The need for usability in electronic lab ordering

The push for electronic health records (EHRs) ultimately aims at cost-effective, safe care. While the adoption of electronic delivery of lab results has been beneficial to providers’ workflows, electronic lab ordering is really where the potential lies for fewer errors and greater efficiency for both the provider and the laboratory, and ultimately better care for patients. Electronic ordering will be in the next big wave of physician adoption following the new Meaningful Use Stage 2 requirement for computerized physician order entry (CPOE) of labs.

To achieve gains in efficiency and reduce errors, however, good usability, completeness, and accessibility are key. Ordering interfaces that confuse the doctor could cause more errors and slow the doctor down. On the laboratory side, orders need to have consistent, complete information that meets defined standards, or else all the manpower saved by inputting data into an LIS will be wasted on trying to patch holes in the requisition.

In today’s healthcare system, most providers are still ordering through paper. For the laboratory, this means that a dedicated team of people must input this information into an LIS. It is commonly estimated that data entry into a computer typically results in approximately an 8% error rate, leading to more delays and increased costs to the business. Electronic laboratory ordering lowers this cost by transferring the data directly into the LIS system—as long as that data is actually coming through clean and complete, and as long as the provider properly enters information.

Weaning providers off of paper

Laboratories that are taking advantage of new technology to streamline their operations still face resistance on the part of practices reluctant to make the switch. Regardless of whether a provider has adopted an EHR, this resistance is often a question of usability. In fact, usability is often the reason doctors don’t transition from paper in the first place. Manually filling out paper forms is fast and familiar for providers who have used them all their working lives. Printed labels for specific patients or situations can make it even easier for them to rapidly process forms.

The argument that paper is easier, however, fails to consider everything that happens before and after the form is filled out. In an EHR system, the patient demographic information can be automatically prepopulated into the form. The system can identify which lab tests the provider uses most frequently, which lab tests the patient has used before, and which tests the provider has marked as preferred (“favorites”). Above all, once the test has been processed by the lab and sent back to the provider, the results appear directly in the EHR tied to the patient’s chart, so the provider can avoid redundant testing and errors.

It’s important to note that these features are not always givens. Usability needs to be deliberately designed into an EHR to ensure there are as few unnecessary steps as possible for the doctor to complete actions.  Information that can be automatically populated should be automatically populated. Shortcuts that the provider can use to get an action done more quickly will help accelerate the doctor’s workflow over time, eventually outpacing the familiar paper workflows. For laboratories to fully reap the gains of an electronic connection to provider clients, these usability measures need to be a key part of the providers’ workflow—to keep them from returning to their old paper workflow. An electronic connection to the provider’s office isn’t much good if the provider decides not to use it.

Clean, comprehensive, consistent

Manual data input and resulting errors don’t have to be necessary evils for laboratories if the right connections are built into practice systems. Electronic orders cut down on errors simply by being connected into a laboratory’s LIS, with no additional human input needed. ABN checks, insurance information, and complete patient demographics can further reduce the amount of time that laboratory personnel need to spend gathering information that might not otherwise be included. These orders are potentially far more consistent than paper forms; there is no handwriting to decipher, and there are no variations in the kind of information submitted from provider to provider.

These practice systems, however, haven’t always been free of problems with uniformity, consistency, and completeness.¹ Incomplete lab results can pose almost as many problems as faulty human input, and laboratories increasingly face fragmented approaches to how data is sent from different EHR systems. Integrating with systems that don’t provide the right information can cost the laboratory more time and money trying to retrieve the information from the doctor and re-inputting the correct information into the LIS.

Adhering to proper standards and message profiles in EHR systems is essential to avoiding the pitfalls of inconsistency that slow the laboratory down. Standards include everything that can be sent for an order, while message profiles narrow the standard to ensure that only the necessary information is present. For many older EHR systems that are installed onsite on servers in a provider’s office, custom interfaces to the LIS often have to be built for each individual practice, greatly compounding the possibility of inconsistent standards and message profiles. From one installation to another, the laboratory might be getting entirely different sets of data back from providers, even those using technology from the same EHR vendor.

Basic usability for the doctor also results in greater consistency of results for the lab. When the EHR automates most of the information included in a lab order, the doctor has to do only a few things to specify additional information needed, reducing the possibility of error upfront. The EHR can include additional functionality to ensure that human error on the part of the provider is avoided, such as preventing the wrong labs or duplicate labs from being sent.

The challenge and opportunity of Meaningful Use

Upcoming Meaningful Use Stage 2 requirements will begin to push providers in the direction of electronic ordering. While providers are not required to integrate with their lab to send orders digitally, the requirements do mandate the electronic input of order information for at least 30% of orders, including labs.² Because they will have to enter their orders anyway, most providers will appreciate the ability to send the order after inputting it.

For laboratories seeking to make their operations more efficient and streamlined, the new Meaningful Use requirements are an opportunity to get providers started on paperless workflows to send their orders. It may even be the case that providers begin to lead the charge themselves in order to save time. E-Prescribing, which has been required by Meaningful Use since 2011, has seen adoption among community pharmacies rise from 76% to 94% from 2008 to 2012,³ in part because of the push for provider adoption. Laboratories should be aware of how these requirements affect their clients and offer them the connectivity that allows them to more easily fulfill these upcoming requirements and benefit.

Implementation: weeks or months

A lab considering the timeline of a possible integration may plan as far as a year out. Accessibility for the laboratory is almost as large a consideration as usability. Labs looking to offer their providers rapid connectivity to help them save time while fulfilling their Meaningful Use CPOE requirements may be unable to do so with server-based EHRs that require discrete connections for each individual provider. For providers on web-based solutions, on the other hand, the laboratory does have the potential to connect quickly and capitalize on the timing of Meaningful Use. While timelines vary from vendor to vendor, web-based EHRs can often take weeks instead of months to integrate and usually offer a one-time integration to their whole population of users rather than to individual providers. This universal connection makes it easier for a lab to offer its services to other providers who decide to go paperless with that EHR solution.

Potential for the future

The biggest potential gains for usability and efficiency in EHR lab ordering are yet to come, for both the provider and the patient. For EHR systems that continue to innovate and improve their products, certain valuable functionality can be expected. Clinical decision support can provide physicians with real-time alerts and guidance about which tests are necessary for their patient population. For example, patients with certain vitals and previous diagnoses might be prime candidates to receive a glucose test for diabetes. For both the provider and the laboratory, time spent on communications can be eliminated with real-time status updates to the EHR, indicating that an order has been received so that the provider doesn’t have to manually check on it. This can help reduce the poor rates of physician follow-up often seen with clinical laboratory results.⁴

For both providers and laboratories, the benefits of electronic laboratory ordering are clear, from reduced costs to fewer errors in the course of care. With awareness of the options available to them and their providers, laboratories have the opportunity to establish connections with the EHRs that provide the most intuitive experience for providers while minimizing implementation time. These connections can eliminate the inefficiencies of data entry overhead, missing data, and time-consuming follow-up with providers.