The Connected Physician
A Special Supplement

Labs online: Everybody wins

As more and more laboratories put test results online, your patients' reports could be as close as your Web browser.

By Helen Lippman

No wonder the patient was leery when the doctor's office called to report the findings on her blood test. The lab had drawn her blood just two hours earlier. "You ordered the wrong test," she insisted. "The thyroid test always takes at least a week."

But not this time. Hayward K. Zwerling, the Lowell, MA, endocrinologist who had ordered the test, explains: "I saw her at 9, she went next door [to Lowell General Hospital] to have blood drawn for a TSH test at 10, and the hospital ran its TSHs at 11." By lunchtime, Zwerling found the results in his electronic medical record and asked his nurse to call the patient.

Welcome to the rapidly developing—but still limited—world of lab connectivity.

"About 50 percent of physicians still get lab results delivered by hand or by fax," says Nancy Ham, chief operations officer of ProxyMed, a connectivity company based in Ft. Lauderdale, FL. "Another 30 percent receive them through teleprinters" with dial-up connections, which many labs supply to high-volume sites. Excluding teleprinters, no more than 20 percent of lab results are delivered electronically, either over the Internet or through proprietary computer networks. Yet it's high on doctors' wish lists, asserts Jane Metzger, a vice president at First Consulting Group's Emerging Practices Group in Boston.

Web-based delivery of lab results promises more than speed, Metzger says. "Getting labs electronically helps ensure that results aren't overlooked. It also eliminates the need to use the phone to get critical results, and reduces the number of pieces of paper flying around the office. But with physician practices sending labs in multiple directions and labs, hospitals, and vendors establishing connections in fragmented ways, putting the pieces together is a messy, complicated job."

For years, companies like Laboratory Corporation of America (LabCorp) and Quest Diagnostics—the two big national lab chains—and large regional labs have been placing dedicated personal computers in some physician offices, allowing them to access lab results by modem over electronic data interchange networks. In some cases, groups are even able to dial up lab results through their practice management systems. But these options, like the teleprinters, tend to be reserved for groups that generate a lot of business.

"The solo practitioners and small groups have been left behind," Nancy Ham says. "Before the Internet, it wasn't cost effective to deliver new technology to them." Now, theoretically at least, lab results are as close as your browser.

Some online results are available to all physicians

Quest Diagnostics' test reporting site, Results Online, has been on the Web since last year (www.questdiagnostics.com). "The great thing about Results Online is that it's universally available," says company spokeswoman Julie Clarkson. "You have to register and request that your results be posted there, but virtually any physician is eligible, regardless of volume or practice size."

Web-based reporting has another big advantage: Results can be accessed from home, satellite office, hospital, or anywhere else there's a computer with an Internet connection. Zwerling tells of getting a weekend call when a patient of his was brought into the emergency room of a hospital that had no record of the patient. "Without leaving my house, I was able to look up and convey the patient's latest lab results in real time," he says.

It's not surprising, then, that the new wave of lab connections, most established in the past year or two, are largely Internet-based. Free-standing labs and health care systems are increasingly paying connectivity firms like ProxyMed and San Francisco-based McKesson for transmitting lab orders and results, so the service is usually free to physicians.

The catch is that the labs retain the right to determine whom to give access to. That gives rise to the same issues of volume and size. But Ham and others in the connectivity business urge physicians who haven't been offered the opportunity to retrieve results online to push their labs to provide it. "ProxyMed charges labs a per-transaction fee," she notes, "so it shouldn't matter whether you order seven tests or 700."

Online access to labs depends on several factors

The sophistication and cooperativeness of the labs and hospitals you use are key determinants of your ability to get lab results online. Another factor is location. While some connectivity companies and application service providers (ASPs) market Internet-based lab reporting directly to physicians, many have online connections with only a few local labs. How many they have depends partly on how advanced the labs are in that region. For now, the West Coast is the winner in the rush to the Web.

Take Santa Cruz, CA, population 240,000. The bulk of the medical community—including 77 physician practices that belong to one IPA, two hospitals, labs, radiology centers, and transcription services—is linked via Elysium, an Internet-based clinical messaging system that stores and delivers test results, transcription, and hospital data. Supplied by Axolotl, a firm based in Mountain View, CA, the Santa Cruz system securely delivers clinical data on some 200,000 patients. Health care systems and physician groups in Cincinnati, Seattle, Florida, Mississippi, and Maryland are also using Elysium.

Robert B. Keet, a Santa Cruz internist who practices in a 28-member group, doubles as Axolotl's medical director. He describes Elysium as "a very sophisticated clinical e-mail system that includes all the data management functions normally associated with an electronic medical record."

Physicians in Keet's group go to their clinical "in-box" to access electronic messages containing the latest lab results and transcribed notes for their patients. They also use the clinical messaging system to automate their workflow. They can, for instance, forward a report to a staffer with instructions on what to do with it, send results to another doctor for review, or download the data needed to chart a diabetic patient's glucose values over time.

Elysium comes at no charge to the physicians, unless a practice adds optional services like electronic prescription writing and refills. And it generally arrives with little effort on the part of the doctors. "They came in and asked, 'Would you like to go online and be connected to the hospital?'" recalls Carl Haller, an internist in a Sacramento, CA, suburb. That was in 1999.

Today Haller, an admitted technophobe, accesses Elysium via a high-speed Internet connection. A courier still delivers hard-copy outpatient test results from the lab around the corner. But Haller's delighted to get electronic lab reports on hospitalized patients. "Having real-time results is very valuable," he says. "It means you don't have to go to the nurse or call the lab. You know exactly what's been done that day."

It also means Haller uses Elysium as a partial EMR of sorts. He no longer maintains paper files with the admission H&P, inpatient test results, discharge summaries, and ER reports. "That all goes into the electronic archive," he says, with a hint of worry in his voice. "I just hope they don't dump the records." But even if the data were lost, the hard copies remain in the hospital. And, while Elysium also holds his own inpatient H&P and progress notes, he downloads those reports, prints them out, and stores them in his paper charts.

Across the country, Boston-based CareGroup Health System has connected its six hospitals and 3,000 health care providers via the Internet.

"In 1997, it became clear that physicians were no longer chained to one location and that they needed secure access to patient information from wherever they were," says John D. Halamka, who simultaneously works as an ER physician at Beth Israel Deaconness Medical Center, chief information officer of CareGroup, and a dean at Harvard Medical School. "The Web is an extraordinary way to do that, particularly with the addition of handheld devices that deliver information wirelessly."

Today CareGroup delivers 100 percent of its lab results over the Internet. "The labs give HL7 feeds to our hospital information system," Halamka explains, referring to an electronic transmission standard that allows computers with disparate programs to communicate with each other.

How security concerns affect online results

The privacy provisions of HIPAA (the Health Insurance Portability and Accountability Act of 1996) require that patients give permission to have their personal health information shared with authorized individuals—and that physicians and other providers restrict access to patient data. These regulations are scheduled to be implemented by 2003.

CareGroup, which gives patients access to their online results, already has an elaborate security system. Each doctor carries a small, token-like device that hooks onto a key chain, displaying a password needed to access the Web site. The password changes once a minute. The system is also equipped with "meta tags" that block users from saving confidential clinical data to their hard discs—and prevent their browsers from saving the data to memory. The online lab reports are available only in look-up mode, with an audit trail that lets patients see who has viewed their test results. A separate, secure e-mail system transmits the reports to CareGroup practitioners in a form that can be electronically downloaded.

The format in which results are delivered may pose a problem for practices that use electronic medical records. For example, Evans Medical Group in Evans, GA, relies on two large labs and one major hospital system for its lab work. But only one of these facilities—LabCorp—furnishes the results in a form that can be automatically downloaded into the EMR of the three-physician pediatric and adult practice. So staffers have to print out e-mailed results and enter them into the EMR.

Medscape, which made the group's EMR, launched a Web-based reporting service more than a year ago, notes internist and pediatrician Robert J. Lamberts. "Now LabCorp exports the results securely to Medscape, and the data are exported to us over a secure Internet link." The next step, according to Hillsboro, OR-based Medscape, will be online test ordering, which should be available soon.

Saving time by ordering tests online

Medical Arts Ob-Gyn, a four-physician group in Utica, NY, has been ordering tests online from a nearby lab called Centrex Clinical Laboratories for the past year and a half. "I used to have to keep a log of everything ordered. Now I just pull a printout at the end of the day," says Zita Graves, who processes lab orders for the group.

Doctors still hand patients written orders to give to Graves, who processes lab orders for at least 36 patients daily. "The biggest timesaver," she says, "is not having to re-enter a patient's name, address, and other identifiers each time a new test is ordered." The software does that for her. The ordering physicians must provide diagnosis and prescription codes, but the electronic ordering system makes sure they match.

Having a lab tech rather than a doctor input an electronic order is consistent with the way other practices use this function—if they use it at all. Cory Fishkin, a product manager for McKesson—which links the Utica ob/gyn group with Centrex over the Internet—says physicians are resistant to ordering labs online if it doesn't fit into their workflow. Melanie Allison, director of integrated solutions for LabCorp, agrees. "Doctors are much more interested in lab results. We care about the round trip," she says. The Burlington, NC-based lab recently added an online ordering function, but has seen little activity so far.

The key problem seems to be that ordering labs on a PC or a wireless device requires changes in physicians' work habits. Merely viewing lab results that arrive electronically doesn't involve any change.

Yet Fishkin points out that clinicians and their staff have much to gain from electronic ordering. Doctors who input data electronically, whether online or in an e-mail message telling a staff member to place the order, eliminate the errors and wasted time entailed in deciphering handwritten orders. No matter who places the electronic order, a practice stands to benefit from the coding check and the reports some labs generate when patients fail to get ordered tests.

As labs and other medical services take to the Web in record numbers, the question remains: When will physicians follow? "When wireless applications become more widespread," Allison predicts. And when there's so much valuable patient information online that practices start using the Internet for clinical purposes.

The author, a freelance writer based in Montclair, NJ, was formerly executive editor of Business & Health.

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Helen Lippman. Labs online: Everybody wins. Medical Economics 2001;24.