HMT According to The Joint Commission, the lion’s share of the information used by physicians for medical decision-making is produced in the lab. Consequently, a major portion of the clinical data populating EMRs comes from the lab. It is therefore not surprising that one of the biggest challenges facing lab managers today is the EMR and the effective electronic integration of data from one information system to another within the rest of the health organization or network. With clinical results such a key component of the EMR, the laboratory information system (LIS) is the critical link in the flow of data that makes the interface and integration capabilities of an LIS critical throughout the healthcare continuum.

Although considered a mature sector, labs of all types and sizes continue to evolve their communication and integration strategies both internally and via critical outreach to physician practices and healthcare organizations. While IT innovation closes the remaining direct communication gaps between lab devices and the LIS, the growing challenge today and on the horizon is integration between the LIS and the EMR. With EMR vendors either embracing or ignoring the data flow needs between labs and their clients of all stripes, the primary burden of facilitating the flow of information often falls to the labs themselves. In an evolving lab/client world where each situation is different, the approaches to LIS client outreach vary from situation to situation as well.

A Tale of Two Labs

As the first licensed independent clinical laboratory in Maine, NorDx Labs is affiliated with Maine Medical Center (MMC), the Maine Medical Center Research Institute (MMCRI), and the Center for Lipid Research and Clinical Research Management. Processing more than 2.5 million lab tests a year, the southern Maine-based lab has a large contingent of practices throughout Maine and southern New Hampshire.

From the perspective of Denis Rochette, director of information technologies at NorDx, lab outreach can be a big part of the business, depending on the size of the lab. "Very large labs have developed object-oriented template capabilities using .NET or similar technologies to interface to the various EMR and EHRs in the real world," says Rochette. "Rather than developing software internally, we exchange information with the EMR through templates provided by Michigan-based Covisint Inc. (formerly Hilgraeve) — a data communications software and Internet-based service provider who acts as a partner to help us pull and push lab data to our various outreach clients."

The challenge for labs interfacing with client EMRs is that there is no such thing as “one size fits all” for labs and clinicians. By providing a standard set of services when interfacing a client EMR with their LIS, MPLN can provide a set of solutions that delivers reports to all of the necessary brokered people via the device, format and time that works best.

Maryville, Tenn.-based Molecular Pathology Laboratory Network Inc. (MPLN) provides a wide selection of molecular diagnostics and cytogenetic tests and services with full accreditation for the states of Tennessee, Florida, New York and Maryland. The full service lab processes some 200,000 tests a year. According to MPLN Information Services Project Manager John McSpadden, the lab originally utilized XML to transfer information from their Web-based system to their database.

MPLN concluded in 2002 that there was no information system that could hold the molecular and cellular information that they were generating, and decided to build their own LIS in 2003 when McSpadden joined the project. "We adopted the HL7 standard side by side with our existing AMT message structure standard, which is the basis for our LIS interface as they were similar as far as message structures go," says McSpadden. "At that time we weren’t interfaced with anyone and were a standalone system."

Where We Came From

As a best-of-breed organizational approach, NorDx utilizes different LIS, Web product, blood bank, finance and pathology systems. The SCC Soft Computer SoftLab LIS is accessible via virtual private network (VPN) to certain clients, however, all instrumentation is interfaced electronically to the LIS so that when results are done, they are sent electronically to the LIS, which manages the results and the patient information within that system.

NorDx also works with Ind.-based Orchard Software Corp., which provides the lab with their Web-based outreach software known as Copia. NorDx brands the Copia software’s Web interface as NorDxNOW. "Each time we expand our outreach program, we find that every practice uses a variety of EMR systems, and consequently, we currently have interfaces to four types of EMR and are currently working on another six," says Rochette.

HMT NorDx chose to have Covisint do the translations due to their understanding of the lab’s LIS and outreach specifications. In practice, NorDx has developed a single interface between Covisint and the Copia software while Copia provides a single interface for the LIS and the pathology system. "The interface only has to deal with a vendor’s EMR, so once that is done, the repeated cycle involves enabling a data specification exchange, building the templates and then running through a testing cycle for results and reports to ensure everyone sees what they should in order to facilitate the proper diagnosis," says Rochette.

Client Outreach Models

As part of the educational outreach to potential lab clients, NorDx provides an outline of the specific outreach models that the laboratory can offer clients in terms of sending and receiving orders and results. The Inquiry Only model allows an outreach client to search their practice’s results without changing any current processes for generating lab orders or receiving results. The Unidirectional Interface model allows electronic transfer of data in one direction only. This is normally the method for sending only lab results to an EMR but can also be used for the acquisition of demographic and insurance data.

HMT The third model is the Bidirectional Interface, which allows sending and receiving data electronically from an EMR. This approach is utilized for those EMRs able to both generate lab orders and receive results.

A fourth possible approach is the Middleware model, which is sometimes used in lieu of a Bidirectional Interface, but also implies the additional existence of a demographic and insurance interface. When NorDx uses its Web product, its interface engine and a partner to facilitate the electronic transfer of all data from and to an EMR, this combination of technological capabilities is generally referred to as middleware.

Although many EMRs are able to accept results electronically, few are capable of lab ordering. For those practices, the Copia/NorDxNOW Web interface allows clients to order labs via the secure Internet interface. From there, the order is sent to the lab’s LIS, which retrieves them and waits for the results to come back from the instrumentation. When the resultant test data comes back, it goes back out through the Copia/NorDx Web interface and populates the practice’s EMR. "If they have a practice management system to store patient and insurance info, then we will do a Unidirectional Interface from that system back to us through the Copia product so that we can feed it to our billing system for billing purposes," says Rochette.

For more information
on Orchard Software

Currently, MPLN has several customer interfaces that utilize several fixed ways of delivering reports to customers. Demographic information to the lab’s billing system emerged as the driving force for interfacing the systems. The lab created their own system that provides HL7 communication from the database to the parser as well as the actual handling of the data and options of data delivery via the Internet or through file drops, for which the lab developed the code from the ground up.

Rollout

From the perspectives of both labs, the internal education process and stakeholder identification of the LIS and Web interface rollout are crucial to the success of implementation. According to McSpadden, the field engineer sent out from Orchard Software enabled a smooth installation that took just a day and a half.

For McSpadden, the single-vendor/two-solution approach of working with Orchard translated to a greater understanding of the database structure for both systems, which allows integration issues to be easily worked out. "Although we were building our molecular LIS from the ground up, it made the most sense to utilize Copia for Web ordering for both laboratory information systems rather than build one specifically for our molecular clients," says McSpadden. "Consequently, we moved our accessioning personnel into the Web order system to put in all of the orders for the molecular side and we worked out the mechanics of that interface from the Web order product to our system. An additional benefit was that our molecular, and now our clinical laboratories, can operate out of one order entry and reporting portal."

For the Orchard integration, the software company provided a project manager (PM) to compliment and support McSpadden as the MPLN internal PM. "They assisted our lab manager in writing the database rather than building it independently so that she understood how it worked and could devise workflow processes that were effective for our lab," says McSpadden.

For the project overall, MPLN ended up three weeks ahead of schedule on integration and a planned additional two weeks of training by
Orchard personnel were unnecessary. "Orchard doesn’t offer billing interfaces, so some integration was necessary," says McSpadden.

HMT With the majority of practices being small, many outsource their IT needs. Some EMR vendors do have sufficient staff to support building the interface between Covisint and their EMR system at the practice. According to Rochette, building the test compendiums can be very time consuming for EMR vendors and practices, which he sees as the longest pole in the tent as far as rollout and integration. "We realize small practices don’t have a lot of time to build test compendiums in their EMR and we don’t have the resources (nor would it be prudent from a liability standpoint) to learn their EMR and build the tests within their environment," says Rochette. "So there is a large onus of responsibility on the practice side."

Client Integration Process

The challenge for labs interfacing with client EMRs is that there is no such thing as "one size fits all" for labs and clinicians. By providing a standard set of services when interfacing a client EMR with their LIS, MPLN can provide a set of solutions that delivers reports to all of the necessary brokered people via the device, format and time that works best. "We have a team that specializes in going to our clients and finding out their reporting and ordering needs and setting that up as a custom solution (within a specified framework) for every client," says McSpadden.

This brings up the question of who should be responsible for what. What level of responsibility should vendors go to, whether they are EMR/EHR vendors or LIS and middleware vendors? McSpadden feels that the true meaning of the word implementation as used by many vendors often becomes vague.

From McSpadden’s perspective, the use of the word "implementation" by software vendors implies that all of the necessary work for successful use has already been done up to that point, but the potential client may not even have Internet access. At that juncture, the question becomes what kind of services can the lab provide in that scenario? In those cases, MPLN looks at the client’s potential volume of yearly test orders the lab will receive, and if it meets certain benchmarks, MPLN may decide to provide the Internet access. If the potential client is part of a parent organization, MPLN must look at the parent organization’s policy for such potential occurrences and whether the lab can even obtain approval to provide Internet access.

Where We Are Going

While many strides have been made on the road towards true LIS/EMR integration, both men see the market for LIS vendors becoming even more aggressive in the future. "We’re looking at automatically sending PDFs, images and binary data between systems in the next three years and I think that sort of a market will make any type of medical software vendor very competitive in their offerings and the ease of integration," says McSpadden. "Some people in the industry feel that the services that are being provided now are good enough and they have another seven or eight years left on their system, but the reality is that if they aren’t looking towards the horizon — even beyond the medical industry — they will be left behind in terms of innovations that become standardized."

• May 2008 FEATURE ARTICLES •

Systems Integration

Back to the Lab

As more practices implement EMRs, a measure of effectiveness is the ability to interface with the lab and the LIS.