LIS-EHR Integration and
Meaningful Use Requirements ea g u Use equ e e s
Raymond D. Aller, M.D., FASCP, FACMI y , , ,
Clinical Professor and Director of Informatics
University of Southern California Pathology
L i Ob j ti
LIS-EHR and Meaningful Use
Learning Ob jectives
By the end of this session, attendees will be able to:
1 S if h i l b i f i d l i
1. Specify to their laboratory information system and electronic health record vendors the requirements for transmitting data from the LIS to the EHR, via HL7, so that
a. Reports are accurately and clearly presented to the physician/provider and
b Data is transmitted to the EHR in a manner that facilitates – b. Data is transmitted to the EHR in a manner that facilitates
decision rules, trending, etc.
2. Describe the advantages of the meaningful use requirements, vs.
the previous voluntary adoption of healthcare information technology.
3. Prepare your laboratory to ensure regulatory compliance in
Session description Session description
This session will discuss the importance of getting p g g lab data to EMR's with a focus on the meaningful use of lab data. Health information exchange and standards as well as challenges of regulatory
requirements for laboratory data validation will be discussed
discussed
Getting understandable and usable lab data to the Electronic Medical Record 1
Orthodox (“discrete-fielded”) method:
Put every aspect of a lab result into the appropriate specific field in HL7 2.3.1 (or later version)
Wherever possible use standard codes to represent data for Wherever possible, use standard codes to represent data – for
example, LOINC code to represent result name
The receiving system can then correlate, drive rules, trend individual analytes, etc.
Works fine for potassium, hemoglobin
Proper presentation of more complex reports microbiology Proper presentation of more complex reports – microbiology,
surgical pathology, genetics – requires more subject-matter expertise in the EMR designers.
Understandable and usable lab data to the Electronic Medical Record 2a
The issue: complex reports The issue: complex reports
Early interfaces represented some – or even all – lab reports as page-images (e.g., microbiology) lab reports as page images (e.g., microbiology) Laboratorians have spent decades learning how to
effectively present complex arrays of data in a y p p y printed report
It is unrealistic to expect EMR developers to have the p p expertise to duplicate those decades of experience when they combine myriads of data fields to a
report presentation
Understandable lab reports in the EMR 2b Understandable lab reports in the EMR 2b
Transmitting and displaying formatted reports g p y g p
Standards for formatting, transmission, and display – all can be used without license fee
Portable document format (PDF) Rich text format (RTF)
Rich text format (RTF)
Clinical document architecture (CDA) – part of HL7 version 3
PDF and RTF can be readily transmitted within a
standard HL7 2.x message – has been common g
practice in Australia for a decade
But how do we get our interfaces to do this?
But how do we get our interfaces to do this?
We must insist that all parties support the use We must insist that all parties support the use
of formatted reports over the interface:
LIS vendors must transmit formatted reports for all LIS vendors must transmit formatted reports for all
but the simplest report types:
• Microbiology gy
• Surgical pathology
• Genetics
• Immunology
Not needed for basic chemistry, wet hematology,
pure single-numeric testing
Data across the interface Data across the interface
Interface specifications must embed these report images within the HL7 2 x data
report images within the HL7 2.x data.
Some interfaces now pass a “pointer” or URL to an image of the page rather than the
to an image of the page – rather than the
page itself – we recommend instead to pass the image itself
the image itself.
Only if a report is very picture-intensive, and
l t i t f th
we can assure long-term persistance of the originating picture store, might the passing of
i t b t bl
pointers be acceptable.
To re-emphasize:
To re emphasize:
Reports of all moderately or heavily complex Reports of all moderately or heavily complex
results must be send across the interface as TWO data streams:
TWO data streams:
1. Fully formatted report images, in PDF, CDA, or perhaps RTF format. And
perhaps RTF format. And
2. Fielded data – all individual result parts in
individual HL7 fields.
To summarize how complex reports To summarize how complex reports should flow from the LIS to the EHR
Report in PDF Format,
LIS or
EHR
embedded In HL7
APLIS
Detail results in
EHR
HL7 fields
Meaningful use?
Meaningful use?
Increasing clear that use of electronic medical Increasing clear that use of electronic medical
records can yield better outcomes at lower cost
cost
How to encourage their use? Financial
incentives and penalties (carrot and stick) incentives – and penalties (carrot and stick) Just installing systems won't help – have to be
i t t d i t l ti
integrated in actual practice
Hence, “meaningful use” - to measure use that
is likely to reap benefits
EHRs EMRs EHRs, EMRs
Electronic Health Records – this incorporates, Electronic Health Records this incorporates,
and is a bit broader than, electronic medical records (EMRs).
records (EMRs).
Very wide range of scope and capability – from a solo physician's office to a multi facility
a solo physician s office, to a multi-facility medical center
C d t d th lt f
Conveys orders to – and gathers results from – a wide variety of other systems – including th LIS
the LIS
For a broader description of the scope of EHRs, we refer you to the references
EHRs are growing in usage EHRs are growing in usage
Especially rapidly since the Meaningful Use incentives were enacted
incentives were enacted
In order to get credit for Meaningful Use,
id t tifi d EHR t
providers must use certified EHR systems – that have been certified by an approved
tifi ti b d ( i f )
certification body (six so far)
Many agencies involved Many agencies involved
Health and Human Services – two branches are making rules
CMS – Center for Medicare and Medicaid Services ONC – Office of the National Coordinator for Health
Information Technology
NQF – National Quality Forum – quality measures
NIST – National Institute for Standards and Technology – EHR certification process
ANSI – accrediting EHR certifiers
Many others
Three stages of meaningful use Three stages of meaningful use
Stage 1 – 2011 - mostly basic requirements, Stage 1 2011 mostly basic requirements,
some optionality/choice – implement now!
Stage 2 2013/4 open for comments soon will Stage 2 – 2013/4 – open for comments soon, will
tighten up requirements. Likely that optional requirements in Stage 1 will become
requirements in Stage 1 will become mandatory in Stage 2.
St 3 2015 f th t f i t
Stage 3 – 2015 - further stages of requirements 2015 – penalties begin for eligible providers who
did not show meaningful use.
But are we eligible professionals?
But are we eligible professionals?
Eligible professional – physicians and others Eligible professional physicians and others
making use of EHRs for direct patient care Most in pathology feel that our practice does Most in pathology feel that our practice does
not fit the CMS definitions – we would be
unable to meet most of the “meaningful use”
unable to meet most of the meaningful use tests
D id t li ibl f i ti
Downside: not eligible for incentives
Upside: not subject to penalties for failure to
implement.
But this is not entirely clear But this is not entirely clear...
Some interpretations of the regulations hold Some interpretations of the regulations hold
that we would be considered eligible
providers – even though virtually nothing in providers even though virtually nothing in the requirements fit our professional practice.
Stay tuned !!
Stay tuned !!
If we are not “eligible” why do we care?
If we are not eligible , why do we care?
Our practices are a very important source of Our practices are a very important source of
data streams which are essential for our
clinician colleagues to show meaningful use clinician colleagues to show meaningful use We must support our hospitals in providing
data streams required by meaningful use
data streams required by meaningful use.
Data to clinicians Data to clinicians
They may choose to incorporate clinical lab test results as y y p structured data
Ever-expanding expectations by clinicians that we (the
lab) provide an electronic interface from our LIS to their office EMR.
Alth h thi i l d ti f l
Although this is already common practice for larger practices, it would become almost universal
Who pays the cost? In the past the answer has been Who pays the cost? In the past, the answer has been
“the lab”. Can we find a less costly way to accomplish
this connection?
Structured lab data Structured lab data
At least 40% of clinical lab tests ordered whose At least 40% of clinical lab tests ordered whose
results are in positive/negative or numerical
format are incorporated in EHR as structured
format are incorporated in EHR as structured
data
Clinical quality measures Clinical quality measures
Required in stage 1 Required in stage 1
Some of these depend on laboratory tests – at least 12 different measures
least 12 different measures.
For example, patients in certain age ranges
ith l f H l bi A1 di
with values of Hemoglobin A1c exceeding a defined cutoff
Rather than attempting to query their own
EMR, clinicians may ask the laboratory to
provide such reports.
Likely coming in stage 2 Likely coming in stage 2
Computerized provider order entry from the Computerized provider order entry from the
physician's EMR to the clinical laboratory
Hospitals Hospitals
They may choose – incorporate clinical lab test They may choose incorporate clinical lab test
results as structured data
They must choose at least one of:
They must choose at least one of:
Capability to submit electronic data to immunization registries/systems
immunization registries/systems
Capability to provide electronic submission of reportable lab results to public health agencies reportable lab results to public health agencies Capability to provide electronic syndromic
surveillance data to public health agencies
surveillance data to public health agencies.
Required interface standards Required interface standards
HL7 – Health Level 7 HL7 Health Level 7
Commonly implemented, but many interfaces will need to be updated from 2.3.1 to 2.5.1
need to be updated from 2.3.1 to 2.5.1
LOINC – underutilized by labs
LOINC LOINC
Published in 1995 Published in 1995
At the time, all LIS vendors were informed that it was important to implement; uniformly
it was important to implement; uniformly ignored
N ti l i th i th l b t
Numerous articles since then in the laboratory literature, urging laboratories to encode their
t t i t LOINC til tl
test names into LOINC – until recently, very
few implemented.
LOINC 2 LOINC 2
Key health systems implemented LOINC Key health systems implemented LOINC
several years ago:
Partners Health Boston Partners Health, Boston
Intermountain Health, Utah Indiana Network Indianapolis Indiana Network, Indianapolis
All major national reference labs have
implemented LOINC translations are
implemented, LOINC translations are
available on their websites
LOINC 3 LOINC 3
To implement LOINC for your lab
1 Identify all tests being sent out to reference 1. Identify all tests being sent out to reference
labs, download those LOINC codes from their websites
websites
2. for tests being run in your lab, become familiar with RELMA (the mapping tool) ( pp g )
3. we are encouraging instrument manufacturers to provide LOINC codes for all tests – call them! p 4. if this is a particularly large/daunting task,
consider using a commercial company that
provides LOINCing services
References References
1. Aller RD, Weiner H: Newsbytes – A case for reporting laboratory results to EMRs in dual formats, CAP Today 2010(August).
2 Walter H Henricks "Meaningful use" of electronic health records and its 2. Walter H Henricks Meaningful use of electronic health records and its
relevance to laboratories and pathogists, .. Journal of Pathology Informatics, Year 2011, Volume 2, Issue 1
3. Walter H. Henricks: ST108 The Impact of Meaningful Use of Electronic Health Records on Your Laboratory, seminar at College of American Pathologists National Meeting September 2011
Pathologists National Meeting, September 2011.
