Do I Need a Lab Interface to Meet EMR Meaningful Use Criteria?

EMR Interface for Lab Orders and Results

Absolutely. In order to meet the “meaningful use” criteria for electronic transmission and CPOE, and to qualify for the federal ARRA incentives, you must submit and receive orders electronically 80% of the time.

Cost of Lab Interfaces

Lab interface costs depend a lot upon your EMR vendor and the lab with which you’d like to interface. Some EMR vendors will offer a lab interface for free (or part of the standard cost of your EMR system) while others charge extra. The same is true for labs. Most major labs are willing to offer their interface for free. Lab interface fees are fairly easy to negotiate because a lab interface benefits the lab as well as the practice.

Be Sure to Get the Lab Interface You Need

There are two types of lab interfaces. A “uni-directional” (one-way or “results-only”) lab interface allows you to receive lab results electronically, but you must place “orders” either by telephone or fax. A “bi-directional” (two-way or “orders-and-results”) lab interface allows orders and results to be sent and received electronically. The current “meaningful use” regulations require a bi-directional lab interface.

The EMR Vendors

Many EMR vendors offer bi-directional capabilities. Be sure to check with the lab companies that you use, the major labs, regional labs and hospital labs. You may be able to get by with a uni-directional interface for a lab you use only occasionally (electronic transmission of results only). But the majority of your labs orders and results should be sent and received electronically. Be sure to ask questions about lab interfaces during your EMR selection process.

Benefits of Bi-Directional Lab Interfaces

Be aware that receiving lab results electronically is not merely a convenience (and a necessity if your are to qualify for the federal ARRA incentives). When you receive them electronically, lab results can be stored electronically. This increases practice efficiencies and allows you to graph lab results, conduct practice studies across your patient population, and satisfy government, insurance, and any “pay-for-performance” reporting requirements.

EHR Meaningful Use Criteria for Eligible Providers

The following list of 25 Stage 1 Meaningful Use criteria for Eligible Providers was extracted from the Department of Health and Human Services (HHS) Interim Final Rule (February 12, 2010): “Medicare and Medicaid Programs; Electronic Health Record Incentive Program.”

You can view the full Interim Final Rule here.

Stage 1 Meaningful Use Criteria – Eligible Providers – Rule in Public Comments Period Until March 15, 2010

Objective: Use CPOE
Measure: CPOE is used for at least 80 percent of all orders

Objective: Implement drug-drug, drug-allergy, drug- formulary checks
Measure: The EP has enabled this functionality

Objective: Maintain an up-to-date problem list of current and active diagnoses based on ICD-9-CM or SNOMED CT®
Measure: At least 80 percent of all unique patients seen by the EP have at least one entry or an indication of none recorded as structured data.

Objective: Generate and transmit permissible prescriptions electronically (eRx).
Measure: At least 75 percent of all permissible prescriptions written by the EP are transmitted electronically using certified EHR technology.

Objective: Maintain active medication list.
Measure: At least 80 percent of all unique patients seen by the EP have at least one entry (or an indication of “none” if the patient is not currently prescribed any medication) recorded as structured data.

Objective: Maintain active medication allergy list.
Measure: At least 80 percent of all unique patients seen by the EP have at least one entry (or an indication of “none” if the patient has no medication allergies) recorded as structured data.

Objective: Record demographics.
Measure: At least 80 percent of all unique patients seen by the EP or admitted to the eligible hospital have demographics recorded as structured data

Objective: Record and chart changes in vital signs.
Measure: For at least 80 percent of all unique patients age 2 and over seen by the EP, record blood pressure and BMI; additionally, plot growth chart for children age 2 to 20.

Objective: Record smoking status for patients 13 years old or older
Measure: At least 80 percent of all unique patients 13 years old or older seen by the EP “smoking status” recorded

Objective: Incorporate clinical lab-test results into EHR as structured data.
Measure: At least 50 percent of all clinical lab tests results ordered by the EP or by an authorized provider of the eligible hospital during the EHR reporting period whose results are in either in a positive/negative or numerical format are incorporated in certified EHR technology as structured data.

Objective: Generate lists of patients by specific conditions to use for quality improvement, reduction of disparities, research, and outreach.
Measure: Generate at least one report listing patients of the EP with a specific condition.

Objective: Report ambulatory quality measures to CMS or the States.
Measure: For 2011, an EP would provide the aggregate numerator and denominator through attestation as discussed in section II.A.3 of this proposed rule. For 2012, an EP would electronically submit the measures are discussed in section II.A.3. of this proposed rule.

Objective: Send reminders to patients per patient preference for preventive/ follow-up care
Measure: Reminder sent to at least 50 percent of all unique patients seen by the EP that are 50 and over

Objective: Implement five clinical decision support rules relevant to specialty or high clinical priority, including for diagnostic test ordering, along with the ability to track compliance with those rules
Measure: Implement five clinical decision support rules relevant to the clinical quality metrics the EP is responsible for as described further in section II.A.3.

Objective: Check insurance eligibility electronically from public and private payers
Measure: Insurance eligibility checked electronically for at least 80 percent of all unique patients seen by the EP

Objective: Submit claims electronically to public and private payers.
Measure: At least 80 percent of all claims filed electronically by the EP.

Objective: Provide patients with an electronic copy of their health information (including diagnostic test results, problem list, medication lists, and allergies) upon request
Measure: At least 80 percent of all patients who request an electronic copy of their health information are provided it within 48 hours.

Objective: Provide patients with timely electronic access to their health information (including lab results, problem list, medication lists, allergies)
Measure: At least 10 percent of all unique patients seen by the EP are provided timely electronic access to their health information

Objective: Provide clinical summaries to patients for each office visit.
Measure: Clinical summaries provided to patients for at least 80 percent of all office visits.

Objective: Capability to exchange key clinical information (for example, problem list, medication list, allergies, and diagnostic test results), among providers of care and patient authorized entities electronically.
Measure: Performed at least one test of certified EHR technology’s capacity to electronically exchange key clinical information.

Objective: Perform medication reconciliation at relevant encounters and each transition of care.
Measure: Perform medication reconciliation for at least 80 percent of relevant encounters and transitions of care.

Objective: Provide summary care record for each transition of care and referral.
Measure: Provide summary of care record for at least 80 percent of transitions of care and referrals.

Objective: Capability to submit electronic data to immunization registries and actual submission where required and accepted.
Measure: Performed at least one test of certified EHR technology’s capacity to submit electronic data to immunization registries.

Objective: Capability to provide electronic syndromic surveillance data to public health agencies and actual transmission according to applicable law and practice.
Measure: Performed at least one test of certified EHR technology’s capacity to provide electronic syndromic surveillance data to public health agencies (unless none of the public health agencies to which an EP or eligible hospital submits such information have the capacity to receive the information electronically).

Objective: Protect electronic health information maintained using certified EHR technology through the implementation of appropriate technical capabilities.
Measure: Conduct or review a security risk analysis in accordance with the requirements under 45 CFR 164.308 (a)(1) and implement security updates as necessary.

EHR Meaningful Use Criterial for Eligible Hospitals

The following list of 23 Stage 1 Meaningful Use criteria for Eligible Hospitals was extracted from the Department of Health and Human Services (HHS) Interim Final Rule (February 12, 2010): “Medicare and Medicaid Programs; Electronic Health Record Incentive Program.”

You can view the full Interim Final Rule here.

Stage 1 Meaningful Use Criteria – Eligible Hospitals – Rule in Public Comments Period Until March 15, 2010

Objective: Use of CPOE for orders (any type) directly entered by authorizing provider (for example, MD, DO, RN, PA, NP)
Measure: CPOE is used for at least 10 percent of all orders

Objective: Implement drug-drug, drug-allergy, drug- formulary checks
Measure: The eligible hospital has enabled this functionality

Objective: Maintain an up-to-date problem list of current and active diagnoses based on ICD-9-CM or SNOMED CT
Measure: At least 80 percent of all unique patients admitted to the eligible hospital have at least one entry or an indication of none recorded as structured data.

Hospital Objective: Maintain active medication list.
Measure: At least 80 percent of all unique patients admitted by the eligible hospital have at least one entry (or an indication of “none” if the patient is not currently prescribed any medication) recorded as structured data.

Objective: Maintain active medication allergy list.
Measure: At least 80 percent of all unique patients admitted to the eligible hospital have at least one entry (or an indication of “none” if the patient has no medication allergies) recorded as structured data.

Objective: Record demographics.
Measure: At least 80 percent of all unique patients admitted to the eligible hospital have demographics recorded as structured data

Objective: Record and chart changes in vital signs.
Measure: For at least 80 percent of all unique patients age 2 and over admitted to the eligible hospital, record blood pressure and BMI; additionally, plot growth chart for children age 2 to 20.

Objective: Record smoking status for patients 13 years old or older
Measure: At least 80 percent of all unique patients 13 years old or older admitted to the eligible hospital have “smoking status” recorded

Objective: Incorporate clinical lab-test results into EHR as structured data.
Measure: At least 50 percent of all clinical lab tests results ordered by an authorized provider of the eligible hospital during the EHR reporting period whose results are in either in a positive/negative or numerical format are incorporated in certified EHR technology as structured data.

Objective: Generate lists of patients by specific conditions to use for quality improvement, reduction of disparities, research, and outreach
Measure: Generate at least one report listing patients of the eligible hospital with a specific condition.

Objective: Report hospital quality measures to CMS or the States.
Measure: For 2011, an eligible hospital would provide the aggregate numerator and denominator through attestation as discussed in section II.A.3 of this proposed rule. For 2012, an eligible hospital would electronically submit the measures are discussed in section II.A.3. of this proposed rule.

Objective: Implement five clinical decision support rules relevant to specialty or high clinical priority, including for diagnostic test ordering, along with the ability to track compliance with those rules
Measure: Implement five clinical decision support rules relevant to the clinical quality metrics the Eligible Hospital is responsible for as described further in section II.A.3.

Objective: Check insurance eligibility electronically from public and private payers
Measure: Insurance eligibility checked electronically for at least 80 percent of all unique patients admitted to an eligible hospital

Objective: Submit claims electronically to public and private payers.
Measure: At least 80 percent of all claims filed electronically by the EP or the eligible hospital.

Objective: Provide patients with an electronic copy of their health information (including diagnostic test results, problem list, medication lists, allergies, discharge summary, and procedures), upon request.
Measure: At least 80 percent of all patients who request an electronic copy of their health information are provided it within 48 hours.

Objective: Provide patients with an electronic copy of their discharge instructions and procedures at time of discharge, upon request.
Measure: At least 80 percent of all patients who are discharged from an eligible hospital and who request an electronic copy of their discharge instructions and procedures are provided it.

Objective: Capability to exchange key clinical information (for example, discharge summary, procedures, problem list, medication list, allergies, diagnostic test results), among providers of care and patient authorized entities electronically.
Measure: Performed at least one test of certified EHR technology’s capacity to electronically exchange key clinical information.

Objective: Perform medication reconciliation at relevant encounters and each transition of care.
Measure: Perform medication reconciliation for at least 80 percent of relevant encounters and transitions of care.

Objective: Provide summary care record for each transition of care and referral.
Measure: Provide summary of care record for at least 80 percent of transitions of care and referrals.

Objective: Capability to submit electronic data to immunization registries and actual submission where required and accepted.
Measure: Performed at least one test of certified EHR technology’s capacity to submit electronic data to immunization registries.

Objective: Capability to provide electronic submission of reportable lab results to public health agencies and actual submission where it can be received.
Measure: Performed at least one test of certified EHR technology capacity to provide electronic submission of reportable lab results to public health agencies (unless none of the public health agencies to which eligible hospital submits such information have the capacity to receive the information electronically).

Objective: Capability to provide electronic syndromic surveillance data to public health agencies and actual transmission according to applicable law and practice.
Measure: Performed at least one test of certified EHR technology’s capacity to provide electronic syndromic surveillance data to public health agencies (unless none of the public health agencies to which an eligible hospital submits such information have the capacity to receive the information electronically).

Objective: Protect electronic health information maintained using certified EHR technology through the implementation of appropriate technical capabilities.
Measure: Conduct or review a security risk analysis in accordance with the requirements under 45 CFR 164.308 (a)(1) and implement security updates as necessary.

EMR EHR Interoperability and Risk

EMR and Interoperability

Interoperability is defined as the ability of a system or a product to work with other systems or products without special effort on the part of the system owner. Interoperability is a fundamental requirement for widespread EMR adoption. For patients, increased interoperability means increased provider choice, greater transparency, lower costs, and better clinical outcomes. The future of interoperability is the sharing of patient information at the point of care, giving all providers within a patient’s care contiuum access to a longitudinal medical record (EHR). The new “standard” of service for providers and care facilities will be defined by their ability to provide optimum care for all individuals, regardless of provider, payor, or point of care.

Increased Risk

But with the technological ability to “transform care” through interoperability comes additional risk. The “seamless flow” of information from one IT system to another requires added security measures, ones that support identification and authentication, audit measures, encryption, and residual protection. The process of identifying vulnerabilities should include include an analysis of the IT system security features, and the security controls (technical and procedural) used to protect the system.

Investment of Resources

While interoperability is the new buzz word in EMR adoption and integration, it will require a substantial investment by the end user in terms of regulatory compliance and establishment of policies and procedures for each user. Establishing the role of Compliance Officer is critical to maintain security and report any threats or breeches as they occur. Contaminated or corrupted data will result in inaccuracy, fraud, and erroneous clinical decisions.

More EMR EHR Planning Advice

Envisioning EMR Benefits

Your adoption of an EMR solution will provide many benefits. By envisioning those benefits as you begin to plan your EMR project, you will maintain an important frame of reference. Ask yourself along the way, “Is this feature or function point really valuable toward our sought-after benefits and objectives, or is it merely something that might be nice to have?” Or, “Is it realistic to believe that our office will actually adopt this workflow (merely because it happens to be supported by an EMR solution)?”

Getting Started With Your EMR Project

Start your EMR project by forming an EMR Project Team. Assign a clinician to be the team lead. Successful project teams often include one or more physicians who believe in the merits of EMR and demonstrate their commitment to your EMR project.

Expect Challenges Along the Way

EMR adoption is not a “plug-and-play’ experience. Rather, you’ll pretty much get out of your new EMR system something aligned with the effort you put into selecting your system. Research and planning are key. Yes, research and planning take time which is in short supply these days, but there is no substitute for becoming truly engaged in your EMR project. Some project teams find it useful to set aside a pre-determined amount of time each week to move their project forward. Regular “lunchbox meetings” also produce some good results. Remember, you don’t have to finish your planning process in one day. “Divide and conquer” is acceptable, and regular progress, even though it may be incremental, will get the job done.

Patient and Office Basics

Gathering some basic information about your staff, patients, and practice habits will help you to clearly
define what it is you want an EMR system to do for you. This process will also highlight potential “pain points” that can be addressed prior to EMR adoption. Technology alone won’t fix all that may be broken in terms of your workflows and routines.

List Must-Haves

Make a list of EMR functional requirements that you can’t live without. Think about the top 20 reasons you want to have an EMR, write them down and make a score sheet out of the list (rank your entries).

Negotiate a Better EMR EHR Vendor Contract

Getting Buyer-Favorable Contract Terms for EMR

In today’s competitive EMR marketplace, there is always room for negotiation. Make sure that you negotiate a contract with your EMR/PM system vendor that protects you and serves your best interests. And remember, your EMR/PM system vendor won’t volunteer buyer-favorable terms and conditions. You have to have to ask and negotiate for them.

Reading the Fine Print

If you’ll look at your EMR vendor’s standard Software License Agreement or Subscription Agreement (ASP), you’ll quickly realize that it’s chock full of vendor-favorable terms and conditions, provisions that serve and protect your EMR vendor. License limitations, disclaimers, exceptions, licensee duties and prohibitions, vendor rights, and so on. You’ll also realize that there’s actually very little in the contract that protects you. In fact, almost nothing. If you want a contract that serves and protects you as an EMR system buyer, you have to know what to ask for, and then how to negotiate for it.

Knowledge Is Power

EMR/PM system buyers can benefit greatly from the advice and counsel of an EMR Specialist Consultant or Software Procurement Professional. Information technology transactions are notoriously complicated, and unless you have appropriate knowledge, you’ll be negotiating in the dark. Knowing what buyer-favorable terms and conditions to request, and how to negotiate for them, are critical. Remember, when the ink is dry on the contract, you’ll have to live with all the terms you got, and didn’t get, for years to come.

Some EMR Contract Terms to Consider

Current adopters of EMR solutions are aware of the federal dollar incentives available, and your receipt of those dollars turns upon “certification” of your EMR solution and your “meaningful use” of the solution over time. Your EMR vendor should warrant both elements, now and into the future. Your measure of damages for breach of these warranties should at, at minumum, be tied to your lost federal incentive payments.

Support of any software is important, and support of an EMR solution is critically important because all viable solutions will be updated regularly, and for years to come. Be sure that you have tied monetary or other penalties to your EMR vendor’s failure to fulfill its support obligations.

Consolidation in the EMR marketplace is inevitable. There are simply too many vendors chasing the same chunk of cheese. Think about what might happen if your EMR vendor is purchased by another firm. Will you have to re-license your software? What if the new owner decides to no longer support your current platform (e.g., Windows)? There are many aderse consequences that affect deployed users when a softare firm is purchased. You can minimize your exposure to such risk at the time you contract with your EMR/PM vendor.

Patient Portal Technology

Demand for Patient Portals

Patients are becoming more technically savvy and impatient, in many instances preferring self service over human assistance. They don’t want to play telephone tag or clipboard tag with their healthcare provider’s office. They know that a better way exists, and they want you to adopt a better way of carrying on your healthcare “business”.

Benefits of Patient Portals

Patients benefit from the ability to communicate electronically, from any computer, on simple requests to their healthcare practice. Healthcare practices benefit from better office efficiencies, not being tied to telephones all day, and a more efficient task processes overall. Clinical leadership (Nursing) benefits from a more streamlined process for medical record requests, prescription refills, and patient demographic changes.

The Future of Patient Portals

Experts predict that patient portals will become more prevalent as patient demand for health information increases and more healthcare practices and hospitals make the transition to EHRs. Studies have shown that even in geriatric patient populations, patient portal acceptance is in the 80% range. Family members often step up and help with access. Family members take comfort in knowing a complete and accurate medical record exists for loved ones, and they’re happy to be involved.

Customization of Patient Portals

Patient portal technology can be tailored to fit needs and preferences. Practices, clinics and hospitals can develop their patient portal technology in house, or they can choose from any number of viable OTC solutions. In either case, configuration and customization to fit needs is always an option.

What Is a Patient Portal?

Web-Based

A Patient Portal is a web-based communication tool that is easy to use, and if set up properly, safe to use.

Extending Office Automation

Adoption of an EMR solution can increase healthcare practice efficiencies profoundly, but you can add even more efficiencies with a Patient Portal. By allowing patients to access their own patient information, including labs and diagnostics, and providing automated health maintenance reminders and procedure due dates, your staff can save a huge amount of time that can then be spent on more profitable activities.

Depending on the communication format you choose, a Patient Portal can serve as a communication tool and information portal to complete office paperwork, request medical records and refills, check co-pays or fee balances, and update demographic information. You can set up patient access within your office through a personal computer and use it self-check in, completion of forms, updating of health histories, and more. Or, allow patient access through a secure, encrypted web portal. Regardless of which solution you choose (both are better!), a Patient Portal is a valuable asset in today’s busy practice.

Some Patient Portal Features

  • Send and receive messages to and from doctor’s office (e.g., patient can send a refill request or request a nurse call)
  • Request appointments or schedule labs
  • Request or examine medical records
  • Enter or modify personal demographic and /or payor information
  • Receive e-mails for reminders, upcoming appointments and statements
  • Patients can pay balances online

EMR and EHR – ASP Versus Client Server

About the ASP or SaaS Model for EMR EHR

An Application Service Provider (ASP) is a firm that hosts a software application through a network, typically the Internet. You do not need to buy the software or install it on your system. This model is also referred to as “On-Demand Software” or “Software as a Service” (SaaS).

As an ASP subscriber, you can remotely access your EMR EHR solution from home, the office, or anywhere you have an Internet connection.

Advantages of the ASP Model for EMR EHR

  • Because it’s a stand-alone system, there is no required integration at the client site
  • Updates and upgrades to software are done automatically
  • Improved reliability, availability, scalability and security of internal IT systems
  • Reduction of internal IT costs (one less application to maintain)

Disadvantages of the ASP Model for EMR EHR

  • Integration with the client’s non-ASP systems may be problematic
  • The client must generally accept the application as provided since ASPs can only afford a customized solution for the largest clients
  • The client may rely on the provider to provide a critical business function, thus limiting their control of that function and instead relying on the provider
  • Changes in the ASP market may result in changes in the type or level of service available to clients
  • Fees for life; you never “own” your application

About Locally Installed or Client Server EMR EHR

Under the Locally Installed or Client Server model for EMR EHR, you must buy (license) your software application and install it on your system. Thereafter, you must maintain the application, including installation of udates and upgrades.

Advantages of the Client Server Model for EMR EHR

  • More control; your application is onsite and accessible by you
  • You “own” your data
  • You “own” your application after you have fully paid your perpetual license fee
  • No down time due to Internet disconnects or outages

Disdvantages of the Client Server Model for EMR EHR

  • You need extra hardware to run your EMR solution (e.g., an application server)
  • Extra hardware also means extra maintenance
  • Application maintenance often must be performed manually (e.g., manually installing udates and upgrades
  • Remote access (e.g., from home) is not impossible, but requires additional enablement
  • Ongoing software “maintenance” fees are separate and apart from license fees

EMR EHR Planning – A Checklist

High-Level Checklist for EMR EHR Project Planning

  1. Assess the readiness of office staff and clinicians to embrace new technology.
  2. Communicate with your staff regularly and involve them in the planning phase.
  3. Look at your budget. Like anything , there are the Cadillacs, and there are Fords. Determine what you need to spend in order to gain the best “fit” for your practice.
  4. Identify key people to lead. Your project will require a team effort, and your team will need leaders.
  5. Determine your goals and objectives for EMR Adoption, and be realistic.
  6. Perform a Cost-Benefit Analysis (comparing the cost of what you’ll be getting to the benefits) and a Gap Analysis (in terms of technology, what do you have now and what will you need to acquire in order to support your new EMR system).
  7. Look at ratings of different systems through TEPR, KLAS, AC Group and MS-Hug.
  8. Understand that any change is difficult at first. Put processes and people in place to help with transitions. Ask a consultant to sit in on your vendor demos. This can take hours off your time investment, and a consultant can point out things that you might not even know enough to ask about.
  9. Relax. EMR adoption will increase your efficiencies and reimbursements and enable office productivity. When you choose to progress to purchase and implementation, you will be prepared and ready.