Connective issue: Linking POC
  with wireless hospitals


cap today

November 2005
Feature Story

Anne Paxton

Most point-of-care testing managers are thrilled with the new devices and software available to streamline their operations. But with connectivity becoming standard operating procedure, POC testing programs are facing a new challenge: making sure that connectivity meshes with hospitalwide initiatives to adopt new treatment paradigms, eliminate patient ID errors, and eventually say goodbye to cables and wires, as well as to paper.

Whether their programs are in a state of steady expansion or extreme makeover, POC testing managers say the possible efficiencies now in view or just around the corner are tantalizing. How are they turning the visionary schemes into smooth-functioning routines?

At Lewis-Gale Medical Center, Salem, Va., connectivity is fairly well established. “We have three different connectivity solutions,” says point of care coordinator John La Rosa, MA, CLS (NCA). “Biosite Census connectivity for cardiac markers has been in place since 2001, we’ve had the Roche Diagnostics glucose meters on Rals-Plus since 2002, and Abbott Central Data Station for the i-Stats just started this summer.”

The laboratory and hospital information systems are from Medi tech. The software updates are included in the hospital’s three- to five-year contracts with the vendors, and may be carried out remotely if the vendors have access to the hospital’s network.

“The big plus of connectivity is it allows us to capture billing that wasn’t captured before, and make sure we are billing to the correct account or patient. We are billing and getting reimbursed wherever we can,” La Rosa says.

Tight glycemic control is the hot topic of 2005 in his region, he says, because the evidence shows that keeping patient blood sugar under a certain benchmark prevents some infections, raises postoperative wound healing rates, and reduces length of stay.

“This year we kicked up tight glycemic control where we monitor blood sugars every hour on patients on insulin drip. Right now we just have TGC in critical areas, but when we move it out to the whole hospital, we expect glucose testing to go up quite a bit.”

Mandatory bar-code scanning, which his program began for glucose testing in early 2004, has made a definite difference in patient identification. “For all our glucose meters you have to scan the patient wristbands; you cannot key in a number. Back when nursing had the POC glucose program, there was no lockout and you’d get lots of patient IDs of 123456 or zeroes.” Once mandatory scanning was in place, patient ID errors dropped from 100 a day down to zero, La Rosa says.

Lewis-Gale Medical Center just started computerized physician order entry as well, allowing physicians to order laboratory testing either from laptops, portable devices, or tablets, and the initial reviews are favorable, he reports.

“They can order anything, but there’s no integration with POC testing yet. We still have paper charts. A lot of our POC testing is auto-ordered when the test is performed. No staff member has to key in the test in order entry, but the physician needs to complete a written order on the chart eventually. A complete electronic medical record is not a reality yet—I think it’s still years away, at least at our facility.”

Echoing many other POC testing managers, La Rosa says his biggest headaches are linked to the POC testing device docking stations. “They work very well if the instrument is placed in the docking station when testing is done. But a lot of our docking stations hook to a PC to use the hospital network, and people don’t realize if the PC is shut off or on standby, the docking station no longer works. That’s probably my second biggest fix, other than people not docking meters when the testing is done.”

Would a wireless system help? Part of the hospital information system is already wireless and includes EMAR, an electronic medication administration record, as part of a hospitalwide patient safety initiative. But wireless is not yet in place for POC testing, La Rosa says.

“What will drive wireless for point of care is the vendors, and I know there are already products on the drawing board that will do away with docking stations. Next year some of the vendors will offer these as replacements for current hard-wired devices.”

Silicon Valley-based El Camino Hospital, one of the most high-tech institutions in the country, took its time before jumping on the connectivity bandwagon. Located in Mountain View, Calif., El Camino is a community hospital with a conservative POC testing program, says Robyn Medeiros, BS, MT (ASCP), QA/ POCT education manager. Though it does about 140,000 to 150,000 POC tests a year, the hospital looks at avenues outside POC testing to improve turnaround time.

“I’ve sat on several task forces over the past four years looking at laboratory TAT in certain critical care areas, and what ends up happening is POC testing is always one solution, but drawing and transport options are also on the table.”

For instance, a few months ago the hospital installed a new pneumatic tube system as part of its remodeling, and “it’s great,” Medeiros says. “You put in the specimen and it goes where it’s supposed to go. It’s a smart system and people trust it. Before, if it was a really sensitive or critical specimen, you wouldn’t trust the tube system.”

The physicians do want more POC testing in the ER, she says. “But the nurses there know how much work it is, so they’ve been willing to work on other ways to get the specimens back to the laboratory faster. For example, they would help draw when it’s difficult for the phlebotomy team to meet the demands of the hospital.”

“I learned about vendor-neutral connectivity in 1998 when Medical Automation Systems came in to speak at our POC group. I remember looking around and wondering how many people got what this company just told us. I was blown away,” she says.

Since connectivity was brought in a year ago, now she is looking at big increases in POC testing. “It’s been pretty stable until this year, but now it’s growing by leaps and bounds. We’ve expanded POC testing in the OR, we’re opening up a Coumadin clinic, and I have four to five POC projects waiting in the queue,” Medeiros says.

Expanded testing options at the point of care change ordering patterns, she says. “Once we bring in POC, the volume of testing usually increases. Our cardiac surgeon explained that he considered the increased testing to be standard of care for open-heart surgery.” Having access to diagnostic tests in real time instead of sending off to the lab and waiting 30 minutes, she says, means results that allow the cardiac team to manage patient status more effectively. “Overseeing POC test use for compliance will be an ongoing challenge for POC,” she adds.

Though Medeiros was one of the early adopters who wanted connectivity, she says, she feels like she “was last out on race day.

“Now, because our hospital has taken huge efforts to become a leader in technology, it’s just a perfect fit. We have a brand-new hospital computer system going live in early 2006, we are totally wireless, have electronic charting, have a hands-free voice recognition system for everyone, and many more innovative technologies.”

The POC testing program has Rals-Plus connectivity for its Roche glucose meters, the i-Stat and Bayer instruments are in progress, and Cou ma din clinic connectivity will be next. But she’s finding that coordinating the connectivity effort is a challenge. “To be successful, you need to work with multiple departments: finance, IT, accounting, nursing, education, facilities. Everybody’s piece is critical, and you have to have a good relationship to make sure implementation goes smoothly.”

When all the modules are up and running, she says, the data from the devices will travel from where they’re being downloaded on the nursing unit, to the laboratory information system, and then to the patient’s electronic record in the HIS. “It will capture the entire audit trail.”

Helped by an alliance with a local computer company, El Camino in the 1960s actually became the first hospital in the U.S. to adopt computerized physician order entry, and has been using the same system ever since.

While the only POC testing results going into the HIS are from the operating room and dialysis units—and that’s via a manual process—the new ES7000 computer system from Unisys Corp. will connect POC testing as well. “We’re just sitting here waiting for that gate to be opened so we can move forward,” Medeiros says.

El Camino Hospital has been named one of the nation’s “most wired” health care institutions two years in a row, but if Medeiros had to name one wish for POC testing devices, it would be: Get wireless. “One of the biggest drawbacks is the tremendous amount of wires and cables at the docking stations. I’d like all the meters to be wireless. The hospital has a totally wireless intercom system and tablet PCs, so it’s just a matter of having a meter that can send wireless data instead of having to sit at a docking station.”

Even though Mercy Health System in Philadelphia closed one of its hospitals four years ago and now operates only three, its POC testing volume keeps rising. “We’ve still seen continued increase in volume in spite of the decrease in bed size and elimination of some services,” says Bette Seamonds, PhD, DABCC, director of point-of-care services for Mercy Health Laboratories. “Some of this comes from the recognition of improved outcomes using tighter glycemic control, but our urinalysis volume has also increased.”

Mercy’s ACT and glucose tests are on Rals-Plus. “We’re experiencing an increase in the number of cardiac catheterizations and there is some correlation with the increased utilization of service,” Dr. Seamonds says. “However, because of the techniques used for cardiac catheterizations, now they tend to do less testing than before, so ACT volume has been static. On the other hand, interventional radiology services at one site are expanding, and we are getting ready to add to ACT testing there.”

In 2006 Mercy will take another giant leap with connectivity, Dr. Seamonds says. “All our instruments right now are hard-wired, but we will introduce wireless connectivity for the Gem Premier blood gas analyzer in the cardiovascular OR.”

The financial commitment for the wireless connectivity is significant, and the hospital had to be convinced the purchase would pay off, she says. “It is well worth the cost, in my opinion, because it will make billing automatic, and all results will be in the electronic medical record.”

“One thing we have learned is that many physicians expect POC results to be part of the electronic medical record. We have ACTs and glucoses online, but urinalysis, OR blood gases, and urine pregnancies are not. And I’ve had one oncologist saying, ‘I don’t see the ER urine results. Why aren’t they there?’”

Connectivity continues to drive decisions among different instruments, she says. “We’ve been with MAS from the get-go, and it would be very expensive to change. That’s a for-life kind of commitment.”

“One of our primary questions to vendors is, do you have connectivity to Rals-Plus? Sometimes the answer is no, as with Avox, but they’re the only game in town for oximetry. Bayer also has connectivity in the works for its urine analyzer, so that will come. But we really look at vendors very carefully, and even if they are not able to set up connectivity immediately, our goal is to have it down the line.”

Mercy Health has used bar-coded wristbands for more than six years, and within the last year upgraded the entire hospital system from an old Addressograph to a new wristband product that provides sheets of 32 stick-on labels that go into the patient chart for patient ID for forms and specimens. But that improvement uncovered a glitch in the POC testing system, Dr. Seamonds says.

“We were not really aware of it until we started seeing some transfers within our hospital system—for example, patients coming to the larger institution for a cardiac catheterization or returning to the mid-size institution after the procedure. Because the wristbands appear identical except for the medical record numbers, occasionally the old wristband is not removed and replaced and Rals can’t transfer the results across hospitals.”

“That’s a new fly in the ointment, because many of these patients are diabetic and those data can’t transfer to the electronic medical record. Rals sees that patient as being from another institution. We were completely unaware of this until now and we’ve been doing cardiac catheterization for a long time.” But, she adds, the system has cleaned up so many other issues that this correction is, in a sense, “fine-tuning,” and they are now addressing changes to ensure patient transfers are handled correctly.

Patient ID errors persist, and some may fly under the radar, Dr. Seamonds says. “Maybe the clinical services staff draws blood and they mislabel it. It does occur. The way we usually track it down is if we get wildly discrepant results we go back and do blood typing. Even with these bar-coded wristbands and adhesive labels, it still happens.”

Obvious errors are caught early, but some may not get “negatived” for two or three days, and “if you have two or three sets of results that are all normal, and nothing gets flagged, you may or may not know. And unless a red flag is raised, you wouldn’t know.”

Billing for point-of-care testing, once a rarity in hospitals, has also become routine. “We made the commitment several years ago and have not run into any difficulties,” Dr. Seamonds says. “For the most part, we don’t get reimbursed because it’s inpatient care, but we have not been challenged on our billing practices, and our philosophy is wherever we’re in a position to collect for services, we’re very happy to do so.”

Anne Paxton is a writer in Seattle. This is the first in a two-part series on POC testing programs. Part two will be published in the December issue.