“In several different countries, laboratories already use
‘distributed computing’, in the form of a single LIS data center that provides informatics services to as many as 25 laboratories in a region. The trend is to increase interoperability and portability of the information for better patient care.”
—Jacques Baudin Executive Vice President, Technidata America Medical Software
CEO SUMMARY: In concluding this two-part interview, Technidata America’s Executive Vice President and General Manager, Jacques Baudin discusses how improvements in information technology (IT) can help clinical laboratories improve their internal operations while also supporting tighter IT integration within the hospital or health system. He describes how labs are using middleware to provide capabilities that extend the useful life of legacy laboratory information systems (LIS). Outside of the United States, in locations as diverse as Singapore and Bordeaux, France, Technidata is participating in the creation of regional LIS centers, designed to serve multiple laboratories from a single LIS data center.
Part Two of Two Parts
EDITOR: During Part One, we covered two of three themes about healthcare, laboratory services, and how labs must respond to changes in the healthcare system. I’d like to pick up our discussion today with your views about the more practical issues triggered by improvements in healthcare information technology that will alter existing laboratory informatics practices. Then we can move to theme three. That is a discussion about new capabilities Technidata is building into its middleware and LIS solutions, and how labs will use this new informatics technology to meet the changing needs of clinicians and the healthcare systems they serve.
BAUDIN: I would like to add some comments on our earlier conversation in Part One about use of information technology (IT) in the laboratory.
EDITOR: Good. This shifts our discussion toward the more practical issues of trends in healthcare information technology that will alter existing lab informatics practices.
BAUDIN: Every laboratory must have an information technology strategy. Because the function of IT is to solve a problem and provide a service, laboratories need to identify the problems in their healthcare community and then craft solutions to solve those problems.
EDITOR: But that recommendation seems to ignore the short-term demands on labs.
BAUDIN: My advice is to “dream in color” when developing the long-term IT strategy.
Meanwhile, every laboratory should take proactive steps to fix existing problems and address current IT weaknesses while building the capability of supporting the evolving needs of clinicians, payers, and patients. Middleware has a role in both short-term and long-term solutions.
EDITOR: Give me an example of a short-term problem that middleware can resolve.
BAUDIN: Middleware is a powerful tool for eliminating waste and improving the lab’s quality. Automation of high-volume chemistry and hematology labs is a great example. When running this type of automation in my laboratory, I want a real-time alarm system to monitor the automation and alert me when something is broken or a process is performing outside allowable limits. That way my
staff doesn’t have to constantly look for a problem and often find it after it is too late.
“Now I want to address a big question mark for laboratory IT planning. That is genetic testing and molecular diagnostics.”
-Jacques Baudin
EDITOR: This is a way of helping the technical staff become more productive.
BAUDIN: In fact, labor productivity in the laboratory is a fascinating subject. As diagnostic technology becomes more complex, the lab needs to hire med techs with more advanced skills and knowledge. But even these people can be overwhelmed if asked to manually monitor all the work processes in the laboratory. In fact, automation in the laboratory is the very reason that middleware has become a high-demand product.
EDITOR: Explain that, please.
BAUDIN: Instruments, analyzers, and automated modules are becoming more sophisticated while, at the same time, legacy LIS’ are not keeping up with the continual improvements in the laboratory’s installed base of instruments.
EDITOR: Why aren’t LIS products keeping pace?
BAUDIN: Because there is a huge pool of legacy LIS installations. Most have been in the laboratory for as long as 10 to 20 years. The staff is trained on the system, the LIS works well. That is why lab managers have a motive to avoid disrupting this status quo.
EDITOR: Let me restate this problem. You describe a situation where, say, every five years the laboratory takes on a new set of instruments with additional functionality. Yet, every time this “instrument upgrade” cycle occurs, the legacy LIS falls farther behind in its ability to support the features and productivity of the new, more technologically advanced analyzers.
BAUDIN: That’s correct. That is why the laboratory will use middleware to allow the legacy LIS to talk to the new instrument systems. Middleware is designed to close these operational gaps. Middleware is also a tool to enable me to improve my lab operations today and, in the near future, my lab can then bring in a new LIS in downstream years.
EDITOR: As you describe it, middleware is a bridge between LIS upgrades. It allows the laboratory to take advantage of a variety of new diagnostic and informatics technology, without having to upgrade or replace the LIS on relatively short time cycles.
BAUDIN: That is correct. Another example of one technology gap to be addressed by laboratories is electronic test ordering within the hospital or from physicians’ offices. Increased use of electronic medical record (EMR) systems gives laboratories an incentive to support electronic test orders and the demand of physicians to have laboratory test reports downloaded directly into the EMR.
EDITOR: Installed LISs pre-date much of this technology, which is why many laboratories opt for a specialized and modern solution to support this market demand.
BAUDIN: That is true. Now I want to address a big question mark for laboratory IT planning. That is genetic testing and molecular diagnostics.
EDITOR: That is certainly a hot topic.
BAUDIN: There are three issues that laboratories must address with their IT strategies. The first issue is that molecular biology is increasingly becoming another way to get an answer. For example, molecular tests for gonorrhea and chylamedia can replace traditional test methodologies.
EDITOR: So the laboratory’s LIS must have a way to accommodate the different technical rules needed to support these new molecular methodologies.
BAUDIN: Yes. It is the “same” test, but the answer is developed in entirely different ways. The second issue is more interesting to me. Cytogenetic testing uses analysis of chromosomes to predict or to identify either prenatal or postnatal problems.
EDITOR: And the third?
BAUDIN: That is molecular genetics. Molecular assays can identify, predict or assess gene-based diseases and conditions.
EDITOR: Would you please explain how laboratory information systems must respond to these emerging fields of molecular diagnostics?
BAUDIN: In the laboratory testing paradigm, it was not necessary for an LIS to collect and process a wide spectrum of data that is now generated to support the ever-increasing number of molecular assays. For example, the database structure required to support genetics testing must include information such as the patient’s family tree (genealogy) and relevant family health information.
EDITOR: There is also the need for the LIS to be able to crunch this data to support the patient’s diagnosis.
BAUDIN: Yes. To perform a risk assessment requires data to make this evaluation— while at the same time maintaining privacy and confidentiality of the data for this patient and his or her family.
EDITOR: What other attributes will be needed by next generation LIS products?
BAUDIN: My prediction is an increase in “distributed computing” to address issues such as interoperability and portability of the information. Also, the “fat client” IT model will diminish in favor of “thin client” LIS solutions. Labs will find it more productive and will get enhanced performance by utilizing a remote host LIS arrangement. “Software as a service” (SaaS) can be done today.
EDITOR: Why isn’t there keener interest in this type of IT solution?
BAUDIN: I puzzle over this. I am surprised at the reluctance of many hospitals and laboratories in the United States to pursue this approach. In Bordeaux, France, Technidata runs a single LIS data center that supports six different independent laboratories in the region. It works well. Maybe hospitals and labs here are reluctant to give up control over the management of their IT hardware or software. It might also be unfamiliarity with an IT pricing model that typically works on a per-transaction basis.
EDITOR: Are you seeing demand for this “distributed computing” model increase outside the United States?
BAUDIN: Most definitely. More and more we are working on projects that cross boundaries. For instance, in Singapore, we are arranging for one server—one system—to provide a common IT solution for 13 different laboratories. In Marseille, France, a city of 1.5 million people, a new contract was issued which will create a single data center. Soon all 26 laboratories in that city will work from the same laboratory information system.
EDITOR: I assume these are projects designed to lower laboratory IT costs without giving up any functionality?
BAUDIN: Essentially, yes but also interoperability, and portability of the information between the different laboratories. Distributed computing is robust, workable, and it helps standardize the way people work. Further, these centralized arrangements are establishing unified sets of laboratory data that support EMRs.
EDITOR: That’s an interesting comment. Am I to assume that, in these countries, remote host LIS arrangements are also part of a more strategic program to provide clinicians with standardized EMR capabilities?
BAUDIN: That’s right. These healthcare systems want to reduce variability in care and encourage “best clinical practices” Standardization of laboratory testing is a part of this. In Thailand, for example, one Technidata installation and system supports all prenatal testing in the country.
EDITOR: Wow! It’s fascinating to learn how laboratory services in other countries are developing IT and distribution models that are not much discussed in the United States. Jacques, I’d like to shift gears now, and deal with the third theme of this interview. That theme is Technidata’s response to global healthcare trends and how its products and services are designed to sup- port the needs of clinical laboratories.
BAUDIN: There are interesting projects under way. But before I talk about those, let me articulate the business strategy which drives our product development.
EDITOR: Please do.
BAUDIN: The first thing that distinguishes Technidata is that we are exclusively focused on laboratories. Our products are developed around three primary objectives. First, we want to support the entire laboratory organization. That includes management of the laboratory, enhancing workflow, addressing individual work processes, and creating clinical knowledge from lab data.
EDITOR: Please continue.
BAUDIN: Second, we believe in “best of breed” solutions. Technology should be harnessed to the benefit of the lab, its referring clinicians, and the patients it serves.
EDITOR: And third?
BAUDIN: Technidata improves its products through constant evolution. Constant evolution allows us to incorporate new technology and new functionality into our products, while preserving the laboratory’s ability to interface its informatics with other systems both inside and outside the laboratory.
EDITOR: What are some specific product initiatives that relate to the trends in healthcare and laboratory testing that we’ve discussed already.
“There is also strong demand for informatics solutions that monitor
the lab’s entire work flow, from pre-analytical through delivering reports and submitting claims.”
-Jacques Baudin
BAUDIN: One big drive is to provide the functionality to laboratories that allow them to interface with the sophisticated, newest generation instruments, while maintaining full integration with the legacy laboratory information systems.
EDITOR: In other words, you are intentionally creating the middleware modules that extend the service life of older LIS installations.
BAUDIN: That’s the goal and more: extending the life—a new lease on life— and offering an upgrade path down the road from legacy to state-of-the-art LIS. It is consistent with our philosophy of constant evolution that supports best of breed performance.
EDITOR: What about helping work flow and work processes? That’s a keen topic of interest among laboratory managers these days.
BAUDIN: You’ve hit one of the hottest trends in laboratory informatics today. There is widespread interest in raising the performance of individual work processes in the laboratory. There is also strong demand for informatics solutions that monitor the lab’s entire work flow, from pre-analytical through delivering reports and submitting claims.
EDITOR: That’s consistent with my observations across the lab industry. Management of laboratory operations is becoming more sophisticated, from the level of laboratory administrator all the way to the med techs at the bench who monitor the performance of individual analyzers.
BAUDIN: To meet this demand, we are developing systems—such as dash- boards—that push relevant information in real time to laboratory staff and management. This allows them to “drive” the lab as they would use their vehicle’s dashboard to drive the car.
EDITOR: What role does integration play?
BAUDIN: Laboratories are demanding more effective integration of their existing informatics systems. Internally, they want and need to flow data across traditional boundaries in the laboratory, such as microbiology, histology, and anatomic pathology. Externally, they need to integrate their laboratory test data with the systems in their parent hospitals and health systems, not to mention office-based physicians and payers.
EDITOR: Do you see any demand for functions that represent an emerging trend in laboratory management?
BAUDIN: That’s an interesting question to which I would answer yes. Laboratories now come to us and request functions that will help them eliminate waste and improve quality. This is particularly true of laboratories where quality management systems such as Lean and Six Sigma are in use. These laboratories want to see data in real time that specifically allows them to monitor performance and improve it on a continuous basis.
EDITOR: This is using data in a different way than in the past.
BAUDIN: More than that. It is a paradigm shift in laboratory management methods. Lab managers now recognize all sorts of problems and inefficiencies—long tolerated, by the way—as unacceptable and no longer to be tolerated
EDITOR: Please explain.
BAUDIN: Here’s a typical comment. “When running clinical chemistry, I want a real time alarm to alert me when something is not working to specification. I don’t want to wait until something is obviously wrong and then have to search to identify the problem before it can be fixed, along with the further need to backtrack to fix the earlier work produced by a malfunctioning process.”
EDITOR: Do they seek real-time monitoring to enable proactive intervention?
BAUDIN: That’s correct. They see middleware as an ideal solution because it functions in real time and it solves another problem.
EDITOR: What’s that?
BAUDIN: Complexity for the staff. These labs now want to steadily raise productivity. To accomplish this, they must more tightly monitor and tinker with work flow and individual work processes. Rules are established to support this increased productivity. But at some point, without soft- ware to automate manual processes, the staff can become overwhelmed.
EDITOR: Thus, rules engines are added to the middleware, so that real time data flows can be monitored and corrective actions taken in an automated fashion. Not only does this relieve the stress on laboratory staff, but it also allows them to focus their skills on higher value contributions to the laboratory. That further improves productivity.
BAUDIN: That is correct. There is another evolving trend to which we are responding. It is the availability of a number of non-laboratory information systems that handle the function of laboratory test ordering without involving that LIS. These systems are being used in many healthcare settings.
EDITOR: Do labs recognize this trend?
BAUDIN: Some do, but they are often at the tail end of their clients’ planning. That complicates the lab’s ability to play a more constructive role.
EDITOR: Give me some examples.
BAUDIN: First, hospitals and health systems are taking active steps to integrate all their disparate information systems and create a single source portal for clinicians to order and view results. Second, as physicians install EMR systems, they want to order laboratory tests directly from their EMR. They also want the laboratory test results (and other clinical results) to automatically populate the patient record in the EMR.
EDITOR: So labs require interface solutions to integrate with these needs?
BAUDIN: Not only that, but as these types of integrated informatics installations become commonplace, it will change the form and function of the LIS. Traditionally, LIS has been the major, long-term repository of lab test data. It is likely that regional and even national patient health record repositories will eventually assume that function.
EDITOR: In the United States, that would describe Regional Health Information Organizations (RHIOs). Jacques, we’ve run out of time. Thank you very much for these insights and recommendations.
BAUDIN: You are welcome.
