“When a hospital or laboratory goes ‘paperless’, it’s no longer ‘business as usual’ for pathologists.”
—Bruce Dunn, M.D.
CEO SUMMARY: One outcome of the Veteran Administration’s (VA) ongoing effort to create a totally-integrated information system was to give the laboratory increased capabilities to enhance diagnostic testing services. It’s also changing the way pathologists practice laboratory medicine and support clinicians. In this exclusive interview, Bruce Dunn, M.D., Director of Pathology and Laboratories for the VA’s VISN 12, provides provocative insights into how and why his laboratory organization has gone “virtual.” He offers tangible evidence that telepathology and other tools will break down geographical constraints and give pathologists the ability to support clinicians across vast distances. This interview was conducted for THE DARK REPORT by June Smart, Ph.D.
TDR (THE DARK REPORT): After the Veterans’ Administration (VA) went “paperless” several years back, fundamental changes took place to your daily routine as both a laboratory director and as a pathologist. How would you characterize this situation?
DUNN: When a hospital goes paperless, it’s no longer “business as usual” for pathologists and laboratory services. In the all-electronic environment of our VA hospitals and clinics, pathologists have added three essential ‘Cs’ to their tool- box: computer, cell phone and car. Mobility and agility are now essential attributes for our pathologists.
TDR: Wasn’t that an unexpected consequence from the VA’s move to an all-electronic information system within its hospitals and clinics?
DUNN: It is! The different things I now do as a pathologist each day are directly linked to the all-electronic world now found in every VA hospital. To understand this change, it is necessary to explain certain events within the VA.
TDR: Please do.
DUNN: These major changes began in the mid-1990s, when the VA decided to move to a PC-based information system. That’s when my personal computer revolution began. Our laboratories used PCs to standardize policies and procedures across all sites. That happened during VISN 12’s laboratory consolidation phase, which involved the laboratory services for eight VA hospitals in our region, encompassing Wisconsin, Northern Illinois, and Iron Mountain, Michigan.
TDR: Was that the first step in what became your paperless laboratory?
DUNN: Yes. Even while this was happening, the VA was rolling out an internal data network. It also integrated the clinical data bases and implemented a computerized patient record system (CPRS). The CPRS is connected to the integrated clinical databases. As a result, all our documents became electronic. The laboratory became much more efficient at moving information. Today, our Virtual Private Network (VPN) allows access to a variety of information, including patient charts and email. Tools like PDAs, USB drives, and laptops enhance the overall effectiveness of what we do in the laboratory.
TDR: Is this why your pathology duties evolved to rely on your “three Cs”: computer, cell phone, and car?
DUNN: That’s one outcome. The VA’s electronic information infrastructure has, in many ways, transformed us into a virtual lab operations team within a virtual laboratory organization. The computer played a major role in allowing us to consolidate laboratory testing services. The computer now allows us to provide all sorts of clinical services, in real time, from any site within the VA. Earlier this year, remote access via the Web was enabled. Our pathologists, even when they are away from any VA facility, can use the Internet to conduct clinical and operational business.
TDR: That is a change.
DUNN: As clinical pathologists and anatomic pathologists, the VA’s computer network unshackled us from specific desks and specific offices. On any given day, regardless of where a pathologist is working within VISN 12, he/she has immediate access to patient data through the CPRS. A legible chart is presented in a tabbed format similar to our previous hand-written charts. It is organized in a Windows-based format, making it surprisingly easy to navigate.
TDR: Did the CPRS system change how clinicians used information, ordered lab tests, and received lab test results?
DUNN: VA physicians are mandated to write their own orders in CPRS and to enter their own typewritten notes. Among other things, a physician entering his/her orders directly into the CPRS decreases errors that might be introduced by having ward clerks enter orders. Another strong point of CPRS is that results from laboratory, radiology and other clinical areas are presented in a well-coordinated manner.
TDR: Do pathologists work within CPRS?
DUNN: Pathologists can enter notes into the chart as needed regarding blood utilization, coagulation consultation, or other issues. These notes are separate from actual lab reports generated in surgical pathology, autopsy pathology, cytopathology, etc.
TDR: As a laboratory director for multiple hospital sites, how has the paperless system influenced your practice patterns and daily routines?
DUNN: The first aspect is access to information. Each VA site has granted permission, as appropriate, for me to access data. That allows me to access CPRS and see relevant patient data, regardless of the VA site. In the past, if I needed to review the chart of a patient with a possible transfusion reaction, it might take several days to get that chart. I now have immediate access to patient charts from any hospital.
TDR: That’s certainly a benefit in providing faster support and answers to clinicians. How has imaging capability changed the practice patterns of your anatomic pathologists, who rely heavily on images?
DUNN: Big changes here when compared to the imaging capabilities of a traditional hospital. Our CPRS has a feature called Vista Imaging. This allows images of radiology films and pathology images to be stored in the patient record electronically. These images can be viewed from the provider’s desktop, no matter where he or she is located in the hospital. It is useful for viewing cases directly and for presentations at tumor board. Pathology images are often matched with radiology images in these situations. The imaging capability is also used within microbiology. There are regular instances when clinicians, discussing specific cases, refer to the stored digital images.
TDR: So this capability is supporting real-time consultations that use an electronic medical record to support the conversation between physician and pathologists. What else does it allow you to do differently in your pathology duties?
DUNN: Here’s a great example. The system known as “Lab Information Manager” allows a pathologist to access the laboratory’s “lab instrument manager” through a VPN connection from home. From outside the laboratory, we can now troubleshoot problems with instruments should they occur during off hours!
TDR: That’s impressive. Tell me about new capabilities in telepathology within your VISN.
DUNN: Telepathology allows the VA hospitals in Iron Mountain, Tomah and North Chicago to have almost immediate access to generalist and specialist pathologists located off station. Moreover, we no longer mark cells on slides with ink and send them via the mail. Instead, we now send digital images—with the precise cells marked—instantly. The clinical impact of this has been significant. Immediate access to specialty care is now available to every VA site on the network. It was impossible to deliver this type of rapid specialty care before the all-electronic system used in our hospitals today. I should also add that all telepathology images are on a shared server, accessible by all sites. It is no longer necessary to send images point-to-point.
TDR: What other capabilities does telepathology bring to your laboratory?
DUNN: Telepathology provides us the capability to offer intraoperative frozen sections without having a pathologist physically at that site. We accomplish this by using a pathology assistant (PA) at that location. This is how we provide this service at the VA hospital in Iron Mountain. Our telepathology system has also been used by microbiology to identify enteric parasites (based on motility in wet preps), Blastomyces in gram-stained sputum, and Aspergillus fumigatus fruiting bodies in a clinical specimen.
TDR: Are there other clinical areas where telepathology has changed long-standing practices?
DUNN: It’s being used to review and discuss problem cases in microbiology and hematology at Iron Mountain and in hematology at Tomah.
TDR: Weren’t you also one of the first pathology groups to use telepathology for autopsies?
DUNN: Yes. We started using telepathology in 1996 when the pathologist at Iron Mountain retired and the closest VA laboratory was in Milwaukee, 220 miles away. At that time, I was watching telemedicine support radiology, nuclear medicine, psych, and pulmonary medicine. I championed this tool for laboratory use. With the help of the PA at Iron Mountain, I use telepathology to do autopsy cases from Iron Mountain. Images are then digitized and the autopsy cases presented to clinicians at Iron Mountain.
TDR: Has this become a routine?
DUNN: Yes. Presentations usually occur on Fridays. I am generally at the VA Hines Hospital in Chicago, about 300 miles away from the actual conference. This is all done electronically with the superb help of our PA.
TDR: Has telepathology contributed to enhanced clinical services in areas outside the traditional spectrum of anatomic pathology cases?
DUNN: It now plays a major role in microbiology didactic and case presentations at the VA hospital in North Chicago. Several years ago, North Chicago’s microbiology services were consolidated into our Milwaukee laboratory. The Dean’s Committee at the North Chicago affiliate was quite concerned. It did not appear to them that we could provide training to their infectious disease (ID) fellows. We now use telepathology as the training medium. ID staff and trainees love it. Another benefit is that we can present cases from throughout our VISN. Recently we presented a case of “culture negative tuberculosis” at Iron Mountain which turned out to be Blastomycosis. Milwaukee’s ID staff now participate in the sessions. Telepathology has been the nidus which brought the ID sections at Milwaukee and North Chicago together to discuss cases among themselves. It’s boosted the learning experience for everyone, including me!
TDR: Are there other uses for the digital imaging capability?
DUNN: When necessary, we digitize serum protein electrophoresis gels performed at Hines [in Chicago] to be read by our hematopathologist located at West Side, where we no longer perform SPEPs.
TDR: You had earlier referenced that the VA’s choice of a PC-based information system changed how you personally perform your duties. I’m curious as to how other pathologists responded to the arrival of personal computers on their desks?
DUNN: The challenge was to encourage pathologists to become computer users and learn how it could help them practice medicine. This was one of our lab’s biggest challenges in the move away from paper and onto electronic data. Both pathologists and med techs did buy into this new mindset. We’ve seen gains in patient care and patient safety as a result.
TDR: Do you have examples of how new computer capabilities changed either laboratory operations or clinical testing services?
DUNN: In Milwaukee, a medical technologist took it upon himself to learn the Access database program. He then developed a sophisticated database into which all labs put their quality management (QM) data. All data can be viewed by all sites. Graphs of key measures are generated automatically. This database is password-protected so only those with the need-to-know have access. It’s allowed us to get real-time snapshots of how all laboratories in VISN 12 are performing.
TDR: Do you have an example?
DUNN: We track many things and Tuberculosis testing is among them. After we consolidated Tb laboratories to a single site (Milwaukee), it became important to track Tb smear turnaround time. Second shift staff at Milwaukee is trained to process the smears. These smears are ready to be read the next morning by our microbiology staff. From time of receipt in an off-site lab to the time when verified results are available in the computer requires about 24 hours. This exceeds the CAP standard, which requires results within 24 hours from receipt in the reference lab. Because of our integrated IT system and network, the consolidated micro labs (Hines and Milwaukee) and the Tb lab (Milwaukee) enter data directly into computers of the sending labs. No time is lost because results were sent to the referring lab and sat until that lab had time to enter them.
TDR: Any other interesting uses of your PC-based information system?
The challenge was to encourage pathologists
to become computer users and learn to like how it helped them practice medicine.
DUNN: We developed an Access database with electronic reports of problems to Quest Diagnostics Incorporated, our single reference lab. Electronic validation of the reporting process with Quest is in progress. Quest has provided a black belt QM trainer from its Six Sigma program to work with us on this project. Other Access databases are used for Blood bank and the VISN infection control committee (chaired by yours truly). Many of our labs also use a local occurrence reporting and safety database which was extracted from the VISN QM database.
TDR: These examples certainly illustrate how much impact a paperless environment has had on the laboratory and your pathologists. But I think this accomplishment is even more remarkable because this all happened even as the laboratories of VISN 12 cut unnecessary costs and became more productive. Please provide us some context for this accomplishment.
DUNN: Prior to consolidation, VISN 12’s laboratory costs per patient averaged $230. This was in 1996. By 2003, our laboratory had reduced this to $150 per patient. That’s a reduction of 35%. Consolidation involved the hospitals of 11 laboratories (seven based at hospitals and four based at outpatient clinics), standardizing equipment across all sites, and implementing uniform procedures. Reductions in laboratory staffing levels was accomplished through attrition.
TDR: What reduction of staff was accomplished?
DUNN: Overall, it shrunk by about 30%. However, during the past seven years, increased utilization raised the workload in the laboratory by 34%. Second and third shift volumes are up, which helped us gain economies of scale. Collectively, the combination of increased workload and reduced staff show that we’ve made impressive progress on boosting the performance of all the laboratories within VISN 12.
TDR: Earlier in this interview, you described your organization as a virtual lab run by a virtual team. Please explain.
DUNN: The structure of our laboratory today is the result of two unique developments. First, since the mid- 1990s, the VA has been at healthcare’s cutting edge with its success at moving so many clinical and administrative functions onto an integrated information system, accessible through either our internal network or the World Wide Web. Second, as this was occurring, the laboratories of VISN 12 were undergoing an extensive consolidation and integration process. As we changed long-standing procedures and work practices in our laboratory, we had the unique opportunity to move them away from paper and onto a computer.
TDR: Do you attribute your virtual lab to this unusual confluence of opportunities?
DUNN: In many respects, yes. How many hospitals in the United States are paperless? How many health systems can allow a physician to access, via intranet or Internet, a patient’s full, electronic medical record? To my knowledge, the VA is unique in giving our laboratory the ability to configure our operations and our services around this capability.
TDR: What about the aspect of a virtual laboratory team?
DUNN: The VA’s information network allows our pathologists, administrators, and laboratory staff to make contributions from any site within the system. On the IT side, VISN 12 laboratories rely a great deal on the efforts of Debbie Sieloff, MT(ASCP), chairperson of our Laboratory Information Management technical committee. Laboratory operations are guided by Tom O’Donohue, DLM, ASCP, Administrative Director of Pathology and Laboratory Medicine Service (P&LMS) for Southern Tier, and John Heffner, MT(ASCP) Administrative Director of P&LMS for Northern Tier.
TDR: Bruce, this is certainly a fascinating look into how a paperless health system allows pathologists to reshape their daily work patterns. Thank you.
DUNN: You’re welcome! In closing, I would like to recommend that pathologists closely track how enhanced information technologies can improve their ability to provide enriched services to clinicians. That’s certainly been our experience within VISN 12 here at the Veterans’ Administration.