Vol. 21 • Issue 8
Middleware, in its most simplistic definition, is a translator. In a laboratory, middleware translates the language spoken by the hardware of an analyzer to the user interface of the laboratory information system (LIS). This conversion can be one way-from analyzer to LIS-or bidirectional, with the LIS sending information to the analyzer as well.
Hardware middleware translation eliminates the need for the laboratory staff to spend time coding results by hand, ordering extra tests based on results, and issuing new insurance authorization requests, therefore impacting productivity. Middleware eliminates the manual process as well as the potential for human-introduced errors.
Software middleware can translate and exchange data between the LIS and billing systems, electronic medical record (EMR) systems, hospital communications networks, websites and more. Middleware acts as the glue between multiple systems, and due to its ubiquitous nature, it has become all but indistinguishable from the standard interfaces we see in the LIS. Middleware is not something a user needs to see and it is not something that a manager should need to administer. Rather, it is the silent servant of the LIS, shuttling information between systems and equipment within the lab, between the lab and other departments as well as to external clients and facilities.
The Hub of the Laboratory
The role of the LIS has evolved significantly through use and necessity. What used to be a simple terminal to catalog tests has become the central nervous system of the lab with an ability to automate unconscious activities. By offsetting the tedium of accessioning, manual results entry, reporting, verifying demographics, etc., the laboratory can focus on efficiency, better outcomes, statistical analysis, turnaround times and accuracy.
Technology, productivity and legislation have created the demand for smart instrumentation, streamlined processes and the EMR. The LIS is evolving into a solution that can control the entire lab, becoming the central hub for web-based order entry and results reporting, email notifications, intelligent, rules-based report distribution, custom report creation, bidirectional communications between laboratory, customers and clients, workload balancing, Medicare and medical necessity checking, communications with billing systems, public health reporting, rules-based analysis and reflex testing, as well as a consultative communication medium.
As the LIS has evolved into this role it has become necessary for cross-matrixed teams to work closely with each other. In the best cases, the vendor actually becomes a partner and consultative resource in conjunction with the lab. The combined efforts of the laboratory director, IT director and LIS vendor work to determine the needs of the lab and create the solution that combines the best use and workflow of equipment, middleware and LIS that will increase productivity and elevate the lab to a highly efficient business entity.
LIS, Instrumentation, EMR Integration
So, how do we make the LIS the central repository of all the data in the laboratory? What do we need to do to integrate all these separate systems and processes into one coherent flow of data capable of the basic functions of an LIS mentioned earlier as well as the more advanced features expected from today's modern laboratory? Features should include Internet/web-based order entry and results retrieval, secure email of laboratory reports, custom report creation, direct interfaces through established protocols with reference labs and other EMR systems, preliminary and final reporting, daily worksheets, workload balancing, Medicare medical necessity checking, billing, public health reporting and a sophisticated rules based system.
The first step in creating this integrated solution is to determine the infrastructure already in place and what would be a necessary addition within the laboratory. Working with the existing investment is not only possible, it would be improbable to reinvest in like technologies. The LIS is the essential focal point and making the correct investment or any necessary changes to have the foundation of the hub in the lab would be the place to begin or consider any incremental spending. Ensuring that all of the existing equipment is seamlessly, cost effectively and quickly able to be integrated with the LIS is the first stage. Middleware, as we are referring to it here, can be provided by either the manufacturer of the instrument or the LIS vendor; however, most innovative LIS vendors are now able to provide truly intelligent and expanded functionality for data. An order is placed to the instrument, then moves from the instrument to the LIS with test data and results which include flags, etc. and in truly automated situations, from the LIS back to the instrument based on additional testing needs.
Items to consider when planning a fully integrated laboratory include:
• Determine which systems instruments and applications will speak to each other. What is the workflow necessary to support your business? Making an outline or data flow diagram is a good visual starting point.
• What processes currently require human intervention or manual labor?
• Are insurance billing and approval systems creating inefficiencies in payment and test completion times?
• What time and cost are required to implement a new system or maintain a current one? Can an existing one be upgraded or modified effectively to achieve the results or is a new investment worth it?
Finally, determine the ROI. Many middleware providers offset costs by requiring the end user to create rule-based systems and adjust settings on their end. This is not the lab's business or knowledge base and can add significant time, setbacks and cost to what started out to be an attractive solution. An ideal middleware solution outsources the entire process; the client defines the problem, and the middleware vendor provides the system integration, programming and training.
A Successful Relationship
Middleware and LIS integration go hand-in-hand. The LIS vendor needs to be actively involved and engaged in your success. They need to have experience to help bridge the gap between instrument and other system vendors to their LIS. A successful relationship between all parties will ensure the success of your truly automated, seamlessly integrated lab.
The final result is a direct, automated communication from your customer-the physician's office through their EMR-direct to your LIS with updated, accurate information and the delivery of patient information and test results back to your customer securely, accurately, timely and in the way they want to receive them. The bottom line for your lab is increased customer satisfaction, streamlined efficiencies, cost savings and meaningful use compliance.
Lisa-Jean Clifford is chief executive officer, Psyche Systems Corp., Milford, MA.