What will Laboratory Information Systems look like in five years?

The LIS system used by Warde Medical Laboratory for the past 20 years has served us well, but was no longer going to be supported beyond 2015. WML is proud to announce that our new LIS had been fully implemented to support our growth for, hopefully, the next 20 years.

This change has required a major effort of resources and commitment from our employees, vendors, and clients. WML would like to thank all of those involved that have made the new LIS a success.

Looking to the future, we thought it would be appropriate to introduce our vision of five years from now to let our readers know where we are headed and why it was worth going through this transition from our old, familiar LIS. Our vision of 5 years from now is LIS 2020.

Ready to Communicate

Most work in health care IT has been designed to improve communication of information between computers and humans. In the next 5 years we will make important strides that allow our LIS to communicate better with other computers. Here is what we expect:

More than 90% of inbound orders will be electronically transmitted from other systems, including insurance and registration information. Lab staff will continue to handle specimens, but not paper. Patients will show up for service and simply require that their blood be drawn. In and out.

We won’t have universal adoption of LOINC or another test naming convention in five years, but an enhanced “wild card” test will allow sending systems to place orders that have not been interfaced using a specific test code. Humans at the receiving end will assign the order a specific test code, and the result will automatically go back out to the originating system under the “wild card” code in textual format. Again, no paper.

Phone volume will be dramatically reduced. The LIS will support real-time web services queries from computer systems used by clients. These real time queries will initiate answers to common questions. This means that our customers can ask for information from our LIS real time, while working within their own computer systems.

Here are some queries that a foreign system will be able to ask our LIS:

• What tests are available for detecting lyme disease?
• Is the blood I ordered for cross matching ready for pickup?
• What is the status of my test order — where is my specimen and when can I expect a result?

We expect colleagues working in their own familiar systems will able to probe our LIS and obtain answers to two-thirds of the questions they call about today.

Push and Pull

Today we “push” results back to the system that sent an order, and this will still be going on in 2020. But sometimes a party that didn’t place the order will want information about a test result. A specialist may pick up care of a patient and want results that were obtained before she began to see the patient — results from tests she didn’t order. Managers of registry may require all of the cancer cases diagnosed at an institution in the past 5 years, or the hemoglobin A1c results of a patient, even though no one at the registry ordered the test. A patient signed into an office patient portal may wish to look up results that belonged to him, but that weren’t transmitted to the physician’s office system.

Requests, Not Orders

By 2020 almost every laboratory will be heavily involved in “utilization management” — making sure only the right care is delivered to each patient, at the right time. An LIS can help manage utilization, but it cannot make value decisions or tell caregivers what to do. At best it can require that a caregiver think twice about an order, or consult before an order is performed.

To understand how our LIS will be involved in utilization management, it is helpful to reimagine test “orders” as “requests”. When a request for testing comes into the LIS, the LIS will evaluate the request and then take a variety of actions, only one of which might be to have the test performed.

Each laboratory client or customer will be able to specify which of the following utilization management services they wish to have enabled for their site:

• Flag all test requests that will cost more than a certain amount for further action. Hold the specimen (if it has arrived). Notify the sender or requesting client by fax, email, preliminary result, or phone. Require confirmation by the caregiver or some other party before proceeding.
• Flag specific tests (“non-formulary” tests) for further action.
• Restrict ordering of specific tests to specific individuals.
• For clients with real time order and result interfaces, provide instant feedback in the form of a preliminary “result” or on-screen message that contains additional information that might be pertinent to decision-making, such as the results of previous tests or the cost of the test. Ask for confirmation before processing the test request.
• Management reports that help with utilization management, such as a report identifying providers with high cost or unusual utilization patterns, or comparing testing patterns of one institutional client with others.

Know Thy Neighbor

While we intend to make great strides in allowing our LIS to communicate with other computers, not every other computer system will develop the same communication capabilities at the same time. For example, some systems will be able to receive “backward” cancellation orders coming from our LIS while others will not. And customer preferences will also differ.

Some customers will want to be called whenever a critical result is generated; others will prefer electronic notification. Some customer will want to be notified whenever a high cost test is ordered; others will not.

It will be impossible for laboratory staff to remember all of these exceptions and know what to do for whom.
Instead, our computer will maintain a database that records the capabilities of each of the systems with which we communicate, and each of our customer’s preferences. Staff in testing areas will focus on testing and will assume that all needed communications will take place electronically. If an upstream or downstream computer cannot handle a particular communication, the task will be routed to a call list for manual processing.

Rather than “dumbing down” the workflow to meet the needs of the least capable system with which we interface, we will design workflow around the most capable and automatically move exception handling to areas that are staffed to deal with exceptions.

How Would You Like Your Results, Sir?

People like their food prepared differently. So it should hardly be surprising that clients want their test results served up to taste. Sophisticated customer may want compact, just-the-facts results. Others will prefer long interpretive comments to help plan next steps. Some clients will want results transmitted using a discrete format where every result element is tagged so that it can lay down in the client’s own database and be reformatted as the client desires; other clients will settle for blocks of text that will simply be read as transmitted.

Even today, we send results in the basic transmission format customers want. But in 5 years we will support more advanced versions of HL7 that allow sophisticated customers to receive tables of results and formatting such as bold and underline.

Perhaps more importantly, we will send a hyperlink with results that allows readers to tunnel back into the LIS for more information. Instead of attaching long interpretive messages to every result that cover every possible value a result can take, users will be able to click on a link that provides detailed interpretations related to the specific results found on the patient in question. Links will also allow access to photographs, graphical information, or highly formatted reports received from reference laboratories that cannot be sent over most interfaces.

Is That Your Final Answer?

In our current model, most test requests are completed with a single final result. Preliminary reports in microbiology and anatomic pathology are exceptions.

A single final result will still be the norm in 2020, but many more tests will be reported in stages, with new information being sent in successive waves. For example, while a result might remain final, the interpretation of the result may change after the results of some other, related test becomes available.

For some tests there may never be a “final” result at all. For example, some molecular sequencing tests may have updates issued months or years after the initial report, when the clinical significance of a gene variant becomes known. These will be “living” tests that for which the concept of “preliminary” and “final” reports don’t apply.
In some cases, when needed information such as the source of a test is not received, the laboratory may issue a “tentative” report that will be updated when source information is provided.

Our LIS will be configured to handle these possibilities. Of course, the ability to continuously update results and interpretations presents the potential for information overload on the receiving end. Caregivers who today cannot keep up with all of the information about their patients will not be able to handle continuous updating. Our LIS may need to be configured to signal the importance and urgency of an update, to help caregivers focus their attention.

Testing Everywhere

Our LIS supports point of care testing, testing in ambulatory office laboratories, hospital laboratories, Warde, and specialized esoteric testing laboratories. It is being configured to allow the site at which a test is performed to change without extensive file maintenance in upstream or downstream systems.

When testing is moved from an esoteric test laboratory to Warde, or from Warde to a hospital laboratory or visa versa, or to a point of care instrument, test codes will remain the same. And financial accounting will automatically be updated, with the appropriate site receiving “credit” for performing the test.

Our goal is to be agnostic about where testing is performed, and to allow changes in technology and clinical needs to be implemented quickly.

A day may come to pass where hospital-based laboratories perform less testing on site, and focus instead on logistics, utilization management, and providing technologist support of point of care and in-office testing. These will be important functions, and the LIS will be configured to meet this need.

A New Experience

It is expected that our new LIS will initially make work for laboratory staff more difficult. Unfamiliarity with the new system and a “shakeout” period required to stabilize the new environment typically makes work go slower for 6-12 months after the new system is activated.

What can we expect when this introductory period is over?

Users will be able to access the system from work or home and some functions will be available through a web portal. Support for some portable devices and voice recognition will be available before 2020.

We expect users will receive more reminders from the system about tasks that need to be performed or information that must be evaluated. Users will rely less on procedure manuals or memory because more business rules and technical steps will be embedded within the system. In some cases the computer will execute a business rule without the need for a reminder.

When an order entry staff member orders a test for Dr. X, the system will automatically remember that Dr. X wants reports for this test faxed to his second office, and will order the fax. When a pathologist orders a cytogenetics study on a bone marrow specimen, the system will notify her when results are available for incorporation into a living hematopathology report.

Finally, we envision a series of dashboards designed to provide audiences with real-time information about processes or results of interest. Dashboards will range widely; one dashboard may display stat requests that are to be performed in a section but are overdue (something we have today in some sections). Another dashboard may display specimens that were due in a laboratory but have not yet been dropped off. Dashboards may display antibiotic sensitivity of bacterial isolates in the intensive care unit, or the names of clients with large changes in testing activity.

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We hope this short vision statement will help you understand why we are making changes to our LIS, and the sorts of functionality we plan to implement during the next five years, after the difficult transition period is over.

Comments, as always, are welcome.