Benefits and bumps of shifting to Beaker

Anne Paxton

November 2017—If they were located in the Land of Oz, laboratories selecting a laboratory information system might not have to make a choice between full functionality and seamless integration with their electronic medical record system. They could just follow the helpful advice of the Scarecrow to Dorothy at a crossroads: “Go both ways.”

Down here in Dorothy’s Kansas, however, having to weigh an LIS that is part of an enterprisewide solution against a standalone LIS creates a classic quandary for hospital laboratories: Follow one brick road and you may have top-flight integration between the LIS and EMR but possibly less LIS functionality. Go down the other road and you may acquire a best-of-breed LIS but risk stumbling on the interface with the EMR.

Increasing numbers of hospital and health care system laboratories, already operating in an Epic environment for their EMR, are casting their lots with integration by choosing Epic’s Beaker for their LIS. As of August 2017, Epic had 375 installations worldwide, 28 of them between August 2016 and August 2017, the company reported in CAP TODAY’s 2017 LIS product guide (see page 37).

The shift to Beaker has brought enhancements and challenges for Allina Health Laboratory, a Minneapolis-based reference laboratory that serves the Allina Health System, said Heather Dawson, MBA, MT(ASCP), vice president of laboratory services, in a recent talk before laboratory industry leaders.

Before installing Beaker, Allina Health Laboratory used the Triple G LIS, later acquired by General Electric and then Cirdan. The health system has had Excellian EpicCare as its EMR system since 2004. So “Beaker came in as an application into a well-established, mature EMR system,” said Dawson in an interview with CAP TODAY. The laboratory chose to implement the LIS in four regional phases, followed by a “big bang” final phase for anatomic pathology.

Dawson cites end user configurability as one of Beaker’s greatest strengths. Configurability leads to fewer problems than does customization, she notes. “Whenever you customize something, you run a risk when there are regular updates to the software. In those cases, your customization has a tendency to break your system. By having software that’s highly configurable, you’re less inclined to have difficulty with upgrades and updates as the software matures.”

For example, Dawson says, “From a preanalytic standpoint, for accessioning our specimens, configurability is available and expected by Epic, as opposed to having to write custom rules that run through an HL7 interface in order to put orders into a standalone LIS.”

The “snapshot report” feature also illustrates Beaker’s configurability. The snapshot report allows the end user to stay in an active resulting window with the ability to read consult notes, op notes from the surgeon, previous histories, clinical pathology results like hematology or microbiology, and so on, for a case. “This is a view that is available in anatomic pathology because there’s no interface needed between Beaker and the rest of the patient’s medical record,” since the EMR and LIS are integrated.

“There is an actual snapshot for the pathologist that shows them everything important related to the history of that patient and helps with their interpretation of the case. There are no fancy rules to write; there’s nothing we have to do to pull it through an interface out of a standalone LIS. It’s all in the patient rec­ord, and because it’s highly configurable, pathologists can pick and choose what they want in their view, so they’re only looking at the information that’s relevant to them.”

One complication of Epic’s “one patient/one record” standard, which allows appropriately released information to be shared across Epic entities, is that 10 or 11 states, prompted by privacy concerns, require that patients have the opportunity to opt out of global record sharing. “We actually have to put those patients’ laboratory test orders into a sequestered portion of the Beaker application because the whole point of Epic is to have this big seamless record,” Dawson says.

Beaker handles add-ons and redraws in a simplified way, Dawson says. “Getting a redraw ordered and sent back to the phlebotomist is really easy. It doesn’t take provider or nurse intervention; it just requires a click of a button.”
Beaker’s “dynamic outstanding list” aids in tracking current priorities. “Using view changes, filters, and sorting, along with flags, batches, and statuses, users can work their way down through a manageable list of patients that actually require their attention today and quickly identify test orders or samples of interest to work on.”

Specimen tracking remains to be fully ironed out, however, especially in AP. “Can we tell where everything is? The answer is yes,” Dawson says. “There is really good tracking on the CP side, but Epic’s AP tracking is designed to track things once the case number has been assigned.” She expects AP order specimen tracking to improve with Epic’s 2018 upgrade.

In Allina’s anatomic pathology group, Dawson says, it’s important to have a standardized form for reporting, and mnemonics are key. “I have pathologists who build the mnemonics themselves through our physician builder program. This ensures the accuracy of the content from a clinical perspective.”

Dragon functionality, or speech recognition, has been particularly useful for creating transcriptions in case results reports, Dawson finds. “With our legacy LIS, we might have had the capability, but I don’t think we had the bandwidth to take on Dragon.” In fact, she notes, overall staffing needs have changed considerably since Beaker was brought in. With the previous LIS, “we had a large IT team to support us. With installation of Beaker, our IT support needs went from a very large team to probably half as many.”

Dawson praises Beaker’s handling of microbiology in general. Allina was prepared for the difficulties of converting its LIS to handle microbiology. “That was one of the few specialty departments in our legacy system that worked very well, and they were hesitant to move off of it.” Adapting the LIS to the microbiology automation the laboratory has been adding also turned out to be a nonevent.

Allina performs Beaker LIS upgrades every 12 to 18 months, though some health systems do them sooner and others may wait two years, Dawson says. Downtimes during updates and upgrades are short, lasting from 15 minutes to a couple of hours, and unscheduled downtimes are “extremely rare.”

Despite these advantages, Beaker is not a fully mature LIS. “It’s not considered best of breed, and it does have some deficiencies,” Dawson says.

That the clinical pathology and anatomic pathology sides of Beaker still operate somewhat independently is one drawback. “CP and AP are still too siloed,” she explains. Epic plans in 2018 to take the two parts of Beaker and merge them so they look almost identical, she says. “So it will no longer be an issue in another year or two.”

Cytogenetics, which the laboratory started building in Beaker a few months ago, is a particular challenge with the new LIS. “We loved our cytogenetics lab in our standalone legacy system,” Dawson says. “The cytogenetics laboratory was running a homegrown system, so cytogenetics is the single biggest challenge for our transition to Beaker. Because of the timing of our coming upgrade, we are forced to wait until 2018 to implement.”

Shared specimen workflows remain problematic. “There is still a whole lot of human interaction related to coordinating and routing tests on body fluids and tissues coming out of the OR that need microbiology, anatomic pathology, and cytogenetics. We have not found an electronic solution for this.”

Dawson has a few additional criticisms: