EMR - interconnected terminals

Any laboratory that hopes to stay in business over the coming few years must deal, sooner or later, with the proliferation of the electronic medical record (EMR). Why it cannot be ignored is an easy question to answer: Physician reimbursement in both public and private sectors is moving toward pay-for-performance models that require EMR use. Once a physician office has bothered to acquire and learn to use its EMR, it wants to use the technology’s ability to improve productivity—particularly if the practice must recover the cost of the EMR through operating efficiencies.

This means that a laboratory that cannot provide at least EMR-based distribution of results will simply fail to compete for business from that office. A laboratory that can add EMR-based ordering and other advanced functions to results distribution, however, will improve its market position.

The more difficult questions that laboratories face are not why, but when and how to approach EMR interoperability. In most cases, the time seems to be now, if not yesterday, since physician practices appear to be demanding EMR access to laboratory ordering and results at twice the rate at which they are asking for Web-based access, by some estimates.

Because of changes in the Medicare antikickback statutes made through enactment of the Health Information Technology Promotion Act of 2005, it became legal for hospitals to supply referring physicians, at no cost, with one of the more than 50 certified-interoperable EMRs—with some state-legislated exceptions. This is driving a flurry of EMR adoption among physician practices; some assessments indicate that four of five large physician practices and more than half of small practices had EMRs in the planning, implementation, or full-use phases by 2006.

The question of how to acquire the needed communication between the laboratory and the EMR has a less obvious answer. The options include expensive, highly customized software set up to address each EMR individually, application service providers (ASPs) that will handle the entire process for a per-test fee, and standards-based interfaces that allow for future needs—and may cost less—but may also require more initial change in the laboratory’s workflow.

Each buyer will need to assess the laboratory’s existing information capabilities and find a trustworthy vendor to help it make the most of its past technology investments in communicating with all the inpatient, outpatient, and outreach clients within its current and future grasp.

Of course, outreach customers— who send in specimens obtained by a physician’s staff rather than by laboratory personnel—are the part of the laboratory’s business most likely to grow or decline in response to the facility’s EMR interoperability, even while its acute and ambulatory workloads remain steady.

EMR Benefits

The EMR is today’s best possibility for turning health care into an industry that makes high- quality care accessible and affordable. By making all relevant patient data available to all providers that need it, no matter where or when that need arises, the EMR can clearly optimize treatment for the individual. It also works at broader levels, however: The ability to assess aggregate and individual health factors can help medicine progress toward deeper knowledge of the relationships among genetic predispositions, habits, exposures, diseases, treatments, and outcomes.

When it becomes possible to assess the risk factors and predict the treatment responses of both large groups and individuals, medicine will be able to boost quality and reduce costs in new ways. In many cases, physicians must now proceed using trial and error—informed, of course, by their own education and experience. Each proposed diagnosis is followed by a waiting period for verification, and each intervention is followed by an assessment of the patient’s response to therapy. With broad adoption of the EMR, evidence-based practice can expand to make both diagnosis and treatment far more specific and rapid.

Of course, societal benefit alone would make it difficult for many health care providers to justify investing their money in EMR systems and their time in training staff to use them. The increasing adoption of the EMR has been driven instead by the immediate and future benefits expected by patients, payors, and employers.

However, providers also benefit from the streamlining that results and from the enhanced ease of compliance with regulatory and administrative data requirements. In some markets, there has been little choice: Providers without EMR capabilities cannot expect to compete for reimbursement in pay-for-performance and mandated-interoperability environments.

This situation has created a climate in which the laboratory that cannot work with the clinician’s EMR will simply be unable to retain business. This change in laboratory operations can be relatively simple for those fortunate enough to have adaptable, powerful information systems already in place—along with adequate capital budgets and informed technology buyers.

Those less fortunate have been scrambling to catch up, but many information products and services have been used to fill the knowledge gap. Choosing a helpful partner in the transition to working with the EMR can reduce not only the potential for lost business, but worry, costs, and downtime, as well.

Even a laboratory that already has interfaces in place between the laboratory information system (LIS) and various EMRs may have to make major changes. Whereas many forms of laboratory results reporting were once considered acceptable, the federal Certification Commission for Healthcare Information Technology (CCHIT) mandated the use of standards-based interoperability, including the use of the Health Level 7 (HL7) protocol for certain kinds of laboratory results, beginning in May 2007.

In 2008, the standards are expected to expand to encompass microbiology reporting. Laboratories unable to comply will be at a distinct disadvantage because physician practices having EMRs without CCHIT certification do not qualify for the EMR safe harbor under the antikickback statutes. In other words, HL7 use will be necessary in most cases. CCHIT also requires laboratory results to be compatible with the use of logical observations, identifiers, names, and codes (LOINC). The intent of the LOINC rule, which covers testing units and methodology, is to make results from different laboratories comparable over time.

On the Market

The LSI: Results module from Impac, Sunnyvale, Calif, is a laboratory systems interface designed in collaboration with national and regional reference laboratories that extends the reach of the company’s IntelliLab LIS to the EMR. It can send results to an EMR and can also accept results from another LIS, making it useful in reference laboratories and central facilities with external satellites, as well as in standard clinical settings.

The LSI: Orders module handles the other side of EMR integration, accepting orders from EMRs and transmitting outgoing reference orders. Other LSI-series modules and custom interfaces add communication with hospital information systems, practice-management systems, and billing systems.

Orchard Software Corp, Carmel, Ind, offers the Orchard Copia integrated laboratory network for order management and results delivery in outreach programs. While retaining its existing LIS, the laboratory can make its single or multiple sites easier for customers to use. The order-entry function is based on a simplified one-window process that can run on any Web-enabled computer. Routing preferences are handled at this stage, and reimbursement is maximized because errors and omissions are caught at this point. When results are returned to the client’s EMR or other system, they have already been consolidated, even if they were generated at multiple laboratories.

Novius Lab from Siemens Medical Solutions, Malvern, Pa, serves as the foundation for modular and customized EMR integration that can be extended from single or multiple laboratory facilities to any type of provider, health plan, payor, or other EMR user. Because it is readily scalable, this system is especially suitable for laboratories now moving outside their core acute care businesses for the first time, since they may not know in advance how much volume to expect as a result of outreach activities. Interfaces with financial systems, automated instruments, and reference laboratories are also part of Novius Lab, along with real-time turnaround tracking and expedited clinician access to results.

4medica, Los Angeles, makes its Laboratory Suite available using an ASP model and a Web browser interface, so no hardware or software purchases are required to use it. The laboratory’s existing LIS must be able to import and export data using HL7; interoperability with providers and systems of all types is handled by 4medica as required. Services are purchased as needed, based on a competitive outreach strategy that 4medica and the laboratory develop together to meet the facility’s needs, including billing. EMR-based ordering and results distribution are available anywhere using physician-designed interfaces, with data security and disaster recovery provided as part of the ASP plan.

LabEMR, available from Atlas Medical, Calabasas, Calif, focuses on connecting EMRs and outreach laboratories using HL7, with a high level of security and seamless operation. Physician offices can use their EMRs to submit orders and obtain results, and LabEMR also integrates the Atlas LabWorks application to add Web-based communication with the laboratory using many kinds of third-party hospital information systems, practice-management software, and billing systems. LabEMR is particularly flexible because it can be implemented alone, with LabWorks, or with third-party systems as the facility’s needs change.

CareEvolve, Elmwood Park, NJ, provides LabEvolve modules for order entry and results distribution. Available in both client-hosted and ASP forms, this adaptable system, designed for hospital outreach programs and independent laboratories, has optional modules with adaptations for the particular requirements of laboratories serving nursing homes and prisons. Results are delivered to the EMR using HL7, and the company states that order entry is so intuitive that users can be trained in 15 minutes or less.

The Interface Technology Framework and ORX tools of Halfpenny Technologies, Blue Bell, Pa, are designed to populate the EMR with the maximum amount of laboratory data using a standardized framework. Orders and results are captured directly using HL7, but there is no need to deal with multiple EMR interfaces; the ORX tools automatically take advantage of the strengths or cope with the weaknesses of each EMR communicating with the laboratory.

Labtest Systems Inc, Midland Park, NJ, makes LabValet in Web-based, ASP, and client-hosted models for order entry and results reporting. To these the Labtest.EMR product adds full integration between single or multisite outreach laboratories and the EMR using HL7, with use of a Web browser for transmitting orders and obtaining results. The ease with which Labtest.EMR adapts to the workflow of the physician’s office promotes its use, adding to the laboratory’s competitive outreach abilities.

HorizonWP Outreach for Lab is a product of McKesson Laboratory Solutions, San Francisco. Intended for use by both outreach programs and reference laboratories, the system works with the Horizon Lab LIS to provide EMR integration for ordering and results. Because medical necessity and billing requirements are checked automatically during order entry, fewer claims are likely to be denied, and reimbursement should be faster.

Why the EMR Matters

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The value to the clinical laboratory of working with the EMR is readily apparent in business terms: retaining and expanding the facility’s referral network, increasing operational efficiency, improving turnaround times, and reducing costs. It is harder to attach a dollar figure to the benefit to patients, but it exemplifies one of the highest uses of information technology in which computers ultimately serve to humanize a system. Continuity of care may finally become a reality that includes not only the regulator, payor, and employer, but every provider—from primary care physician to laboratory to pharmacy to imaging center, from specialist to clinic to hospital to skilled nursing facility, and from home health provider to rehabilitation facility to surgical center.

When this dream is fulfilled, every person who cares for patients can know, from their births through their deaths, who they are, where their risks lie, what they have experienced, what has harmed them, and—at last—how to help.

Kris Kyes is technical editor of CLP.

More Go-Betweens

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While interoperability for electronic medical records and the laboratory information system (LIS) may be holding center stage at the moment, there are other important kinds of software for LIS connectivity. They also extend the laboratory’s reach beyond its walls and promote its efficiency and productivity. Middleware is one such category; although this can be a catch-all term, it usually refers to software that allows the LIS to control or communicate with other laboratory software, either within the facility or at a satellite location.

One type of middleware lets a laboratory that has an LIS and multiple computer-driven instruments graduate to centralized automation, controlling the intake, movement, analysis, storage of specimens, or a combination of those functions. Another software category covers multisite laboratories, integrating their operations so they function as a single unit for many purposes. Some products even combine these capabilities.

For example, Fletcher-Flora Health Care Systems Inc, Anaheim, Calif, makes FFlexConnect, a combination of middleware and an interface engine that works with the company’s Web-based LIS. It provides connectivity for remote laboratory facilities and also allows the LIS to control information exchange with satellite and local workstations using secure Internet technology. It manages automated instruments and devices, label writers, and printers, and it communicates with clinical-system interfaces from third parties. High-speed Internet access is required, but there are no other limitations on where the LIS can be used via FFlexConnect.

SoftExpress from SCC Soft Computer, Clearwater, Fla, is designed to support a laboratory outreach program. This software incorporates modules that manage courier activity, customer service, inventory, and reporting. It emphasizes functions that are not always part of an LIS, but that help maximize the laboratory’s ability to compete for business by providing a high level of service. Tracking and management of orders, pickups and deliveries, specimen inquiries, incidents, service requests, notifications, and pipeline status are among the activities automated by SoftExpress.

Misys Laboratory, from Misys Healthcare Systems, Raleigh, NC, is a classic LIS that is available in customized configurations to handle tasks that would otherwise require additional software; it performs the functions of an LIS plus those usually managed by middleware, according to the facility’s needs. Automation, with instrument control, is covered from requisition through reporting, and interfaces with hospital information systems are available. Other modules address multifacility support, compliance, blood banking, microbiology/epidemiology, anatomic pathology, bedside patient identification, and outreach needs.