Although Electronic Health Records (EHRs) have been around since the 1960s, major advances in information technology, abundant federal regulations, higher expectations by providers, and more informed healthcare consumers continue to raise the bar and demand more from the EHR. EHRs allow providers to access an electronic patient chart; however, as healthcare reform takes shape, the EHR or other systems, possibly systems that don’t yet exist, will need to provide tools that support accountable, evidence-based care. If used to their full potential, EHRs can be very powerful, particularly when coupled with strong laboratory information systems (LIS) that supplement in areas where EHRs have not focused their efforts.
Most readers will be familiar with the Health Information Technology for Economic and Clinical Health (HITECH) Act. HITECH incentives are driving EHR adoption. The EHR incentive program, which rewards healthcare professionals monetarily for achieving certain Meaningful Use (MU) objectives, began in 2010 and has been a driving factor in EHR adoption. Already, more than 219,000 providers have received checks totaling more than $12 billion in incentive payments for meeting Stage 1 of Meaningful Use. According to the New England Journal of Medicine’s February 2013 report, 58.5% of attestations were by organizations utilizing the top five EHR vendors.
Integrated, value-based healthcare
On October 1, 2014, the ICD-9 code sets used to report medical diagnoses and inpatient procedures will be replaced by ICD-10 code sets. That coming transition from International Classification of Diseases (ICD) -9 to -10 will require EHR improvements and upgrades. On top of that, the Affordable Care Act (ACA) is asking the healthcare industry to prepare for value-based payment, bundles of services under fixed payment, and accountability for the healthcare needs of specific patient populations. With healthcare heading toward the delivery of integrated care, EHRs will have to determine how to be interoperable. If the EHR is the central database of your healthcare information and is critical for proper diagnosis and monitoring of patients, then how can you maximize the EHR strengths? Where do you need to supplement the EHR’s weaknesses?
The EHR and the LIS have different, but complementary, tools to support the analytics needed by Accountable Care Organizations (ACOs). As healthcare facilities tackle the improvement of the overall health of a population and consider entering risk-sharing payment models that require reporting of detailed analytics, they are turning to payors and health IT vendors for benchmarking analytics and patient risk stratification data. Laboratory data is needed for screening, prompt diagnosis, and treatment decisions, and to monitor and measure effectiveness—all parts of the overall goal of improving the health of a population. Inefficiencies such as overutilization, redundant test orders, and lack of follow-up on lab results must be eliminated in order to achieve the cost savings and efficiency required by the new performance-based business models.
CPOE offers provider education opportunity
One of the MU Stage 2 core objectives requires that Computerized Physician Order Entry (CPOE) be used for a minimum of 30% of laboratory tests. Although capable EHRs provide an easily accessible place for providers to perform CPOE, often EHR order entry functionality does not take into consideration the actual workflow of processing specimens through a laboratory, including medical necessity flagging, Advance Beneficiary Notices of Noncoverage (ABNs), and splitting and routing of orders based on insurance. Order entry is an example of an area where many labs decide to continue to use their web-based LIS ordering feature to supplement their EHR’s CPOE process.
Additionally, it is important for laboratory managers to help staff understand that there is a learning curve for providers performing CPOE. Laboratorians can be instrumental in the shift to CPOE by creating a more intuitive EHR test order compendium that is considerate of the providers’ workflow process and by offering guidance to providers when incorrect or duplicate test orders are received. Rebecca Burk, Laboratory Manager at Central Ohio Primary Care Physicians (COPCP, Inc.) began group-wide CPOE in its EHR in September 2012. “Now that providers are performing CPOE in the EHR, rather than the subcategory tabs provided by the LIS,” Burk says, “the EHR has one large test compendium, and there may be several tests with similar names, which makes it more difficult for providers to choose the correct test.” She continues:” For example, Hepatitis C may have five or six choices. When providers order the incorrect test, we have the opportunity to reach out and provide education. It’s important for labs to be realistic about that; you cannot do enough educating—even after the fact.” Burk adds that she finds that her providers are very receptive to this interactive education.
Connectivity challenges
Because lab integration is absolutely essential, connectivity between the LIS and the EHR is a must-do. Lab results need to be seamlessly integrated into the patient chart for best patient care, and to feed into MU requirements. Successful implementation requires a team, yet IT departments can be stretched thin, sometimes making lab connectivity a low priority.
EHRs and Health Information Exchanges (HIEs) can sometimes offer unfulfilled promises when it comes to the laboratory side for integration and functionality. Even capable vendors have difficulty meeting timelines due to a backlog of installs attributable to recent increases in EHR requests as practices strive to participate in MU.
POC testing
As we create more networked healthcare and strive to reduce hospital admissions, this may add workload to the primary care doctors, causing more Point-of-Care (POC) testing to be performed at remote locations. How do you build a lab network in an ACO model and make sure everything is getting back into the EHR in a codified, structured way, so the provider can easily use the information to monitor the patient’s progress? As an example, COPCP, Inc., is using an orders and results management software program that serves as a simple “review, click, and go” cost-effective bridge for electronically passing orders and results between remote, low-volume, POC analyzers and its LIS, then into its EHR. If we think about the direction the value-based care model needs to take and how that impacts laboratory testing, there’s a logical assumption that some lab work needs to take place close to the patient. The point can be made that lab testing performed near the patient is best for the care of the patient, but in order to get the full benefit of POC testing, results must be captured electronically and routed to the electronic chart.
As healthcare moves toward a more integrated care delivery model, much more will be required of the primary care provider. There may be more centralized lab testing within networks with various POC instrumentation to monitor patients at the ambulatory sites. With this in mind, the need for integration of POC into the EHR becomes more important. Healthcare will need integration to coordinate services across a spectrum of organizations and providers to achieve more effective operations, reduce waste, and lower costs.
Opportunities going forward
In order to successfully achieve value-based healthcare reform, strong leadership is needed. Laboratory leaders must align with physicians and organizational leaders to help determine how to best utilize both the LIS and the EHR to their full potential, combining the unique strengths of the two systems to maximize efficiency and reduce costs, resulting in improved patient outcomes and satisfaction.
The goal is not just to automate the paper record, but to use technology to care for populations based on their disease-specific needs in a proactive and patient-interactive manner. Although it’s difficult to predict the exact structure the new healthcare system will take, we can expect significant changes.
Laboratory leaders need to be thinking about where the lab fits in the big picture of a value-based healthcare system and how the lab can best fit the needs of its healthcare organization and the patients it serves. The lab is the repository of massive amounts of data needed for analytics that facilities are combining with claims data to achieve population health management. The future may entail the LIS and the EHR working in conjunction to absorb information from pathology, molecular, radiology, pharmacy, and other ancillaries, and then feed that data to a supercomputer capable of analyzing patient symptoms, along with the clinical data and any applicable research data, and presenting probable diagnoses and treatment options to assist providers in more efficient patient care. Think about this new paradigm and begin to position your laboratory to add “value” to value-based healthcare.
