CEO SUMMARY: In British Columbia, two commercial laboratory competitors have found common ground. BC Biomedical Laboratories and MDS Metro Laboratories are using LOINC to link their laboratory test databases. Physicians use a single system to access their patient’s test results, regardless of which lab performed the test. Coming enhancements to the system include wireless access to patient test data in emergency rooms, enriched reporting, two-way order entry, and treatment ordering algorithms. The first of several hospital laboratories is now participating in this system.
EDITOR’S NOTE: This is the second of a two-part feature on how pioneering laboratory organizations are using LOINC (Logical Observation Identifier Names and Codes) to standardize laboratory test data on a major scale.
WITHIN GEOGRAPHICAL REGIONS, integrated clinical healthcare requires easy and quick access to laboratory test results, regardless of how many laboratories may have done testing for a particular patient.
Yet the ideal of a uniform capability for pooling laboratory test data across
multiple lab organizations for the benefit of attending physicians is still just a dream and a wish for most laboratorians. That’s because technological and organizational barriers continue to make it an extraordinarily difficult feat.
Lab Data “Tower of Babel”
In two regions, pioneering laboratories are tackling the lab data “Tower of Babel” problem with the goal of creating a standardized laboratory test result repository. Clinicians can retrieve and view standardized lab test data on their patients, regardless of whether different laboratories originally performed the laboratory tests.
Earlier this summer, THE DARK REPORT provided updated information about efforts within the United States Armed Forces health system to create a common lab test data repository that uses LOINC (Logical Observation Identifier Names and Codes) to eventually link laboratory test data generated by Army, Air Force, Navy, and Veterans’ Administration laboratories throughout the world. (See TDR, June 24, 2002.)
An equally ambitious LOINC-based project is unfolding in the Canadian Province of British Columbia. Two competing commercial laboratory companies have joined forces to create a “one-stop” method of pooling all the lab test data generated by the province’s independent laboratories and hospitals.
Douglas Buchanan, Managing Director and CEO of BC Biomedical Laboratories, Surrey, British Columbia and John Rayson, MD, CEO and Vice Chairman of MDS Metro Laboratory Services, Vancouver, British Columbia (owned by MDS Inc.) formed a joint venture called PathNET to provide seamless transfer of information from their lab facilities to physicians’ offices throughout British Columbia.
Together, these two labs perform 70% of the laboratory tests ordered by physicians’ offices in the province. As politicians discussed reforms to British Columbia’s single-payer health system in the mid- 1990s, the two labs recognized that it was an auspicious time to collaborate and demonstrate that the private sector could innovate in ways that improved patient care in a cost-effective manner. “Both lab companies had a common vision: to deliver laboratory results to all BC physicians in a seamless manner, regardless of which lab or hospital the patient visited,” explained Buchanan and Rayson.
Uniform Lab Data Standards
“In 1998, BC’s Ministry of Health formed the HealthNet/BC Project to improve the way healthcare data was collected, stored, and accessed,” noted Buchanan. “The Lab Test Standard Task Group was part of this project. It included representatives from HealthNet/BC working groups, the BC Health Information Standards Council, and private and public sector labs.
“It was that task group that originally brought our two laboratories together,” recalled Buchanan. “Because our two labs provide more than half of the laboratory work in the province, we could each see that, if we collaborated successfully, we could improve clinician’s access to lab test data in a meaningful way, on a province-wide basis.”
BC Biomedical and MDS Metro decided to create a stand-alone joint venture to develop and provide this service. Called PathNET, it is a 50/50 partnership between the two lab companies and was organized to develop patient-centered diagnostic reporting.
“The province’s Lab Test Standard (LTS) defines the business and technical requirements for the electronic exchange of lab test data in BC, including a unique patient identifier,” said Buchanan. “The LTS includes all information exchanges from the time an order is issued until the time when a final result is achieved. Effectively, LTS allows our labs to develop PathNET with the confidence that all providers in the province will have the common capability to access and view the lab test data in our repositories.”
This province-wide capability may lead PathNET to some further opportunities. As PathNET is built to BC’s lab test standards, it is positioned to participate with other agencies working to develop a pan-Canadian electronic health record.
Efforts in U.S. to Develop Health Info Standards
BRITISH COLUMBIA and other Canadian provinces are not alone in their work to develop common healthcare information technology standards.
Similar efforts are under way in the United States. The National Alliance for Health Information Technology (NAHIT) has 30 participating organizations. It’s first goal is for voluntary bar code standards on all medication and biological packaging, then all medical surgical supply packaging.
Other priorities include standards for connectivity and network communications, computerized order entry and medication administration, electronic medical records, universal identifiers, and nomenclature. This is the second effort to achieve consensus on health care information technology standards.
Another related initiative has been funded with $2 million from the Markle Foundation, based in New York City. Called “Connecting for Health,” it will convene meetings of various healthcare interests during the next nine months to identify and develop standards for healthcare information which also meet privacy requirements. The consortium intends to build upon existing standards, such as HL-7 and LOINC.
In tackling a province-wide lab test data repository, the two laboratory competitors were helped by the fact that the province developed and defined the key components of the health information management plan. Included were 1) an integrated record of health services received by an individual over time (regardless of the source of the service); 2)a common information repository to enable health planning, evaluation and research activity; 3) a common data format and processes to ensure consistency of similar health activities across BC (e.g., consistent demographic, eligibility and enrollment information); 4) a common information-sharing network to ensure the ability to exchange health information; and 5) standards, policies, and practices necessary to ensure privacy and confidentiality concerns.
“PathNET became feasible because the province was supporting this common vision of healthcare informatics,” commented Buchanan. “Strategically, each of our labs had certain information technologies already in place. Our challenge was to develop the software necessary to pull lab test data from each of our laboratory systems and allow clinicians to communicate with our lab test data repository.”
Trust was an issue as the two lab competitors developed the business strategy for PathNET. “Shared vision is the key to our relationship,” declared Rayson. “This is an unusual joint venture between rivals. One partner, BC Biomedical, is wholly owned by 41 pathologists. The other, MDS Metro, is a publicly-held company.
Advantage By Partnering
“Given the evolution of healthcare in British Columbia, there was competitive advantage in partnering,” he added. “PathNET’s leadership group used our shared vision to create a viable business plan. To foster trust, the board consists of three people from each lab and meets on a monthly basis to make sure we remain on the right track.”
In tackling a province-wide lab test data repository, the two laboratory competitors faced some interesting challenges. Not the least was money. “Development costs were almost C$2 million,” commented Buchanan and Rayson. “Both our labs consider this an ongoing investment. It requires a total of about C$500,000 per year to sustain PathNET. As other laboratories join the PathNET venture, they will share in the costs.”
“However, PathNET is not a business play, it is part of our strategic plan; to put the patient information in the right place at the right time,” emphasized Buchanan.
PathNET is built on a virtual private network (VPN) platform using Web technology funneled through the Internet. By intention, the system is simple. “Nicholas Szirth (CIO at BC Biomedical) and Stephan Meuller (system architect) lead our development team. They recognized that most physicians are not computer-savvy. Their computer systems still use dial-up modems and often run on Windows 95,” said Buchanan. “Szirth and Mueller built a low bandwidth solution. It provides clinicians with a 2-second response time at 56K to view or print patient results.
“Both labs contributed labor to the PathNET venture,” Rayson stated. “We had a mixed group of staff from each lab working together over a period of four years. As many as 35-40 people at different times worked on getting PathNET up and running. In addition, senior staff contributed considerable time to the project.”
One lesson learned is the importance of having medical technologists involved in the LOINC coding. “In our lab, Judi Morgan was central to the system for compliance of coding. Our project managers all have lab back- grounds,” noted Buchanan.
Must Work Immediately
Rayson and Buchanan also knew that they had to make PathNET work the first time it was offered to clinicians. “In the laboratory business it is difficult to make a comeback if the initial rollout fails,” observed Buchanan. “Physicians are critical thinkers. They have low tolerance for any product or service that fails to deliver as promised.”
PathNET has ambitious launch plans. By April of this year, it had introduced PathNET to 2,000 physicians. This number will increase to 3,000 physicians by the end of August 2002. “Our next goal is 4,000 physicians by August 2003,” added Buchanan. “At that time, almost 80% of physicians in BC will have access to lab test results through PathNET.
“To accomplish this goal, PathNET appointed Lindsay Allan as its first General Manager in June 2001,” continued Buchanan. “This gave Lindsay just nine months to prepare an aggressive rollout of PathNET to 2,000 physicians.”
In using LOINC to link lab test data across multiple laboratory sites, PathNET shared a common challenge with the U.S. Armed Forces’ laboratory LOINC project. “Assigning LOINC codes to routine chemistry and hematology tests is much less difficult than assigning microbiology and anatomic pathology (AP) codes,“ declared Buchanan. “Coding micro and AP is significantly more complex.
“In particular, anatomic pathology is highly textural and varies widely. Each pathologist has individual preferences in the formatting and style of reports. We are working on a mixture of LOINC and SNOMED for AP. To tell us whether we are on the right track, we are doing a pilot project with Surrey Memorial Hospital. Working with the public sector takes a long time, as it is difficult for them to find funding and technology.”
Marketing PathNET to physicians was another challenge. “Our strategy was to have the product sell itself,“ Buchanan said. “It must add value to physicians. It is also easy for both technical and non-technical staff to use.
“Currently we offer test reporting, cumulative charting based on the historical data and an HL7 interface to the Clinicare and Wolf Medical patient management systems,” he added. “PathNet also supports an interface with McKeever, for MacIntosh PCs.”
“By the end of September we plan to provide service in five emergency rooms, two of which are on a wireless basis,” noted Buchanan. “Using a flat panel monitor, physicians will tap in the patient’s unique identifier to obtain any data in the PathNET system. This is a practical example where a life-saving use of data intersects with privacy concerns, but we are resolving that barrier in consultation with the province’s Privacy Commissioner.”
Prior to PathNET, both MDS Metro and BC BioMedical used Medinet for the electronic reporting of lab test results to physician clients. But Medinet was not Internet-capable. “When PathNET was ready to launch, we notified clients that Medinet was to be retired in favor of a significantly better service,” explained Buchanan. “This is one reason why some clients converted so rapidly.
Docs Saw Immediate Value
“At BC Biomedical Laboratories, we loaded six months of historical lab data in the PathNET system,” he explained. “Right away physicians could see added value.
“In the next phase of PathNET’s market roll-out, we are developing graphics, two-way order entry, and results forwarding with note attachment for consultations,” observed Buchanan. “We are also excited about two added value features: treatment ordering logarithms and logic links to artificial intelligence. These could assist the physician in ordering the appropriate test based on the patient’s symptoms.
“To add functionality to PathNET, we are experimenting with an 80211b wireless system and flat panels to transmit AP or slide confirmations to physicians. This equipment configuration provides better resolution and system access throughout a facility. All these features are under development.”
PathNET’s Shared Costs
PathNET’s laboratory owners bear the cost of the service. “Our two labs currently split the cost of PathNET, which currently has 14 FTEs,” said Buchanan. “The cost of each patient encounter is C42¢, regardless of the number of tests, number of locations that the result is sent to, or number of times the encounter is accessed.
“We consider this a bargain, since our laboratories no longer have to pay for printing reports, then sorting, faxing, and delivering them,” he added. “We see net savings in shifting to this type of lab test reporting system.
“To further drive down costs, we are enlisting more labs to become part of PathNET,” declared Buchanan. “We are also negotiating with several hospitals
to have them join us and make their lab test results available through the PathNET repository.”
St. Mary’s Hospital, New Westminster, is the first hospital to join PathNET. “St. Mary’s now uses PathNET to deliver lab test results,” said Rayson. “It performs numerous outpatient surgeries throughout the province. We anticipate that more than 1,000 doctors will benefit from access to PathNet. The contract is priced for 80 to 100 patients a day. There is great potential for improved patient care and much better utilization management.”
Competing Labs Learn Interesting Lessons From LOINC Mapping
SEVERAL RELEVANT MANAGEMENT LESSONS emerged from the experience of BC Biomedical Laboratories and MDS Metro Laboratory Services in mapping their labs’ test catalogs to LOINC.
IT Vendor Support
“One critical component for PathNET is the Internet service provider (ISP). Telus is the major ISP for BC and they helped us make this possible. On the other hand, PathNET’s use of new technology has stretched the ability of our LIS technology business partners to support it.” —Buchanan
Physician Use of PathNet
“Physicians use a two-button system: they view results and print a copy. PathNET acts as their storage vault. At any time, physicians can access cumulative reporting and historical patterns of their patients’ health. Most only use the 2-button approach and do little else with the system.” —Rayson
“It’s essential that participating labs agree to use a standard approach. It is ideal to work with the payers in development of the standards, as there is instant credibility with the end result.” —Buchanan
“Technology must be robust, ‘thin client,’ and provide true functionality— not lots of bells and whistles. Physicians still want hard copy and do not want their workflow changed. Your solution must fit with their work patterns and allow them to evolve technically.” —Rayson
“There are always concerns about privacy and how clinical data is shared. The
public and private sector lab relationship is slow to develop, but there is now some recognition of the value of the product, cost and efficiency.” —Buchanan
Marketing Team Beefed Up
To sustain momentum in launching PathNET to physicians, Buchanan and Rayson decided to beef up the marketing effort. “We provided opportunities for couriers, phlebotomists and MTs to become part of the marketing team,” noted Buchanan. “Some have a natural sales ability, others are technical and good with installing software and taking care of clients’ needs.
“They work in teams of two: one with the technical competence on the computer side and the other with technical competence in laboratory medicine,” he explained. “In opening these jobs to all laboratory staff we saw many people blossom in their new role. This is a great morale-booster for each lab and the PathNET staff.”
One unexpected consequence of the PathNET joint venture between two lab competitors is their mutual interest in going to higher levels of collaboration. Rayson and Buchanan are both enthusiastic about the future. “We see the opportunity to become the early adopter and provider of digital information in BC,” stated Rayson.
PathNet Is improving patient care even as it reduces lab costs associated with reporting test results to physicians.
Data mining is a potential and obvious opportunity with PathNET, but Buchanan notes that several privacy issues in Canada remain unresolved. “The government is likely to err on the cautious side and look closely at invasion of privacy,” he predicted “From the public health point of view, CDC would like to access to this type of data. But the data will be made anonymous and so be limited to research purposes.”
Demand For New Services
PathNET is a reminder that the changing healthcare marketplace wants new services and solutions from clinical lab- oratories and pathology group practices. Both Canada and the United States underwent widespread consolidation of clinical services during the 1990s. One basic goal of consolidation was to integrate clinical care in ways that would improve the quality of care while eliminating or reducing redundant and unnecessary costs.
PathNET is a direct consequence of this healthcare consolidation trend. It represents two laboratory competitors working together to provide integrated access to lab test data by physicians throughout British Columbia. In the process, PathNET is improving patient care even as it reduces lab costs associated with reporting test results to physicians.
Benefits From PathNET
From this perspective, PathNET is a double win. It’s good for physicians and it’s good for the two lab competitors who invested considerable time and money in PathNET.
THE DARK REPORT sees LOINC as a step in the evolutionary process of laboratory standardization, which is likely to become mandatory in Canada during the next five to ten years and may encourage a similar directive from the Medicare and Medicaid programs here in the United States.
Because laboratory test data is an important part of the digital health record for individual patients, any effort to create regional repositories of healthcare data will require a response from laboratories serving that region. The early efforts and successes of PathNET in British Columbia and the U.S. Military’s Global Laboratory Interoperability Project (G-LIT), built upon using LOINC to map results across multiple lab sites, provide early evidence that it is possible to pool laboratory test data in ways that are useful to clinicians.
LOINC can also be viewed as part of the healthcare quality movement gathering momentum in the United States. Effective use of LOINC across different laboratories doing tests on the same patient can help doctors reduce errors attributable to interpreting test results. It can also lead to lower costs through improved utilization of lab tests.