress. And nearly all find themselves having to dance delicately around what physicians and their office staffs are used to doing and how these systems ask them to change all that.

For some labs, implementing a Web-based system that gives customers access to lab data has been as straightforward as could be hoped for.

"It’s been a very positive experience for us," says Linda Tannenbaum, senior vice president of BioPath Lab- -oratory and Radiology in Van Nuys, Calif., about BioPath’s use of a Web-based results-reporting system from Atlas Development Corp. BioPath installed Atlas’ LabWorks in mid-2001, and today some 500 nursing-home clients use the system.

"Physicians and nursing home administrators use it to look up lab results," Tannenbaum says. "Our lab system here posts results to the Web and users can then look them up from any location." To date, BioPath is using the system only for results reporting. "We’re not ordering on it yet," Tannenbaum says, "but we do have some clients that would like to set up order entry."

Response to the system has been excellent. "Physicians were very excited to hear about it and jumped on it right away," she says.

For the laboratory, it has meant fewer telephone calls, Tannenbaum says, but its chief value is that it has helped BioPath become more competitive. "It has been particularly effective as a marketing tool," she says, "since we are the only nursing home laboratory in southern California that offers this service."

Thousands of miles away, in Edgewood, Ky., St. Elizabeth Medical Center is using the online system, Elysium, from Axolotl. "Physicians who sign up for the service are assigned an electronic mailbox," says Jay Pemberton, MD, medical director of the laboratory at St. Elizabeth. "Lab results, x-ray results, and medical record transcription reports, such as op reports and narrative summaries, are all delivered into physician inboxes." The Axolotl software that St. Elizabeth uses is licensed and administered by a not-for-profit organization, Healthbridge, which was formed by hospitals and other major employers to connect health care in the Cincinnati region.

"Results are first verified on our Cerner LIS then sent through an HL7 interface to Healthbridge," Dr. Pemberton says. The system has been up and running since mid-2001, and like the BioPath installation, it’s not yet used for order entry. About a third of the physician offices affiliated with St. Elizabeth have signed up to use the system, Dr. Pemberton says, and many of them now rely on it as their primary means of obtaining lab results. Physicians who do not want to access results online can have them faxed or printed out at their offices, he adds.

Healthbridge installs the system in the physicians’ offices and maintains it. The cost to St. Elizabeth Medical Center for the system is $24,000 per month; that includes the Healthbridge sponsor fee and monthly operational license fee. "We don’t pay Axolotl directly," Dr. Pemberton says. "Axolotl receives payment from Healthbridge."

At St. Elizabeth, too, the number of phone calls has dropped. "The Healthbridge server went down for about a day recently for the first time," Dr. Pemberton reports, "and there was a noticeable increase in phone calls to our laboratory." A secondary benefit for the laboratory is lower printing costs because reports are now mainly printed out in the subscribing physician’s office.

Ultimately, the promise of such systems is improved efficiency in the physician’s office. "It can change the way doctors manage information flow," Dr. Pemberton says. Advanced physician users can, for example, annotate reports and forward them to office staff for use in patient letters. "A patient may come in with a high lipid level, for example; the doctor can quickly annotate and generate a customized letter that’s printed by the office staff and sent to the patient," says Dr. Pemberton.

St. Elizabeth Elysium users can also consult with one another by e-mail, attaching results to their exchanges. Using a specialized Healthbridge program, office staff can verify ICD-9 and CPT codes. A physician who works at more than one member hospital can obtain results from all of the hospitals without having to access each system separately.

Many other functions can be integrated into the Elysium system—for example, claims eligibility and submission, patient eligibility, prescription writing, patient-physician communication, and supply ordering—and the information can be combined as needed. "Because we bring together information from multiple sources, we can, for example, integrate test results from a reference lab as well as from a patient’s hospital stay and trend or graph the results, across all those facilities," says Ray Scott, chief technical officer and co-founder of Axolotl.

Order entry is typically the next core function to be implemented after results reporting, and it is generally regarded as more difficult. But it’s not technology that’s the sticking point, says Axolotl’s Scott. "We have a full-fledged order-entry system," he says. "There are a few complications, like making sure physicians can check Medi-care necessity rules and generate advance beneficiary notices, but it’s not harder to do technically."

What is hard is changing the way physicians work. "From an office-workflow perspective, results reporting is fairly simple and straightforward," says Cory Fishkin, president of CareEvolve. "There’s not a lot to do—the systems automatically dial themselves, connect to the reference lab, download the results, and automatically print them out." CareEvolve is a physician-oriented Web-based results-reporting and order-entry system licensed by Bio-Reference Laboratories in Englewood, NJ. It offers claims eligibility, prescribing, and other services and is used by about 125 Bio-Reference customers.

Online order entry, by contrast, is a bit more work. "It requires sitting down in front of the PC, logging on, and typing in information," Fishkin says. Using a traditional paper requisition is straightforward, at least as far as the physician is concerned. "It’s really fairly easy to just check a couple of boxes on the form, fill in a name and perhaps an ID number, pass it on to the patient or the lab, and leave it to the lab staff to check it and process it," Fishkin says.

The traditional paper-based order-entry method works, to be sure, but not without imposing costs, mainly in the form of lost opportunities to make sure that orders are correct and complete from the start. "What the lab needs is completeness and correctness at the point of placement of the order," says Axolotl’s Scott. Electronic order entry can make this possible, but implementing it tends to shift some of the burden of order entry from the lab to the physician or the physician’s office staff.

For busy physicians, making this change may not be welcome or feasible, at least not without reinforcement or reward. "The physician’s office does benefit in the long run," Scott says. "There will be fewer cases where payment is not forthcoming due to order-entry issues, and automated order entry introduces other benefits, such as the simple fact that the process automatically creates a copy of the order," Scott says, "something most labs do not now track."

Regulatory forces may help drive order-entry automation. Medicare necessity and advance beneficiary notification requirements, for example, are likely to add impetus. "Physicians are required to produce an ABN for patients—to review medical necessity guidelines and tell patients in those cases where it appears that Medicare may not pay for a test," Fishkin says. "With the right order-entry system this is a breeze—the physician doesn’t have to thumb through thick manuals, check diagnosis codes, and so on, because the system does this quickly and automatically."

None of the clear benefits of the systems come easily, though, since physicians are not accustomed to working in ways that require interaction with a keyboard, mouse, and computer screen. "The one thing we’ve learned about using it here is that it’s awfully hard in a busy office to change how doctors do their work," says St. Elizabeth’s Dr. Pemberton. "So although we’ve signed up a lot of doctors, in most situations it’s the office staff who are using the system to look up results." Axolotl’s Scott agrees. "We’re trying to move—I guess ’drag’ is really the right word—physicians kicking and screaming into the current century, to adopt modern technology rather than the paper flow they are used to," he says.

Age plays a factor here, of course, and because it does, time favors the adoption of online modalities. "The picture is changing as a new generation of doctors make their way into practice," Scott notes. "Doctors coming out of med school now want to know what system they’re going to be using. For them it’s not a question of do I use a PC; it’s a question of what software is on my PC, what am I going to be doing with it, and can I do some of this on the Web?"

At St. John’s Health System in Anderson, Ind., medical technologist and systems analyst Avis Witt sees the entire spectrum of responses to its Elysium implementation. In place for well over a year, the St. John’s system interfaces to the hospital’s Mysis (formerly Sunquest) laboratory information system via an HL7 interface, then delivers results to physician offices. The large majority of physicians affiliated with the hospital subscribe to the service, Witt says, which to date supports only results reporting.

For many months, the laboratory had not seen the falloff in phone calls and faxes it had hoped for. More recently, though, the number of phone calls and faxes has dropped noticeably. "Perhaps this reflects the length of time for the learning curve and confidence building within the physician offices," Witt says.

The St. John’s implementation picks up lab results and transmits them to subscribers frequently throughout the day, but most offices seem to check results only occasionally, once or twice a day, perhaps first thing in the morning and, in some offices, at noon. Witt speculates that most subscriber offices are too busy to check results more frequently, and notes that some offices do call the lab throughout the day, presumably in between the times they access Elysium. To gently encourage greater reliance on the system, she responds to these calls by first confirming that the caller is an Elysium subscriber, then mentioning that the test result is available and should be online before adding that she will fax the result to the caller.

The St. John’s lab is sufficiently satisfied with the system that, though it has continued to print all outpatient reports at the end of each day as a backup measure, it has stopped supplying hard copies to the doctors who are Elysium subscribers. "I’m glad we still print our reports because I can refer to them when offices call, but I don’t think we’re likely to need them," Witt says. "The system has been up for almost two years now and has never been down, so we’ve never had to use them for backup purposes." The lab has, she says, thus already realized a modest workload savings from the system implementation. "We have a clerk who goes through the printout to deliver hard copies, and that person no longer has to pull out reports for doctors who are Elysium subscribers," she says. "That sorting process has been simplified immensely."

Problems are rare, and those that do arise result mainly from a simple lack of familiarity with system functions. "Recently, a doctor’s office called and told me they had a patient in the room who had not received his micro result, that it -wasn’t in Elysium," Witt recounts. "It was there, but they had simply looked in the wrong place." Office staffs also have occasionally called because they think they’ve deleted a lab report, but again, in these cases Witt typically determines that the report has not been deleted but has instead been mistakenly moved to an archive area of the subscriber’s inbox.

No one knows the lessons of implementing a Web-based lab data system better than John Yurko, senior director for the laboratory in the eastern region of Pennsylvania’s Geisinger Health System. Yurko has been at the helm of one of the earliest and most ambitious such projects for almost two years now. With the help of Labportal and other system vendors, Gei-sing-er has been working to build an extensive outreach system designed to connect a wide range of physician practice types and sizes over a large geographic area to Geisinger lab services via a Web-based service known as GML-link.

"We’ve made a lot of progress," Yurko says. "We currently have about four sites live and four more coming online within the next 60 days." Some of these sites receive results only, while others can also enter orders.

Yurko readily admits that implementing the Web-based system has taken longer than he or anyone else at Geisinger expected. The reasons, he reports, have little or nothing to do with the core Labportal system. "One thing that took us longer than we anticipated was the interface to our billing system," Yurko says. "It took us several attempts to collect insurance information correctly and build pull-down menus of the most frequently used insurance carriers, but we are now comfortable with this aspect of the implementation."

Building an interface to a practice-management system can pay significant dividends, Yurko says. Order-entry systems that automatically download patient information from practice-management systems speed and simplify order entry considerably. "As we began to move forward with some of our clients we realized it would be very useful if we had a way to download and manage current data from their practice-management system," he says. A subsequent relationship with practice-management system vendor MediGate led to an effective interconnection with a database of 10,000 patient records. Based on the success of that endeavor, Geisinger is preparing to begin connecting to an even larger practice-management system, says Yurko.

Though client sites have taken time to adjust and adapt to the system, most have been able to make it operational within a few weeks, Yurko says. The labs love it, he adds, particularly with respect to orders. "They get a requisition that’s totally readable, medical-necessity checking is done, and now, after a lot of work, billing is much, much easier."

Yurko learned, above all, that infrastructure is critical.

"All I can say to people who are considering a venture like this is that you need infrastructure," he says. "You don’t wake up one morning and say, next month we’re going to have an outreach program without it." By "infrastructure," Yurko is referring to a support system that includes, in Geisinger’s case, customer representatives and outsourced services to handle tasks like installing physician office hardware and software, obtaining Internet connections, and providing ongoing support.

"We built a base of customer care reps who not only implement Labportal but also do myriad other things, from checking in with the client now and then to making sure their supplies are sufficient to general troubleshooting at the client site," he says. They have also entered into a contracting agreement with a company that does their installations for them and provides Internet service. "Having this company provide the Internet service for us removes any inducement issues for our organization," Yurko explains.

Yurko says the two-year process has been demanding and rewarding. "We have had a positive experience," says Yurko. "I’m still very enthusiastic about the project, but I admit that I did not know how much effort it was going to take to make this work."

Thus far, Web-based order-entry and results-reporting tools have met with moderate success, but new tools, business processes, and technology will speed up their adoption, says Care-Evolve’s Fish-kin. "There’s still real work to be done—interfaces, loading data tables, configurations, and training are demanding and time-consuming," he says. But "with proper planning, the benefits are there."

Eric Skjei is a writer in Stinson Beach, Calif.