LIS: a key component of specimen collection and management

May 1, 2011

Specimen collection and management is administered by care providers in dynamic, often-distracting environments. In “controlled chaos,” mistakes can result in adverse patient events (e.g., delayed or inaccurate diagnosis). Mistakes can bring a myriad of consequences (e.g., negative reimbursements, patient injury, incomplete order fulfillment, duplication of efforts, and misdiagnosis leading to potential loss of life). An organization striving for zero errors in patient care should take a look at a specimen-collection system that works within its laboratory information system (LIS) — ideally, a system that would provide the lab:

  • accountability/user identification — who handles specimens;
  • automation — eliminate potential for human error;
  • safety — patient safety is a priority;
  • simplicity —easy to use;
  • extensibility — effectively extends the LIS to every hospital bedside, allowing technicians automatically and immediately to see changes made to orders; and
  • regulatory compliance — meet The Joint Commission’s national patient-safety goal (NSPG.01.01.01), which stipulates use of at least two identifiers when providing care, treatment, and services.

A specimen-collection system should help a lab achieve workflow excellence by gaining efficiencies wherever possible and enabling lab personnel to drive down costs, improving physician and patient affinity, and increasing revenue. In fact, a good specimen-collection solution can deliver productivity gains for phlebotomists, as well as nursing staff, and has the capability to extend its benefits to other areas (e.g., emergency department [ED]). A lab can conduct in-house research on return on investment for its specimen-collection solution based on real-life examples throughout its hospital departments. As shown in Figure 1, in one major hospital’s ED, improvements increased capacity by reducing turnaround time (TAT) for every result. Patients could be discharged an average of 10 to 15 minutes earlier; thus, with 40,000 patients on average per year, time saved added about 200 days of capacity, with no increase in staff or beds. Two more examples here show how a specimen-collection system can support the laboratory in solving many of its problems.

A Florida acute-care hospital

At Orlando’s 880-bed acute-care Florida Hospital (FH), 38 full-time phlebotomists collect 15,000 blood specimens monthly — estimated at 50% of all those drawn at the hospital. The lab’s multistep specimen-collection process included patient identification; specimen collection, labeling, and transport; and data entry. Several steps indicated actions that could lead to potential errors. Florida Hospital conducted a LEAN analysis of the process, which showed 50% to 60% of phlebotomists’ time was spent on non-productive activities (e.g., walking from place to place, waiting for elevators). Using LEAN principles established during the analysis, the new system moved the lab from its batch specimen-collection process to a just-in-time process, removing variation and ensuring accuracy (e.g., scanning patients with a barcode reader for positive patient identification, printing out I.D. labels at patient bedsides).

Since the system began operation, FH’s lab has reduced patient-identification errors to less than one per year — significantly better than areas in the hospital not using the collection-management system. While lab personnel initially were reluctant to adopt the workflow change, today user reaction is positive. The LIS team adjusted the hand-held devices to make their functions easier to use, adding enhancements like placing bar codes on phlebotomists’ name badges instead of having them enter user-access codes at each collection. Because each collection takes less time, the hospital accomplishes more with less staff. Phlebotomists’ traveling time was reduced from 50% to 60% to 10% to 15%, and time-per-collection went from 40 minutes to 15. Before implementing its new specimen-collection solution, only 40% of FH’s STAT samples were done within the lab’s established goal of 120 minutes after they were ordered. Now, more than 76% of the STAT samples are done within this time frame. Reduced TAT increased the lab’s capacity to take in additional test volume. Capturing even a small percentage of this increased capacity results in additional revenue.

ThedaCare community-owned health system

Because of its quality initiatives, ThedaCare — a northeast Wisconsin community-owned health system — ranked as a “top 100” healthcare organization with recognition from Solucient and HEDIS (Health Employer Data Information Set). One key technological initiative supporting patient-safety goals was its lab’s automation using a collection system with related modules. Implementing new solutions enabled ThedaCare to save three full-time equivalents (FTE) in the phlebotomy and central-processing areas, equating to more than $101,000 yearly.

Automating clinical-lab operations

ThedaCare began automating lab operations as early as the late 1980s, when physicians entered orders into the hospital information system (HIS), which were then printed in the lab and entered into the LIS. Labels were printed in batches for sample collection, and samples were collected by phlebotomists. Samples were either a) received at the lab with technologists performing the testing and manually entering data into the LIS, or b) instruments interfaced directly to the LIS transferred results into the database. Technologists monitored test results for critical values, then relayed those to physicians. In cases where additional tests were ordered on already-received lab samples, technologists had to manually locate those samples . Reports were printed and either delivered by courier, mailed, or faxed to physicians. The pathology lab sign-out had multiple steps, including paper requisitions culminating in a hand-written signature on the final report.

To support broader patient-safety initiatives, ThedaCare re-centralized its specimen-collection process. Specimen collection, performed by care-center staff, was reassigned to a centralized lab phlebotomy team. Though errors decreased, mislabeled specimens remained problematic. Phlebotomists now achieve positive patient I.D. by scanning their own I.D. badges and the patients’ barcoded armbands. A portable printer prints each label for that patient’s samples for that collection time at that patient’s bedside — eliminating mix ups of labels for multiple patients and different collection times.

Following collection, phlebotomists verify collection time and date on their handheld devices and send all collection documentation via ThedaCare’s wireless network. Samples are automatically received into the LIS, eliminating manual receipts. The LIS auto-verifies patient results by user-defined algorithms that verify results are within specified limits and that eliminate the need for user-defined “normal” results to be reviewed by a technologist. Again, this process reduces specimen-collection time, resulting in faster results delivery to doctors with a corresponding acceleration of patient treatment.

Over time, ThedaCare added software to enable improvement in the lab’s workflow. Today, while tests are still ordered through the HIS, the orders move automatically through the LIS into software designed to automate the specimen-collection process. The newest LIS software allows real-time transmission of all lab orders, including STATs, directly to phlebotomists’ handheld devices, eliminating the lab call center that once dispatched them to collect STAT specimens.

“Lab results automatically go into patients’ electronic medical records (EMR),” says Jo Ann Lang, director of Lab, Outpatient and Guest Services,” so those records are automatically delivered to hospital physicians who have account links on the EMR system. For the 30% of the lab’s business from physicians who do not have EMR account links, test results are sent through an automated fax system. Paper reports need to be printed for only a very small number of physicians.”

Kelly Feist is vice president of Marketing at Sunquest Information Systems headquartered in Tucson, AZ, and maker of the Collection Manager used by Orlando’s Florida Hospital and Wisconsin’s ThedaCare.