POC connectivity takes hold





cap today

June 2005
Feature Story

Anne Paxton

Point-of-care testing connectivity presents POC coordinators with a dilemma: Should they let other hospitals be the early adopters while the bugs are ironed out? Or should they rush to take advantage of the streamlined, comprehensive data capture that connectivity has to offer?

Both choices have their pluses and minuses, but point-of-care testing coordinators who have taken the leap into POC connectivity say once they got past the learning curve blues, the payoff was worth it.

With the array of POC vendors and diverse analytical profiles, POC data can’t be handled by the laboratory information system or HIS without a local data-management system that connects them on a single platform.

Helped by the industrywide POC connectivity standard approved in 2001, POC data-management systems are gaining a foothold in the nation’s hospitals, but obstacles remain before point-of-care results glide swiftly, seamlessly, and accurately into hospital records.

Making sneakernet obsolete has been one of the rewards of the glucose connectivity system at McLendon Clinical Laboratories, University of North Carolina Health Care, Chapel Hill.

The DataLink Data Management System manufactured by LifeScan allows for bidirectional remote transfer of information between SureStep Pro blood glucose bedside units, which test 26,000 patient glucose samples a month, to a central PC workstation. The UNC system has more than 600 beds at four hospitals and outlying clinics, all within a five-mile radius.

POC coordinator Beverly Robertson, MT (ASCP), MPh, says the system frees up the many hours of time she used to spend downloading manually. “When sneakernet was in place, that was your ball and chain. To get any type of patient information or lot number updates we had to physically go to the glucose meter with a laptop and transfer information.”

“That could take up to 10 minutes for each meter and we have 120 meters, so obviously there was no real-time patient data collection. Now we have the glucose meters uploading every day.”

At the start some nurses resisted, she says. “It required them to take the meter to the docking station and transfer data, but once they realized it takes less than a minute, they accepted that it was worth the reward.”

Next on McLendon Clinical Laboratories’ connectivity agenda are the hospital system’s 30 urine dipstick readers, also now checked out each month manually. “We’ve been using semiautomated Roche Chemstrip 101s for about two and a half years. We are evaluating another vendor’s urine dipstick reader that will give us the capability to interface with Telcor, out of Nebraska. The information would go into our data manager and would interface from Telcor to SCC, our LIS, then into WebCIS so physicians can review results,” Robertson says.

All of this is occurring as the hospital ramps up computerized physician order entry, or CPOE, through WebCIS and moves toward electronic charting that includes pharmacy and radiology as well as the laboratory.

“Obviously all the databases have to be very, very similar so orders can cross,” Robertson says. “But we have many different vendors, and the IT department has to handle all the interfaces between hardware, software, and wireless communications.”

The point-of-care program just went wireless with IL Gem blood gas analyzers located on several nursing units. “The respiratory therapists can perform blood gases at the bedside and the results are transmitted real-time via the wireless system to the central PC workstation.”

“So far not very many POCT vendors support wireless technology,” she says, but she thinks the hospital will continue moving toward wireless POC testing as it becomes available. “UNC Health Care implements new technology as it becomes available, within the resource availability constraints of a large academic institution. A small community hospital may be able to make changes more rapidly.”

Bar coding is also being looked at for 2005–2006. “We want an established system from a reputable vendor that provides growth potential and advanced capabilities that can be used collaboratively throughout the health care system. When a hospital this size makes that type of investment, the training alone requires a substantial amount of resources.” But with bar coding, data input errors will drop and patient safety and satisfaction will rise, “so the reward is worth the effort,” she says.

Making the transition to a connectivity solution drives home the lesson that IT people are your best friend or your worst enemy, Robertson says. “I don’t think any POCT coordinator implementing connectivity can be successful without an IT department that’s willing to work with them.” UNC’s IT people have been “tremendous,” she says.

Before 2002, it was the same story at the Medical Center of Aurora, Aurora, Colo. A staff person had to go to every glucose meter once a month and download each one. It was expensive to do with 55 glucose meters at one site and two other hospitals in the system.

That changed after Abbott Laboratories’ Precision Web was installed. It’s now used to connect, manage, and interface multiple POC systems at the medical center, says point-of care coordinator Victoria Savarese, MT (AMT-HEW).

Precision Web tracks the glucose tests as well as i-Stat blood gases, Criterion urinalysis, and HemoCue for hemoglobin. “Those four instruments are connected, with the possibility of Hepcon in the future,” Savarese says.

Tracking the numbers has made billing easier, in part because the manual system deprived the POC coordinator of basic information, she notes. “We had no idea how many people we were testing. Now we know the nurses are doing 10,000 glucoses a month, and we have radiology doing i-Stat protimes and ACTs, and respiratory therapy doing blood gases.”

“They’ve always had POCT, but never to the intensity they do now,” Savarese adds. “Now the nursing staff is doing more and more glucose testing and they have computer access to the system, which they absolutely love,” she says.

“When we went to download once a month, basically we just made sure the meter was working properly. The operators were supposed to keep logsheets, but it was hardly ever done. They’d document results in patient charts, but it was mostly handwritten. All of this comes across electronically now.”

The POC coordinator also has daily updates on whether QC is being performed. With the lockout feature, operators can’t run the meter if they haven’t done QC, and that’s improved things “tremendously,” she reports. “I give them their compliance monthly by operator number, so they can figure out who is making errors and whether it’s one particular operator.”

“In this system they have operator certification lists,” she says, “and you can actually get them automatically certified every three months or six months, whichever you choose. You set up a popup 10 days before they’re going to expire, with an e-mail saying they haven’t done a control in six months”—as a warning before they are locked out.

At Duke University Hospital/Health System Clinical Laboratories, too, Precision Web has “changed how we do business,” says Susan Utley, MT (AMT), POC program supervisor, who says they have 154 meters and more than 3,000 operators and monitor nearly 40,000 tests each month. Precision Web was installed in September 2003 and she is enthusiastic about the 100 percent Web-based technology, which makes it possible for her to monitor the system after hours and weekends from home using a VPN account.

“We are able to sign in from anywhere within our intranet and perform any function we want—troubleshoot, assign operators or meters, change meter functions, e-mail reports, and do anything else needed.”

David Colard, MT(ASCP), point-of-care coordinator for Saint Luke’s Hospital, Kansas City, Mo., the largest hospital in St. Luke’s Health System, uses International Technidyne’s IDMS data-management system and Medical Automation Systems’ Rals-Plus.

“The proprietary DMS systems like ITC’s provide a little more affordable data management than you get from adding multiple devices to some of the bigger companies’ systems,” he says.

St. Luke’s has had ITC equipment since 1996, and though it is still using Hemochron 401s and 801s for ACTs, this year they’re upgrading to ITC’s Response. By the end of the year the laboratory will have five Hemochron Response coagulation systems and the catheterization laboratory will have another five—all integrated into IDMS.

The goal is to get to a plug-and-play state where the hospital can purchase one data-management system interface, then be able to add any smart POC device without having to duplicate equipment.

“The main reason we haven’t combined everything is basically cost,” Colard says. With QML and Rals-Plus, he adds, if you want to add a device you have to pay for the additional module that will handle it.

“It’s not per-instrument, but if we wanted to add a Hemochron Response to one of those systems, we’d have to pay MAS for the module, they’d do the software, and there would be an annual software licensing fee. You’d also have to pay for download locations.”

The cost factor means that, to keep the testing affordable, nursing units doing ACT testing will come to the laboratory, check out the device, take it to their unit, and then return it for download.

“Ideally, you’d have a download location at each nursing station and the device would just stay there. In fact, with the IRMA Trupoint portable blood analyzer, they’ve changed the software so they can leave it plugged into the network if they’re not taking it around to the bedside.”

“As results are available, IRMA automatically sends them to the data-management system so they can be put into the LIS, and from there be sent to the electronic medical record,” Colard says

For manual POC results including urine dipsticks, Hemoccults, and Gastroccults, “what we’re thinking is that the manual tests would be typed into the EMR.” But the hospital may end up using the Inform meters from Roche Diagnostics which, when used with a Rals-Plus module, allow for entry of manual tests.

St. Luke’s POC testing program is less integrated than the programs of some other hospitals. “There are certainly hospitals that are way ahead of us and have many more devices connected than we do. Basically that’s because we try to limit POC testing and provide quick turnaround for tests in the laboratory,” Colard says, noting that all the critical areas have tube systems linked to the laboratory.

But St. Luke’s has overcome one hurdle many other hospitals face: “A major holdup is having a good mechanism to enter patient ID, like a bar code. The folks I’ve talked to that weren’t interfaced, one of the things they’re waiting on is a really reliable and accurate way to enter patient ID into the device.”

In December 2002, when the hospital implemented a bar-coded patient armband, POC glucose meters were the first devices to make use of it. “We’ve since added a device, basically a PDA used by our LIS vendor, Cerner, to document specimen collection, so each of the collection labels has the patient’s bar code printed on it.”

However, bar codes have drawbacks. “With the scanners that are on most of the POC devices, it’s a pretty common across-the-board problem that if the bar code is not perfect, it won’t scan. So if the label has been subjected to wear, or maybe the toner was low, you run into problems with it not scanning very well, and in the worst case it scans in an invalid number.”

Ultimately, he hopes, the hospital will dodge these problems by switching to radio-frequency identification, or RFID.

Even more mundanely, the spaghetti of cords for meters, dataports, and network ports at a docking station can make a mess, Colard says. “It’s very easy to unplug something with that bunch of wires.” At St. Luke’s, in 99 percent of the cases where there is a dataport problem, the cause is the power supply being unplugged from the dataport.

Colard says one of the frustrating things with connected POC devices is the results are not always in real time, and some aren’t immediately available in the electronic medical record.

“One of the goals of the data-management system is to provide some filtering. So if a glucose is repeated, for instance, the system holds the results for human review, or some facilities may choose to hold critical results. With IDMS I use exception management, so results are imported into IDMS; then the system decides whether, according to criteria I’ve put in, they should be held for review.”

By 2007, he hopes, the hospital will not only have entirely electronic medical records but also POC devices that connect wirelessly to the data-management system. “I think most of the major vendors are heading in that direction. One of the big questions is what format it will be—Bluetooth or 8021B or a new higher-speed version—and I think there’s a lot of discussion with the vendors about how to have the flexibility built in.

The same applies with bar-code scanning versus RFID.”

High volume has been the main challenge of POC testing at Florida Hospital Clinical Laboratory, Orlando, part of a 1,048-bed, seven-hospital system. It has used Rals-Plus as data manager for the last three of the eight years since POC testing was started. “We started out with Roche’s Accu-Chek GTS meters, and to capture data from those we had to have someone take a laptop around to all 200 of them. It took about two or three days on all seven campuses,” says Herald Waldon, MT (ASCP), POC testing coordinator

“We did not have Abbott’s i-Stat analyzers then. In fact, the laboratory wasn’t even managing blood gases”; they were done by the respiratory care department. But once Florida Hospital started using i-Stats, “any test we could move to i-Stat we would move because the connectivity was there.”

About four years ago the hospital system switched to Accu-Chek Inform meters, and it implemented patient bar codes on the same day. “It’s been fantastic,” Waldon says. “The errors we’ve encountered have been drastically reduced because of bar codes.”

Roche was ahead of the curve on connectivity with a system called Data Care, he says. “We had it here, but it was not robust enough to handle the volume we had.”

It took Rals-Plus to deal with those numbers: last year 900,000 glucose tests alone and about 700,000 tests on the i-Stats.

“We’ve been well satisfied with Rals-Plus,” he says, but it has been a slow process to get the nurses used to having the laboratory work and glucose results all in the same part of the patients’ electronic charts. “They were still telling physicians the results written on the patients’ flow sheet, another part of the chart, but they’re slowly moving away from that.”

Now the hospital information system is moving to Cerner Millennium, which will make the migration flow sheet a thing of the past and will work nicely with Rals-Plus, Waldon says.

“Right now we’re interfaced to Misys in the laboratory. Once results are downloaded on the floor, the Rals system sends the record to Misys, asks it to generate a glucose order for the patient, then Misys takes the test result and sends it to Siemens where it’s integrated into the patient chart.”

He says the POCT1A connectivity standard has worked well with Rals: “It’s a very open system, and it’s just a matter of getting the vendors to work with Rals.” The majority of testing is done on the i-Stat, but he is having preliminary discussions with other vendors about connectivity with Rals.

The laboratory plans to stick with Misys a few more years. “We didn’t want to disrupt the laboratory system while trying to work through all the Cerner issues, but after that we’ll look at migrating the laboratories to Cerner.”

At the moment none of the instruments are wireless, he says, but the entire hospital is set up with wireless technology. “I am working with several POC vendors who are looking at developing this, and Roche is leading in that also.”

“All the vendors know that’s the way most hospitals are going in the future.”
Boston Medical Center, which also uses Rals-Plus, reports another unexpected source of problems. “For us it’s a chronic problem that people have free Internet access, so they download things that interfere with programs on the PCs,” says Kim Gregory, MT (ASCP), NCA, CLS, POC specialist with the Department of Laboratory Medicine.

Medical articles, theater tickets, or even pornography can be the culprits. At another Boston hospital, downloads took down the entire network for four days, Gregory recalls. “IT put the machines out without guidance, and humans being humans, people went on Napster all the time, or downloaded spyware or funny programs like Spinner or Gator. These programs can make a mess of your computer.”

To address the problem, her IT department is working on a lockdown where the PCs become clinical workstations so people can view Internet sites but can’t download.

Other snags have arisen when meters refuse to download. “We’ve started implementing tight glycemic controls, and the staff is used to seeing them in the computer system. So they start calling when the meter doesn’t download. They think something’s wrong with the meter, but they don’t realize it could be a problem with the docking station, the cord, the PC it’s attached to, the network, or the server. But usually the problem is right there where the meter is docked,” Gregory says.

Another potential source of incompatibility is Internet protocols versus those of the hospital intranet. “The IT department here decided to go through and change all the IP addresses in the hospital because we were affiliated with Boston University Medical School and now we’re going to split off our IP addresses. But when you change the IP address of a dataport it stops working, and someone has to go in and change it.”

“Often when individuals first get connectivity and it doesn’t perform to their expectations, they are quick to blame the data-management vendor. The reality is that if the specifications of the instrument aren’t built by the instrument vendor, then the data-management company can’t give the operator full functionality as expected,” Gregory says. Some instruments, for example, don’t attach a lot number to each test, but the data-management system may be expecting one.

Not every test result can get to the LIS, either. “We have a HemoCue connected electronically but at this time it just goes to Rals and stops.” The reason: One of the clinics in their system has its own unique medical record numbers which could conflict with those of the hospitals.

“Until we solve that problem, we can’t put the HemoCue into our LIS because it might merge the results into the wrong patient’s record,” Gregory says.

Loyola University Medical Center, Maywood, Ill., was able to buy into a connectivity solution because of lucky timing, says Geri Augustine, BS, MT (ASCP), technical specialist for near-patient testing. Her hospital, a large university facility with more than 500 beds and several satellite sites, was ready to replace all of its glucose meters in 2002.

“We had meters that were uploaded manually with a laptop computer, had to be plugged in, and gave data always after the fact. We were uploading three or four weeks after results were reported, with no patient identification. It was old equipment and it was a good time to do the whole shebang.”

Roche Inform meters with Rals-Plus offered the best connectivity at the time, she says, so Loyola went with 123 new glucose meters and Rals-Plus. “It was a good pairing between them, they already had sites up, and hospitals were happy” with performance. “The POC coordinator could monitor usage and QC for all meters from the Rals system.”

The laboratory began its plan to implement the Rals system about six months before implementation in January 2003. “Implementing the Inform glucometers and Rals connectivity required the involvement of our IT staff, and in a large hospital like this it’s hard to get someone from IT to be dedicated to a project.”

“We had some bumps in the road,” she says—patient identification being the main one. Interestingly, Loyola’s admitting director had already foreseen that bar codes would be an asset, and the new armbands had bar codes, but they weren’t being used.

“The armbands did not have a plastic coating and were getting damaged, so in the first couple of months they worked fine but then they decided they needed a plastic coating, which was good. But they didn’t realize when using the bar-code scanner that the plastic would reflect light. Suddenly the operators were locked out and there were screaming phone calls that the bar-code scanner couldn’t scan our wristbands.”

Once the hospital switched from the large code 39 format bar code, which curves around the wrist, to a smaller bar-code symbology, the international standard of code 128, the problem disappeared, but for the last two years, the POC department has been the only one in the hospital that uses the wristbands.

Loyola now has about 2,400 operators and nearly 80 docking stations, at least one on every nursing unit, Augustine says. After getting past the bar-code snafu, “the system worked very well for us and the nurses love it.” It helped that the Joint Commission was at the same time coming out with patient identification goals, and bar coding was on that list, she says.

The number of errors has dropped noticeably, except at the satellites that don’t have the armbands. “We do about 25,000 glucoses a month and probably our outpatient area accounts for a couple hundred.” In neonatal ICU and the emergency room, she says, the lockout option has to be disabled because newborns and trauma victims often don’t yet have patient records linked to them.

In some ways Loyola’s POC testing program is ahead of the pack, she says. “Many hospitals have Rals and glucometers but don’t have scannable wristbands, so operators type in numbers manually. In addition, our system requires an operator to scan the bar code on their security badge to gain access—this gives us an audit trail.”

Loyola plans to move all five i-Stats and its coagulation equipment, which they are trying to standardize to the ITC Hemochron Signature, to the Rals-Plus system as well.

“The QC is fabulous,” Augustine raves. Operators are locked out if QC is not performed every 24 hours, and the system has an automatic competency recertification requirement for each operator.

That took some adjustment. “The first six months to a year were horrible that way because people kept getting locked out, but once they understand the competency rules, that it’s part of their evaluation and they must do quality control on the meter,” the problems tended to disappear.

Another thing that has improved greatly is monitoring of patient glucose results, Augustine says. “Our new paperless HIS called EpicCare allows for glucose results to be posted to the EMR and provides a graphing function that physicians can use to graph glucose changes over time. As a result, patients on tight glycemic control, mostly ICU patients, have better outcomes because their glucoses are kept within a certain tight range, they have fewer infections, and they’re out of the hospital faster.”

What does connectivity cost? In Loyola’s case, “we actually lucked out,” Augustine says. “We were looking at new glucose meters and the OneTouch glucometer strips were dropped off our contract with Novation. This increased the cost of the strips and made the cost of buying the new meters and Rals system more favorable.”

“So in the long run, we have had a clinical improvement from the physician standpoint, more user-friendly meters, and it’s proven to be cheaper.”

Loyola, too, is on its way to becoming wireless, Augustine reports, noting that remodeled floors and a new outpatient facility have gone wireless, and the other half of the hospital is slated to do the same. “We’ve been asking the vendor when the Inform meters are going wireless, and they say they are looking at it.”

Yes, POC coordinators have had to sort through some sticky issues, but no one looks back. Some even have their eyes on what’s ahead. “The next couple of years should be pretty exciting,” says Colard. “As we progress into EMRs and new ways to connect POCT devices and get information to nurses and physicians, the potential is really almost limitless. It’s almost like science fiction.

Anne Paxton is a writer in Seattle