new executive war college · 2008. 5. 13. · solving the gordian knot of laboratory informatics...

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Solving the Gordian Knot of Laboratory Informatics and IT Integration

Robert D. AtlasPresident & CEO

Robert M. ClymerChief Architect - Atlas Medical Division

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Executive War College

1. THE AMERICAN CIVIL WAR – Bob ClymerLessons for Laboratory IT

2. SPECIAL FORCES – Bob ClymerLight, Quick, Maneuverable IT Solutions

3. FAULTY INTELLIGENCE – Bob ClymerAvoiding IT Blowups

4. A WINNING LAB IT STRATEGY – Rob Atlas“Wrap-Around” Software for Client Connectivity Success

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Lesson of the Gordian Knot

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Effective Network Administration

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Two Primary Commanding Generals of the Union Army

1. George McClellanTop of his West Point class

Brilliant technocrat

Self-confident and arrogant

Always asked for more and more resources

Organized the world’s first modern army

“Make the perfect army”

Lincoln could not get him to use the army to wage war

The American Civil War

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2. U.S. Grant

Bottom half of his West Point class

Hated and feared by entrenched bureaucracy

Too fond of drink and cigars

Used resources he had to overwhelm enemy

Relentless pursuit of victory

“Win the war”

Both McClellan and Grant were needed to succeed but…


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$50 Bill does not have a picture of President McClellan


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American Civil War – Lessons for ITToo many McClellans, Too few Grants

1. McClellan’s IT Department

Focus on hardware, processes, academic analysis

Reliance on expert knowledge for decision making

Organized by technical function

Applications and users must comply with IT policies

Risk adverse

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American Civil War – Lessons for ITMcClellan being asked by sales if he can establish a non-

standard VPN to a large IPA in order to capture the business from LabCorp – What will he say?

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American Civil War – Lessons for ITGrant’s IT Department

Focus on servicing client and business needs

Treat IT as a tool and a weapon

Organized by application set or customer type

Flexible enough to react to changing client needs

Maximize business success

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American Civil War – Lessons for ITGrant’s army working on a Sunday after completing a

Cerner Classic to Millennium upgrade

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American Civil War – Lessons for ITMcClellan War Story – Identifying Infrastructure Problem

Complex hardware deploymentSprawling IT organization structured by function

• Network group• Windows O/S group• Storage (SAN drive) group• Hardware hosting group

End user application performance problems

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Each functional group could not find any problemProblems only clear when seen across the functionsIdentified Issue 1:

External user encrypted Internet traffic was very slow

Solution:• Replace complex (expert recommended) hardware

encryption with simple software encryption• IT literally had not been looking at the problem from

the user point of view

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Identified Issue 2:• Server disk I/O was abnormally slow

Solution:• Correct O/S and driver settings to match SAN and

database performance characteristics• Problem crossed O/S and storage functional

boundaries• Only by performing cross boundary tests were the

functional groups convinced to work together to solve the problem

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American Civil War – Lessons for ITCreating a Grant IT Department

When hiring, focus on how candidate created a flexible organization rather than the technical details of their dominationOrganize by mission, not technical functionMake sure the IT staff uses the application occasionally – order entry, error correction, etc.Emphasize that IT = Customer Service

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American Civil War – Lessons for ITSelecting a Grant Software Vendor

Focus on detailed problem solving scenarios and workflow analysis rather than kitchen sink RFP check lists and superficial (1 to 2 hour) demosFocus on ability to provide IT flexibility rather then adhering to arbitrary software standards (e.g. must be in Java)Software is a means to an end, not an end in itselfBeware of vendor who tells you that they know your business practices best and that you should conform your operations to match their software……Tail wagging dog

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Special ForcesLight, Quick, Maneuverable IT Solutions

Getting 5 servers for price of 1 – VMWareBest Buy backup solution – External Hard drivesThe VPN is down again – Use HTTPS file transferOn-board system administration tools

• PERFMON• Event Log• Ping Scripts

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Faulty IntelligenceAvoiding IT Blow-ups

Infrastructure needed to host an Internet based enterprise application may be a surpriseShared resources across applications

(SAN, network)Overlooked single points of failure

• Vacations• Power• Internet• Network components

Interfacing without integration is a hollow victory

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Interfacing vs. IntegrationIntegration is more than Interfacing

Interfacing• Static Transformation Rules• Static Table Cross Referencing• Dataflow Divorced from Workflow

Integration • Dynamic Transformation Rules

Example: Real Time Test Routing• Information Aware Data Transformation

Example: Patient Matching Algorithms• User Workflow Matching Dataflow

Example: Referring Laboratory Batch Verification

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Framing the Problem

The Mission:

Labs must integrate with a larger number and types of systems with increasingly complex workflows in more sophisticated ways:

Traditional (McClellan) Strategy:

Relying on functionally narrow legacy systems that were (are) not designed for this mission

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The Solution

Winning Strategy:

Software that Facilitates:

Workflow across disparate organizations

Data Integration across disparate software systems

Increasing the value of the lab’s services to its customers

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EMR

Host Systems Outside World

Ordering

Reporting

HIS 1

LIS 1

APSystem

Billing

Wrap-Around Platform

Middleware

Lab OuterWareTM

PMS

Doctor’s Office

Referring Lab

Patient ServiceCenter

Ordering

Reporting

LIS 2Ordering

Reporting

DiseaseManagement

Systems

DecisionSupportSystems

Wrap-Around/Middleware Platform

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Enables the deployment of advanced integration and value added services such as:

1) Clean, Electronic Orders 2) Successful Integration with EMRs3) Cross-System Integrated Reports – combining

Clinical, AP, Molecular, information & data, etc.4) Customer Service and Electronic Communications

with Clients5) Disease Management & Decision Support

Wrap-Around Strategy

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Business RulesLab specific workflow

Electronic HIS registration

Payer directed testing

Departmental driven requisitions

Flow through accessioning

Site customizablemanifests

Billing RulesMedical necessity

verification

Payer specific requirements

Insurance & relationship cross referencing

Unapproved insurances

Required/optional fields

Field pattern matching

Clinical RulesDuplicate order

checking

Cascading AOE Questions

Reflex testing

Unsolicited results

The “Right” Tests forage and gender

Valid Ordering Codes

Clean, Electronic OrdersClean, Electronic Orders

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================================================================

All Orders Must (Should) meet the Clinical, Billing and Business Rules of the Lab

Future Orders, Standing Orders, PSC Orders, Split Orders routed to Multiple Labs including Clinical, AP, Esoteric, POL, Alternate Reqs for Payer Directed Orders, Digital Imaging Orders, …

Take Orders from any External Ordering System – EMR, LIS, POL, POC, & from other Lab Order Entry Systems

Clean Orders from ClientsClean, Electronic Orders from Anywhere, Everywhere

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Improve customer service, client satisfaction &brand recognition

• Make it easier for your customers to order correctly• Reduce hassle factor for your customers• Faster reporting• Bill correctly the first time• Get on the Customer’s Desktop (The Competition is!)

Reduce cost of operations, improve efficiency

• Decrease billing issues• Decrease errors• Eliminate data entry at the lab and PSC• Reduce customer service activities• Reduce ABN denials and write-offs

Benefits from Clean Orders…

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Increase Revenue

• Take customers from competitors• Grow existing customers, reduce splitting• Retain more customers• Leverage lab ordering volume for additional

ancillary services

Benefits from Clean Orders…

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There are 100’s of EMRs…

How do you efficiently connect with all (or most) of them and still not allow “Dirty” orders into the backend LIS and AP systems?

By deploying a translation, validation and workflow engine that efficiently integrates outside systems with your inside systems - a Lab to EMR gateway

EMR Integration

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EMR Weaknesses/Complexities:Can it accept unsolicited results?Does it need an order number, or PatID?Are the EMR’s test and result codes mapped correctly withthe lab’s codes? Is the mapping up-to-date?

“Ask at Order Entry” questions?Specimen Requirements?Medical Necessity Verification?Duplicate Checking?Office-based versus Internet-based?Images in reports? PDFs?Support for partials and finals?Order routing based on Payer Plan or other business rules?Exception handling?Oh yeah, costs?

EMR Integration - Challenges

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How can the Lab maintain control over:

The proper display of resultsUnsupported result formats like microbiology, and other formatted textMolecular resultsPartial versus final reportsReports with embedded images

Lab Branding and Business:

If there is no “Lab System” interaction with the physician’s desktop and staff, what stops the EMR from just sending orders to another lab (not yours)?

EMR Integration - Challenges

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Lab Ordering Embedded in the EMR

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EMR sends the HL7 order to the Wrap-Around central server platform via the Lab to EMR gateway – the EMR order codes get translated into the Lab’s test codes, etc., and then the:

a) Order is sent to the LIS directly, if it passes the correct clinical, billing, and business rules

Or b) Order is queued up for completion by a physician office userOr c) Order is made available for completion in Patient Service CentersOr d) Order is queued up in the Customer Service module for processing

by the lab’s client services staff…

… Contact physician office for correct ICD-9s, or insurance information,… Print req. with instrument-ready bar code labels? Print other info?…

Multi-Staged Order Entry, EMR Integration

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Multi-Staged Order Entry, EMR Integration

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EMR


Ordering

Reporting

HIS 1

LIS 1

APSystem

Billing


Lab OuterWareTM

PMS

Doctor’s Office

Referring Lab


Ordering

Reporting

LIS 2Ordering

Reporting

DiseaseManagement

Systems


Wrap-Around the Legacy Systems

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Cross-System Integrated Reports

Wrap-AroundPlatform

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Customer Service

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Customer Service

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Electronic Exception Management w/Clients

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• Disease Management is a 1.2 billion industry and growing quickly

• Dark Daily: “By the end of 2008, the Disease Management Association of America (DMAA) plans to refine its guidelines and supplement them with a set of disease-specific clinical metrics. The National Committee for Quality Assurance (NCQA) hopes to fold these metrics into its own accreditation program by late 2008”.

• Dark Daily: “There is a need for the disease management community to establish quality standards and effectiveness metrics that also include guidelines for specific standards to track whether the patient, and their physician, is getting the right lab tests at the right time and whether the lab test results are followed up in an appropriate and timely fashion”.

• Physician Quality Reporting Initiative (PQRI) - Centers for Medicare and Medicaid Services: 2008: 134 measures

• Bridges To Excellence® (BTE) is a not for profit organization that designs and createsprograms that encourage physicians and physician practices to deliver safer, more effective and efficient care by giving them financial and other incentives to do so.

• Labs should fight for the “Diagnostic Desktop” and not let their customers be owned by the EMR vendor or someone else. It’s a competitive advantage.

Disease Management, PQRI & P4P

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• Chronic Disease Cost – By the year 2010, 47% of Americans will have a chronic

condition (RAND Corporation, October 2000)– 75% of total health care spending in 2005 went toward

treatment of chronic disease (CMS 2007 & CDC 2007)

• Disease “Avoidability”– The U.S. Centers for Disease Control and Prevention

estimates that: • 80% of heart disease, stroke and type 2 diabetes is

avoidable• 40% of cancer is avoidable

Chronic Disease Crisis in America

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Disease Management & Decision Support

PatientHistory

Wrap-AroundPlatform

Lab OuterWareTM

DiseaseManagement

Systems


Lab Results

PHYSICIAN OFFICELABORATORY

Lab Orders

Lab Results(optional)

ReportsDisease RiskManagement

Reports

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Know Your Number® for the Participant

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Know Your Number® for the Provider

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Individualized Participant Letter

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EMR


Ordering

Reporting

HIS 1

LIS 1

APSystem

Billing


Lab OuterWareTM

PMS

Doctor’s Office

Referring Lab


Ordering

Reporting

LIS 2Ordering

Reporting

DiseaseManagement

Systems


Wrap-Around the Legacy Systems

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Balance I.T. “Get Results” focus with I.T. Infrastructure focusDeploy a “Wrap-Around” Platform that enables Integrated Workflow to meet the Needs of the LabEmbrace Integration Aggressively - Do Not Just InterfaceClean, Electronic Orders are Important to a Lab’s SuccessEMRs (and other external ordering systems) will be Pervasive and Initiate Higher Percentages of Lab OrdersUse a Lab to EMR Gateway and a Platform of Workflow Options and Services to Overcome EMR Weaknesses and Integration ChallengesLeverage the “Wrap-Around” Platform to provide other Value-add Capabilities to Physicians and other external Clients

Conclusions

new executive war college · 2008. 5. 13. · solving the gordian knot of laboratory informatics...

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