College of American Pathologists
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cap today

Stopping the paper blizzard in its tracks

January 2003
Andrew Pasternack

It was a busy week for Diane Carr, clinical information systems chief at Queens Health Network. On an autumn Sunday last year, she watched a long-awaited computer system go live. Though Queens’ physicians had been consulted on every aspect of the system, by Monday morning the help desk’s 10 incoming lines were jammed with pleas from disoriented doctors. But by late in the week the phones were mostly quiet. Online ordering of inpatient laboratory tests and real-time results reporting were finally underway for the thousands of specimens tested daily in the hospital system.

The network had just taken another step toward a paperless computer-based patient record, or CPR.

Queens Health Network’s (QHN) CPR was designed to be physician-friendly. It is now used daily at the point of care by 800 physicians and 3,400 nurses, dieticians, social workers, and laboratory and radiology technicians. The CPR earned QHN the prestigious Nicholas E. Davies Award, which honors innovation in computer-based patient records. The award symposium was held last November at the annual meeting of the American Medical Informatics Association.

Queens Health Network, a member of New York’s public hospital system, is the major provider in the borough of Queens. Its more than 6,000 employees work at 19 locations—11 clinics, six school health clinics, and two teaching hospitals, Elmhurst and Queens, both affiliated with Mt. Sinai School of Medicine. QHN is the first public hospital system to receive the Davies Award.

Elmhurst Hospital Center computerized in 1987 with a system from CHC (later acquired and maintained by ADAC). It was ready for a new technology by 1997, when the hospital began installing its CPR system, Per-Se Technologies’ Ulticare/Patient 1, says Valery Glezerov, MD, regional director of pathology, Mount Sinai School of Medicine Services at Queens Health Network. “The old LIS was cumbersome and had unreliable interfaces with our management information system and patient care system,” he says. “The different systems were not built for each other.”

QHN’s laboratory staff expected a tradeoff between functionality and integration. Many pushed for a new stand-alone system from another vendor. Says Carr: “One of our goals was a system where all the departmental systems can talk to each other. The functionality about how a lab uses an information system to translate orders into results—all of that is there. But in addition, that LIS functionality is integrated into the general computerized patient record. That level of integration makes it different.”

The high level of integration is needed to serve an outpatient population that generates one million visits each year at 19 locations. QHN’s patients are part of one of the most diverse urban communities in the world, representing 100 nationalities and speaking 167 languages. There are other challenges: Twelve of the area’s 18 ZIP codes fall below the federal poverty income level. The network’s service area includes 65 percent of Queens County households with annual incomes below $15,000.

“Our patients wait longer before seeking care, either because they can’t afford it or they don’t know where to go,” Carr says. “The number of languages creates a whole other issue.”

In the mid-1990s, QHN leaders recognized they had to increase the network’s ambulatory care capacity. QHN’s laboratories had a strategic role to play in that business plan. “When you have a plan that calls for expansion, you will be depending on the labs, and our CPR information technology strategy supports that,” Carr says.

In January 1997, after six months of planning, training, and installation, the hospital activated its ambulatory order-entry system. QHN’s physicians began to order laboratory and radiology tests online for the hospital’s outpatients. They could also look up results, patient diagnoses, and clinical documentation. Ultimately, more than 3,000 personal computers were installed in exam rooms and in all ancillary and emergency departments.

“It was rocky in the beginning,” Carr remembers. “The doctors’ response at first was, ‘Hey, I didn’t go to medical school to do data entry.’”

Dr. Glezerov says almost all the clinicians and laboratorians hated the new system at first “because they were used to the old outdated one.” Eventually, he says, “people realized the new system was easier to use, with more options like management reports, statistics, and easier ordering.”

Physicians accepted the system largely because it lets them order tests and review clinical data easily and quickly, Carr adds. For example, a physician can select a diabetic patient’s most recent fasting blood sugar result and see not only the current value but also where the result falls in a chronological list of the patient’s most recent glucose levels.

The system’s chief benefit is the near-elimination of paper from the results-reporting process. “The doctors love it,” says Carr. “The moment a test result is sent from an instrument, it’s available on the doctor’s computer desktop.”

The lab system has many timesaving features such as partial name search. Enter the letters “glu,” for example, and all glucose-based tests come up. The system also saves time by creating multiple events from one order. If a doctor orders a CBC for her patient each day for a week, the system automatically generates a new order every day.

When QHN switched to Ulticare, twice as many instruments were interfaced to it than had been interfaced to the old system. It also added a bidirectional interface to the organization’s primary reference laboratory. An interface was added, too, to North Central Bronx Network, for which QHN serves as reference lab for cell immunology tests.

The bidirectional interface, Carr says, is “fabulous for patient care—we avoid all the paper lab results that used to be faxed from the reference lab and had to be entered. Our turnaround time has been cut down by several days.”

The system suppresses nonreportable microbiology sensitivities. “The tests are so sensitive now, they can present a cacophony of information,” Carr says. “So the lab sets the threshold below which results aren’t reported.” The laboratory also defines the test levels for which results display immediately, as well as the levels at which results are suppressed until department supervisors or physicians verify them, such as cytopathology results.

Reports identifying organisms, diseases, and patient conditions that must be reported to regulatory agencies can be reviewed online. “We are FTPing immunization data to the health department. Eventually, possibly in a year, we will transmit certain communicable disease results to the health department,” Carr says.

In the clinics, the Ulticare lab system helps staff communicate with patients, says Veronica Henry, QHN’s regional associate director for laboratory administration. “For example, if a patient loses their requisition, the laboratory assistant can retrieve the doctor’s order and reprint a requisition so that the specimens can be taken, processed, and resulted.”

“The system works for us in the laboratory,” adds Henry. “The change in operation has been challenging to both the doctors and laboratory staff, but the benefits far outweigh the previous hospital laboratory system.”

New York is home to not one but two Davies award winners. The other is Maimonides Medical Center, a top cardiovascular institution based in the Borough Park section of Brooklyn. The hospital has 245,000 ambulatory visits and 37,000 inpatient admissions yearly. Its five sites serve Brooklyn’s population of 2.5 million.

Ann Sullivan, the center’s vice president and chief information officer, has helped the system’s hospital and 10 clinics leapfrog into the paperless record. The Maimonides Access Clinical System, or MACS, a computer-based patient record, has earned accolades, among them the 1998 Computerworld Smithsonian Award in Medicine.

The implementation budget for MACS included $2.3 million to integrate a Misys (formerly Sunquest) LIS into MACS, which is based on an Eclipsys 7000 system.

Upgrading the Misys system meant all the data going into the LIS would show up in the hospital information system, and orders entered into the Eclipsys system would be transferred automatically into the Misys system. After the system went live, the hospital quickly achieved 100 percent order-entry with staff and community physicians.

This should not, however, be confused with 100 percent compliance. “As the older doctors retire, replaced by newer ones who are more computer literate, there will be 100 percent compliance,” says Lisamarie Alba-Sedutto, administrative director in the Department of Pathology and Laboratory Medicine. “Right now, if a doctor doesn’t want to enter orders, he gets a resident to do it. Either way, it has to be ordered online. There’s almost no paper anywhere.”

Quicker results and fewer printouts have made a difference. “Doctors can see the results of tests they’ve ordered in almost real-time,” she says. “You never get rid of paper completely, but you do get rid of all the little slips everywhere.”

Alert values have been programmed into the Misys system. “Anything that’s out of range and might be considered life-threatening prompts us to call the floor and alert the physician or the attending to call it up,” Alba-Sedutto says. This information, including details about who was notified of an alert condition, is delivered to the hospital information system. The physician can see, then, that life-threatening results were called into the floor nurse in the middle of the night, for example.

The system’s menus display the order sets most commonly used in the physician’s area of specialty. For an obstetrician, the test for magnesium might come up first, whereas an oncologist might find the reticulocyte test listed first.

In the past, “physicians would order an entire panel, such as the comprehensive metabolic, when all they wanted was one or two individual tests,” Alba-Sedutto says. “The tests would be reordered until they showed up on the chart. Now physicians can click on an order, see if it’s in process, and find out how long it’ll take. They get faster results and they don’t have to draw as many vials of blood.” In addition, tests can be added to an existing order. Blood vials are saved for seven days, during which time most of the standard chemistry tests can be added to the original order.

According to Robert Kalter, MD, director of the Department of Pathology and Laboratory Medicine, the number of lab tests ordered has dropped drastically, thanks in large part to the increased access to the Misys system after it was integrated into MACS. Previously, Maimonides’ physicians ordered more than three million tests a year. Now that duplicate and superfluous tests have been all but eliminated, they order one million. The system alerts physicians when tests have already been ordered. According to the Maimonides information systems staff, chemistry tests decreased by 48.9 percent, urinalysis by 41.6 percent, microbiology by 40.6 percent, serology by 8.5 percent, and hematology by six percent—all this while admissions rose.

Maimonides doesn’t bill for individual inpatient tests—patients are charged a flat fee for their hospital stay. Reducing the number of tests performed eliminated unnecessary expense, but its real benefit is staff productivity, Alba-Sedutto says. “We used to have people who just sat here all night, entering orders for blood drawing the next morning. Now that the information system is integrated, we generate a blood collection list in the morning. The person who might have previously sat there entering orders can now work with patient specimens or answer the phone and help doctors find results,” she says.

Despite the benefits, some doctors still hold out. “A lot more of them come and complain about the system, which shows they’re using it,”Alba-Sedutto says. “But the number of those complaining is definitely dwindling. That’s a good thing.”

Andrew Pasternack is a writer in Richmond, Calif.