Two years ago, the University of Arkansas for Medical Sciences in Little Rock took what chief medical information officer Thomas Powell, MD, calls the “big bang” approach to changing software throughout its hospital and clinics. Every department simultaneously converted to Epic, including the laboratory, which switched to Epic Beaker. “We were actually, I believe, one of the early major institutions in the U.S. to go with Beaker as our laboratory system,” Powell said.
This transition was not seamless, as laboratory staff noticed problems immediately. Beaker lacked some basic functionality, such as recognizing duplicate orders. “They were wasting a lot of reagent doing a second version of a test that had already been run,” Powell said. Beaker has since improved, according to Powell, and though it is not perfect, healthcare systems are increasingly converting their laboratories to enterprise-wide systems like Epic and Cerner for one important reason: integration. “The big push in healthcare is to bring access to all of the relevant data concerning the patient into one location,” he added.
Since 2009, the U.S. Centers for Medicare and Medicaid Services has pushed health systems to integrate their information technology (IT) and use electronic health records. For many doctors’ offices and hospital departments, this has meant switching from paper records to computers. For clinical laboratories, which were largely already computerized, it often has involved switching to an integrated system like Epic or Cerner.
“Because laboratory software has been around for so long, there are some fantastic best-of-breed systems out there that laboratorians love,” Powell said. “So you are prying that best-of-breed out of their hands sometimes in the name of integration.”
In many cases laboratories have little say in the decision to adopt enterprise-wide systems, according to Noah Hoffman, MD, PhD, an associate professor in the department of laboratory medicine at the University of Washington in Seattle. “If your enterprise is, for example, purchasing Epic and gets Epic Beaker for free, the substantial expense of a standalone lab system may be out of the question,” he said. “It is just not going to happen.”
Yet the system laboratories use is only part of the story. “People focus a lot of attention on the [information] system itself,” Hoffman said. “I think that another really large component of the conversation, perhaps even more important, is how laboratory IT is staffed.”
The people who configure laboratory information systems are often former lab techs, Hoffman noted. Yet their domain knowledge goes by the wayside when an institution centralizes its IT departments, which often happens after the whole enterprise moves to an integrated system. “Everybody I’ve talked to who is at an institution that has integrated IT has had nothing but complaints about it,” Hoffman said. “The lab has to compete with the general pool of requests, so it’s difficult to prioritize the lab’s work.”
Domain knowledge is important so that the people who configure the information system make decisions based on laboratory workflow, not the other way around, Hoffman emphasized. “I think that there is a big danger in having the tail wag the dog, in the sense that there is some configuration that is arrived at in the lab system and then that drives the laboratory workflow,” he said.
In an integrated system, any change in the laboratory system could have unintended consequences for other departments, so IT must be centralized to some extent, according to Powell. Yet it is still critical to involve staff with domain knowledge. “What you need is strong and consistent clinical and administrative participation from your subject matter experts in the laboratory,” Powell said. “You need to show up at the meetings.”
The laboratory at the University of Virginia (UVA) Health System in Charlottesville intends to keep a dedicated IT staff when it switches from Sunquest to Epic Beaker in 2017, explained James Harrison, MD, PhD, associate professor of pathology and public health sciences. “One of the very first conditions we put on this move was that we would be able to maintain our IT team,” he said.
Harrison is pleased with the process at UVA. When the institution switched to Epic for medical records 6 years ago, hospital administrators respected the laboratory’s decision to keep Sunquest. “We thought that [Beaker] was not mature enough then to serve our needs,” Harrison said. Last year during planning for a second phase of Epic conversions, UVA administrators asked pathology to take another look and write a new recommendation. “We actually decided that Beaker had come a long way and looked to be pretty usable, and it was also on a good trajectory because Beaker is one of the relatively few lab systems that are being actively developed,” he added.
Competition and Change
In looking again at the lab component of an enterprise-wide system, UVA lab staff found that Beaker had advantages over Sunquest in certain areas, such as quality control across multiple instruments, Harrison remarked. “In order to make best-of-breed worthwhile, the system really has to be best-of-breed,” he said. “If you have a system that was largely written in the 1980s and hasn’t changed much since then and isn’t currently being developed, I think there’s a question of what is really best-of-breed.”
Laboratory information systems face competition not only from integrated hospital information systems but also from laboratory information management systems (LIMS), which are information systems originally designed to manage samples in analytical testing laboratories. “Recently, LIMS have made a huge play into the diagnostics area because they provide a broad set of capabilities, or functional footprint, for use in managing many aspects of the laboratory and beyond,” said Brian Brunner, associate partner at the informatics consulting firm LabAnswer. LabAnswer is helping some specialty or niche diagnostics labs to shift from their homegrown, custom-built spider web of computer systems to fully integrated systems that store all their scientific data in a single repository. According to Brunner, many LIMS companies are small and eager to work in the clinical market, so they are responsive to customers.
Certainly one of the disadvantages of switching to an integrated system like Epic, Powell said, is that laboratories have to wait along with all other customers for new functionality. Also, it is harder to walk away from a vendor when your whole organization is involved in a contract worth tens or even hundreds of millions of dollars. Yet Powell’s team has adopted the philosophy that if Epic’s product has 75%–80% of a competitor’s functionality, the health system goes with Epic because of the potential benefits of integration.
In Powell’s opinion, those benefits often feel theoretical, but his experience with an enterprise-wide system is still early. “Because in integrated systems all the data is in one location, I can ask very complex questions about the patient and receive interesting answers,” he said. “Now we’ve got to get smart enough to use that analytics engine to more fully prove out the benefits of integrated data.”
The benefits of enterprise-wide systems may go beyond improving patient outcomes, according to Harrison. If the laboratory has access to data from beyond the pathology department, it can create more valuable reports that help make a case for the value of laboratory medicine services. “If they can show that what happens in pathology has a positive impact outside of pathology, I think that that will be very beneficial,” Harrison said.
The irony is that this sort of sophisticated data analysis requires more staff, which somewhat negates the other advertised benefit of integrated systems—staff reduction through consolidation. “One site we visited indicated that Epic Beaker was requiring more system support staff overall than the previous independent system because it allowed them to do valuable things they hadn’t previously been able to do,” Harrison said, “but doing those things took time and effort.”
Julie Kirkwood is a freelance journalist who lives in Rochester, New York. +EMAIL: Juliekirkwood@gmail.com