Clinical labs do not own electronic medical records systems (EMRs), but when their physician clients have them they plug into EMRs; hospitals have separate hospital information systems (HIS) that integrate with EMRs as well. Thus, labs need to be conversant with EMRs, despite their still somewhat limited use. Otherwise, their alternatives to transmitting medical records are pretty much limited to paper files sent physically, usually by mail or by fax.

According to Steward Macis, director of products and support services for Antek HealthWare LLC, Reisterstown, Md, the EMR securely stores patient medical records such as physician’s notes, medications, health history, prescriptions, and test results in a discreet electronic format. But Macis cites a recent study by the New England Journal of Medicine that only about 17% of physicians have a basic EMR, and, of those, only 4% are using it to its full capacity and 13% are using only pieces of the system, not the entire system.1

Why such limited EMR usage, and, given that limited usage, why should labs be concerned about EMRs?

Macis says three scenarios need to be studied. In smaller laboratories where testing is moderately complex, about 35% to 45% of practices use EMRs. In larger sites where testing is highly complex, there is an 80% to 90% EMR adoption rate. In both scenarios, facilities are interfacing their EMRs in a variety of ways, including demographics, lab orders, lab results, and billing. In many cases, all four interfaces are implemented.

“There is a third scenario, which we now are exploring due to our middleware product,” Macis says. “Practices that perform waived testing are also utilizing the power of their EMR. The use of middleware allows for waived testing to be integrated into the EMR. Waived testing can now be a part of the interfacing process, which opens the door to all medical practices.

“In all three scenarios we are seeing the adoption rates continue to grow each quarter. ‘Waived testing’ is defined by the FDA as testing that can be categorized as waived from regulatory oversight if it meets certain requirements established by the Clinical Laboratory Improvement Amendments of 1988 law. This type of testing would be considered low complexity.”

But for those practices that are not using EMRs, why not? And how do they keep and transmit medical records?

EMR Usage and Adoption

EMR usage is still far from universal, says Curt Johnson, vice president of sales and marketing at Orchard Software, Carmel, Ind, and the slow adoption and use of EMRs puts the medical industry way behind. What hinders acceptance and implementation is the project’s scope and that costs can range from several thousand to millions of dollars.

Large clinics are overwhelmingly the biggest EMR users, with more than 75% of them utilizing EMR, he says. Midsized clinics are increasingly adopting it, and smaller clinics and provider groups eventually will. Some providers have years of experience with paper and may be more reluctant to switch to an EMR system, but younger physicians are much more conversant with the use of technology. Johnson notes that EMRs have been in use for about 10 to 15 years, and HIS have been in use for longer than that.

Macis concurs that there are several reasons why physicians have not adopted EMRs to the extent that the health care industry has predicted. The price tag involved is probably the main reason for the slow adoption rate.

“We also believe the absence of tying true financial incentives back to the doctor for purchasing an EMR has contributed as well,” Macis says. “Another reason may be the complexity of learning and using the EMR. For some doctors it can be more time-consuming to utilize the EMR when compared to traditional methods.

“In the absence of an EMR, doctors are keeping paper records and are using manual methods to manage their practice. I’ve seen unique file cabinet systems which take up a tremendous amount of office space. You will also see staff listening to dictation and transcribing that dictation to paper charts. In reference to how these practices are transmitting medical records, we can only assume that files are being mailed or faxed to other third parties such as insurance companies and referring providers.”

With EMR on labs’ radar to an increasing extent, labs need to be aware of two scenarios, according to Johnson.

When an EMR is owned by an entity that also owns the lab, the issue becomes how the results actually get into the EMR. Regular mail is one way, but a more efficient way is through lab information systems (LIS) using HL7 interfaces. Some labs prefer to interface instruments directly into the EMR, but the downside of that method is that quality control can be lacking, Johnson explains. So typically, results get into the EMR via the LIS, where quality control can be properly monitored.

EMRs Allow Data Integration

Johnson says the biggest EMR benefit for physicians is that they have electronic access to patient files, replacing the use of paper files, which require storage and can be lost. In addition, some EMR systems provide secure access from any terminal that is connected to the Internet.

“It’s well-documented that 75% of all quantifiable data comes from the lab, so integration of that data is critical, and that should maximize the use of EMR,” Johnson says.

With EMR-LIS interfacing, Johnson notes, some are bidirectional and send orders to the LIS and receive results back, but other EMR systems provide only the results interface. It all depends on the system being used.

Dennis Nasto, CEO and director at SecureCARE Technologies Inc, Austin, Tex, agrees that a relatively small percentage of physicians have moved away from paper medical records to EMR and the growth rate is slow, with cost an issue as well as the challenges of converting old paper records to EMR (since they all have to be scanned and entered electronically). Also, using EMR can interrupt a physician’s workflow, Nasto says. EMR adoption is much greater in larger group practices, where it’s more efficient and easier to pay for. Clinical labs tend to run their applications on lab software, and lots of labs’ records are already electronic, he says.

One big challenge EMRs pose is integrating with such other systems as LIS and HIS. Also, EMR currently does not support the transmission of such images as slides and graphics, a big downside for physicians who depend on such graphic test results. Moving graphics from LIS, which does support graphics, to EMR is thus a big issue for both physicians and labs, Johnson says.

“All the systems—EMR, LIS, and HIS—are connected,” Johnson says. “The question for labs is how do they connect with the electronic environments they are involved in?” Most hospitals today have HIS, and some include labs as an element of their HIS. Overall, though, it’s a patchwork of systems that need to interface with one another.

Increasingly, they are, but to improve communication and to interface, what are labs looking for in EMRs’ next generation? Macis says that from the laboratory perspective, labs seek:

  • The ability to apply insurance filtering to their lab orders. When a physician places a lab order, there are instances when the patient’s insurance provider will dictate where diagnostic testing can be performed. There are many instances when certain lab panels will receive insurance reimbursement only when they are sent to a specific reference laboratory.
  • The ability of EMRs to handle unsolicited results. The normal workflow is to create a lab order in the EMR, pass the order to the LIS, and when the results are complete, send them back to the EMR. However, it is quite common for an EMR to post lab results even when the order (or add-on test) was not created in the EMR (but in the LIS). In this scenario, when a LIS sends results to the EMR it should be capable of importing and posting the results to the correct patient and encounter. If for some reason the patient identification does not match in the EMR, the user should be able to select the closest-matching patient or, if necessary, build the patient in the EMR.
  • The ability to handle amended results more eloquently. When results are reviewed and released in the laboratory, the original data sent to the EMR may not be the results that were originally intended. The lab may recalibrate and rerun controls to stabilize the testing environment, and tests may be rerun, producing new results. Those new results are sent back to the EMR. Many EMRs will post both the original and amended results and confuse the physicians.
  • The ability to handle graphical data as well as attachments placed on results. A good example of this is the ability to post the histogram of a complete blood count or pathology images.

Macis says one of the gaps with some EMRs is their ability to create lab orders or the presence of a laboratory module. Not all EMRs are able to communicate with other health care informatics systems. In these situations, lab results are either manually charted into the patient’s electronic folder or are stored and retrieved in the LIS. The LIS is placed in more front offices and drawing areas of practices so that data can be more accessible. Web-based solutions, which allow physicians to retrieve their results via a Web portal, are also available via the LIS.

Importance of Scalability

Some EMRs lack scalability, which could limit a practice’s growth, Macis says. “When physicians grow their practices, the EMR needs to be able to grow with it,” he continues. “There are some EMRs that lack the ability to function over a true Wide Area Network, which affects scalability. There are other instances where EMRs can handle only a finite amount of data, which adds the task of archiving data.

“When historical data needs to be reviewed, the archived data needs to be retrieved and reloaded to the live system in order to view that data. This is a procedure that practices find time-consuming and counterproductive. Today, we see EMR vendors building their software on better database platforms such as Oracle, for example. We also see the architectural design of the EMR evolving so that the application can now be securely implemented across multiple locations with greater performance and interoperability,” he says.

Interoperability is where health care informatics is heading, which is where middleware comes into play in the waived lab environment. With so many practices running waived tests, the need to get their test results into their EMR is an issue that most EMR vendors rely on middleware to solve. Middleware provides the pathway for their waived analyzers to transmit testing data into their EMRs.

“We also see EMRs that do have a lab module lacking the ability to provide ‘ask at order entry’ questions,” Macis says. These are specific pieces of information that the laboratory needs when performing the data analysis. Also, the inability for the EMR to perform ICD-9/CPT code validation is also an issue. Both of these scenarios should be covered by the LIS, Macis says.

He notes that the adoption of the tablet PC has helped with real-time adoption of EMR in the exam room. “We are hoping for the new generation of Tablet PCs to promote EMRs to fully handle handwriting notes directly to the EMR,” Macis continues.

SecureCARE’s Nasto says that sending, receiving, and filing faxes is central to managing any health care organization. But while other systems and requirements—especially HIPAA-mandated security issues—have evolved, fax technology has hardly changed since the 1980s.

Secure Faxing

Nasto’s company’s Sfax offers the secure transfer of patient health information, a feature he says is virtually nonexistent with manual faxing. The system is an easy-to-deploy, scalable solution that turns faxing into a paperless operation by tracking, routing, and storing electronic faxes on a HIPAA-ready, Internet-based platform.

Nasto says that Sfax can save health care organizations 95% of the time and 80% of the cost of manual faxing. A simple three-page fax costs upward of $1.20—which includes paper, toner, phone line, and labor—and takes more than 5 minutes to completely process. “Multiply that times 1,000 faxes per month, and you can see how it negatively affects your bottom line,” Nasto says.

He says that with Sfax, all the costs of manual faxing—equipment, paper, ink/toner, dedicated phone line, and labor—are eliminated. All that is needed to use Sfax is a computer with an Internet connection.

Nasto says that labs that are not using EMR can use Sfax to integrate with their software. Pressing a button electronically faxes medical records to physicians without manual log-on, simplifying the information-exchange process between lab and physician.

“All labs have the same problem; they have to send their results somewhere,” Nasto says. “Labs using EMR are already likely using a computer system for results, and there’s no software—everything is done via hosted sever, very like an e-mail server. It’s paperless for the sender, but it spits out a paper fax at the receiving end, and it’s also less complicated for use by home health care agencies, which can send documents to doctors for signatures and trigger billing.

“The system can also be used to provide records to pharmacies, hospitals, radiology, and for referrals. And it also helps protect patient records without the risk of them getting lost as paper records. And regarding security concerns, the system is HIPAA-ready.”

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Recently, Azalea Health Innovations, Valdosta, Ga, which Nasto says has not yet widely adopted EMR, partnered with Sfax to provide a fully automated clinical laboratory resulting solution for the medical laboratory community. The partnership is providing a Web-based portal called Azalea LabHub™, which is designed to deliver lab results to physicians via the Web through EDI connectivity and automated faxing using Sfax. Baha Zeidan, CEO of Azalea Health Innovations, says he plans to eventually interface the system with such personal health records systems as Google Health and Microsoft Vault so patients can have more control of their personal health data.

The integration of LabHub with Sfax will allow physicians 24/7 access to their patients’ laboratory results. In addition, errors due to illegible handwritten data will be greatly reduced. The system is HL7 and EDI standards compliant and can be interfaced with EMR applications, reference laboratories, and many other health care systems. All of this will lead to a higher quality of patient health care while saving its users valuable time and money, Nasto says.


Gary Tufel is a contributing writer for CLP.

Reference

  1. DesRoches CM, Campbell EG, Rao SR, et al. Electronic health records in ambulatory care—a national survey of physicians. N Engl J Med. 2008;359(1):50-60.