The importance of laboratories makes the disconnect between them and electronic health records-the anointed hubs of clinical and financial activity-all the more frustrating. But disconnect there is and with rapid advances in lab capabilities, patient well-being could be at risk. Molecular and genetic information now is being sent to physicians, but they may not fully understand the messages that signal certain propensities to disease, or may not understand that even something as simple as glucose levels are not measured as they once were.
"Fifteen years ago, when EHRs first started coming on the scene, I would ask EHR vendors about how they could connect to labs, and they told me 'Oh yeah, we can interface with them, no problem,' " says Karen Williams, the laboratory manager at Internal Medicine of Northern Michigan, a Petoskey-based group practice of 11 physicians that operates its own lab. "But their idea of an 'interface' was that they could display results. They didn't understand laboratory workflow and the complexity of the information coming from the labs. And 15 years later, they still don't seem to have a good handle on it."
Meaningful Use
The EHR meaningful use incentive program was supposed to address that disconnect, and to some degree it has. Stage 1 treated lab connectivity with kid gloves: optional menu items required the import of at least 40 percent of lab data that could be represented in a numeric or structured format, as well as lab results be reportable to public health agencies. Stage 2, however, ramps things up considerably.
Core measures require that more than 30 percent of lab orders be initiated in the EHR; more than 55 percent of lab results must import to the EHR in a structured format; lab results must comply with the LOINC vocabulary; and support for the 2.5.1 messaging standard from Health Level Seven International is required.
That bodes well for the future, but the situation on the ground indicates that reliable lab/EHR connectivity is going to be a long time coming. And the disconnect is becoming an ever-growing problem as clinical tests become more refined and molecular and genetic testing come online in the industry. "All the detritus is starting to float to the top," says John Spinosa, M.D., chairman of pathology at Scripps Memorial Hospital in La Hoya, Calif., and a former chief of staff at the hospital.
"The industry hasn't really taken the existing standards seriously, and the effects are starting to be felt. It's getting very difficult for pathologists to communicate all the information they need to in lab results, and that problem's going to grow acute as more complex testing becomes the norm."
Scripps Memorial is part of Scripps Health, a San Diego-based health system that comprises four acute care hospitals, more than 2,600 affiliated physicians and a sprawling network of ambulatory settings.
Physician understanding
Spinosa says that physicians have an understanding of how critical laboratory/EHR connectivity is to their clinical operations. Scripps Health has, like its health systems peers, taken on the role of interface between ambulatory EHRs and the health system's labs (which run on laboratory information systems from Tucson, Ariz.-based Sunquest Information Systems), as well as reference labs. Getting into that line of work has been an eye-opener for the Scripps informaticists, he says.
"It required us to learn whole new skill sets, and it also gave us an idea of how messy building interfaces to ambulatory systems can be," he says. "Interfacing to a vendor's EHR system, we've learned, doesn't mean that we then can automatically interface to the vendor's other EHR systems. In fact, it doesn't even mean we can use the same interface for that same version of an EHR-the variance in implementations is enormous."
The blame for the variance in the use of messaging standards is shared by providers and EHR vendors, Spinosa says. "I feel that we've negotiated away a lot of the potential interoperability in this industry," he says. "Providers have not yet held their vendors' feet to the fire and insisted that they use the newest blocks of messaging standards. That's caused a lot of the 'fuzziness' we encounter when trying to get our labs to talk to all these EHRs."
Nothing comes easy
The variance in the use of messaging standards by EHR vendors is one big roadblock, but another issue holding back lab/EHR connectivity is their fundamental lack of understanding about lab-related workflow, says Williams at Internal Medicine of Northern Michigan.
A straightforward example: the group practice treats patients covered by a multitude of health insurers, and each insurer has their own set of rules around laboratory testing. Many require that certain types of lab tests, based on CPT codes, be conducted by national reference labs instead of the practice's in-house lab. As a result, the practice sends some tests that it can't perform in-house to the laboratory at the local hospital, McLaren Northern Michigan.
All in all, nearly 30 percent of the group's tests are sent to outside laboratories, Williams says. Physicians, she says, don't need to know where a test order is going, they just need to be able to order tests during their clinical workflow. But when Williams explained that complexity to EHR vendors, their response was that they would build a drop-down menu within the application that would enable physicians to choose the order's destination.
That solution, Williams says, is no solution at all. "A drop-down menu would basically require the physicians to know what the payer rules and our capabilities are for each order they place, and then pick the correct destination. That's not realistic," she says.
