If government goals are met, 360,000 physicians who don’t use electronic medical records today will be using them by 2015. That takes the total to 480,000 physicians using ambulatory records, says Pat Wolfram, vice president of marketing and customer service at Ignis Systems, a software and services firm that specializes in EMR-to-lab integration. Wolfram spoke at a Dark Report audioconference in January about the $20 billion the government has allocated to promote physician adoption of EMRs.
For laboratories, one of the challenges will be the number of physician office practices requesting that labs integrate their systems with the physician offices’ EMRs. “You’ll see twice the volume of integration requests,” involving dozens of EMR vendors, Wolfram told CAP TODAY. “This integration is needed first and foremost to provide better patient care, but it is also required to satisfy EMR meaningful use, for which a physician can obtain Medicare reimbursements of up to $44,000 over the next six years.”
And whereas test ordering has almost always been a later, deeper phase of EMR adoption, “that adoption can’t happen during a later phase anymore if the meaningful use criteria remain unchanged and the physicians want the reimbursement,” he says. “The meaningful use criteria require that all of the ordering and resulting functions are in place to obtain Medicare reimbursements.”
The EMR the physician uses has to meet meaningful use criteria to qualify for the government payments. The two criteria (of a total of 28) that most directly pertain to the laboratory:
1. Physicians must receive and import structured lab results to the EMR patient charts.
2. More than 80 percent of what a physician orders, such as tests, imaging procedures, and medication, within an ambulatory environment must be placed through an EMR. This doesn’t require that the order be transmitted electronically. When a doctor orders the test inside the EMR, it can be printed and sent to the lab on paper to satisfy the ordering requirement. “There are a lot of good reasons to make it electronic,” says Wolfram, “but it is not required at this first phase.”
The meaningful use requirements were undergoing a comment period at CAP TODAY press time and are expected to be solidified by this summer. If they don’t change, says Wolfram, then lab result interfaces that propagate structured values to the EMR flowsheet must be installed, lab orders must be set up in the EMR and adopted by physicians and their staff, and lab reports must be shared with a public health agency. “ARRA [American Recovery and Reinvestment Act] is pushing that schedule,” Wolfram adds.
Criterion No. 2, computerized physician order entry, is the more difficult of the two to implement, Wolfram says, in part because it requires physicians to change their workflow and because lab order rules, such as those for medical necessity, often are not modeled well in the EMR.
How well EMRs can perform the CPOE function helps to differentiate one from another. “They all try to be easy to use. Some of them have nailed it and some haven’t,” Wolfram says. “It’s something you want the physicians to seriously evaluate when they’re looking for EMRs. It’s not something you can influence after the EMR purchase is made.”
What the lab can influence, however, is EMR selection. And the lab can help evaluate how well the EMR can replicate its ordering needs. For example, the EMR should be able to read the laboratory’s compendium, which consists of the directory of services, medical necessity rules, specimen details, ask-at-order-entry rules, and pricing information. Furthermore, the EMR should be able to read the lab’s utilization report for the practice. This helps to build the right CPOE environment within the EMR. (See box for Wolfram’s checklist of the workflow and set-up functions that should be available in an EMR.)
Labs should try to “get ahead of this game,” Wolfram advises. “Reach out to your practices. Find out where they are in their EMR selection and ask to be part of that.” Become educated on meaningful use and then “show up as the savvy group” that understands it, at least as it pertains to labs. “I’m not suggesting that the criteria that have to do with lab connectivity carry enough weight to sway their [the physicians’] vote,” he says, but labs can influence decisionmaking. “And you want to get in front and help coach your practices through this EMR selection. Partner with them to get them through it.”
Labs should conduct their own research to determine which EMRs are being used and what functions they offer, Wolfram adds. Ask your lab colleagues. Find out if they’re receiving orders from an EMR. If they are, how does the EMR stack up against the checklist (at left)? “And then dig a bit deeper into your EMR vendor evaluation.”
Determine whether the EMRs deploy orders in a more general or customized way. And if the CPOE function is customized for a particular physician office, can this customization be easily supported? “It’s difficult to deploy custom environments at a high scale,” says Wolfram. “So can the EMR read your compendium, for instance, to set things up? Or during set up of the EMR orders, must the staff hand enter the orderable tests into the EMR database?”
Adding to the turbulence of the times is that there is a plethora of EMR companies. Some of them have been around a long time and have “matured their deployment and workflow methods,” says Wolfram, and some of them are less savvy and have not.
If you’ve been working with an outreach partner to connect to physician practices, reach out to that partner, Wolfram continues. “They have experience getting results into the EMR and gathering orders out of EMRs, and they can let you know which of those EMRs they have good experience with.” The lab can share that information with the physician practice, saying, “We’ve done this before and here’s how we can do it again.”
When Massachusetts General Hospital needed an information system for its new lab, established to support the testing and tissue banking needs of its translational and clinical research community, the hospital didn’t look for a LIMS—it turned to its LIS.
“Use of the LIS allowed immediate leverage of existing infrastructure for specimen order routing, resulting, billing, IT support, and training, as well as access to the enterprise clinical data repository and the clinical laboratory for off-hours support,” says John Gilbertson, MD, associate chief of pathology and director of pathology informatics for MGH.
The hospital was able to use the LIS in the new laboratory, opened last year, without compromising the system’s performance in its clinical lab because its LIS, like many large lab systems, has enterprise capabilities. Such capabilities allow one LIS to serve multiple laboratories while permitting each lab to configure the system to meet its specific needs.
An enterprise module allows laboratories to share the same dictionaries, populated with local codes and lists, or create different instances of the dictionaries and content for each lab. It’s also possible to mix and match, sharing some dictionaries and not others, Dr. Gilbertson explains. “This gives the impression of different laboratory information systems for each lab while, in fact, it is one LIS that operates differently in different labs largely because some or all of the dictionaries are set up differently,” he says.
MGH uses Sunquest’s laboratory information system, which has a set of dictionaries populated with such information as test codes, billing codes, and interface information that is specific to the hospital, Dr. Gilbertson continues. These codes drive the way the system handles, for instance, specimens, orders, results, and interfaces.
MGH added tissue banking to the LIS as a medical test to support the tissue banking needs of its researchers. Researchers order tissue banking, and then the LIS instructs a device in the lab to take an aliquot of a sample and store it in an archive. As for any test, the lab sends a bill to finance and the results to an enterprise clinical data repository when appropriate.
This creates a valuable repository in which banked specimens can be easily located, categorized, and linked to relevant clinical data, Dr. Gilbertson says. “The connection between the LIS and the electronic health record is very important,” he adds. “The repository allows researchers with appropriate credentials to obtain clinical data about patients and patient populations.” If, for example, researchers are interested in 50-year-old asthmatics with heart disease, they can check the EHR and determine how many such patients are in the system. The tissue banking data from the LIS tells them if blood specimens from these patients are available for research.
“The hospital systems are collecting all that data [and] making it available in a unified form to the researchers in a formal way with all the controls in place,” Dr. Gilbertson says. “We are simply adding to that data set the presence or absence of blood specimens for research and when that blood was collected.”
Using an existing LIS instead of purchasing a LIMS offers several advantages, he continues, the most obvious being the savings incurred by not having to purchase or build and maintain a new system. Users don’t have to be trained on a new system, he adds. And interfaces with other hospital information systems, such as billing, order entry, results reporting, and patient safety, don’t have to be rebuilt.
Being able to communicate through interfaces is especially important in terms of patient safety, says Dr. Gilbertson, citing the value to some researchers of being able to access the critical values alarm in the hospital information system. “Patients in clinical studies are still patients, and there are situations in which the hospital’s critical values alerting system can be very important,” he notes.
But there are drawbacks to using an LIS in a laboratory dedicated to supporting research—the most significant being the need for customization. For example, these systems aren’t made to handle batch accessioning, Dr. Gilbertson explains. At MGH, clients might submit batches of specimens—often as many as 5,000 in a batch—with data on computerized spreadsheets. Manual accessioning of this data is tedious, he continues, so the hospital has to create programs to parse the spreadsheets and accession the data automatically. “Technically, it’s not an issue, but it’s something we have to deal with,” he notes.
Another problem is that many laboratory information systems have only a small number of accession numbers, which they continually reuse. This is a potential problem for tissue banking because specimens are often banked for years, so long-term accession numbers would be very useful, Dr. Gilbertson says. MGH is working with Sunquest to address these challenges, he adds.
Overall, Dr. Gilbertson concludes, using an LIS for research support has worked out well for Massachusetts General, a high-volume institution that conducts more than half-a-billion dollars in research annually. This strategy, he says, can work for any lab. “You basically have something that virtually every laboratory can do—create another instance of their LIS and dedicate it to the research community.”
Verizon Business recently launched an information technology platform for sharing physician-dictated patient notes in a digital format.
The platform, the Verizon Medical Data Exchange, allows medical transcriptionists to share digitized notes about patient care and treatment with physicians, hospitals, and other health care providers.
The exchange, which is designed to meet the requirements of the federal government’s Nationwide Health Information Network, allows medical transcription firms to maintain their current information technology systems, procedures, and workflows.
The platform uses a central directory to automatically verify the identities of senders and recipients. It also encrypts all information being communicated. Companies using the platform must be certified by a qualified third party.
Verizon Business developed the platform for the Medical Transcription Service Consortium under an agreement announced late last year. The consortium anticipates that its entire membership will be using the platform by August.
Sunquest Information Systems has announced that it will install a range of products in the new reference laboratory of the nonprofit St. Luke’s Health System, which operates medical centers and clinics throughout Idaho.
St. Luke’s has purchased for its new reference lab, slated to open later this year, the Sunquest Clinical Financial so-lution and the full suite of Sunquest Outreach Advantage products, including Connect, CLM, and Mobile.
In a separate announcement, Sunquest reported that Massachusetts General Hospital, Boston, is installing the Sunquest CoPathPlus anatomic pathology system. And Bon Secours Health System, Marriottsville, Md., is implementing CoPathPlus in its three facilities in the Hampton Roads region of Virginia, completing Bon Secours’ adoption of the product systemwide.
Dr. Aller is director of automated disease surveillance and team lead for disaster preparedness Focus B, Los Angeles County Department of Public Health. He can be reached at email@example.com. Hal Weiner is president of Weiner Consulting Services, LLC, Florence, Ore. He can be reached at firstname.lastname@example.org.