Electronic laboratory data quality and the value of a health information exchange to support public health reporting processes

There is increasing interest in leveraging electronic health data across disparate sources for a variety of uses. A fallacy often held by data consumers is that clinical data quality is homogeneous across sources. We examined one attribute of data quality, completeness, in the context of electronic laboratory reporting of notifiable disease information. We evaluated 7.5 million laboratory reports from clinical information systems for their completeness with respect to data needed for public health reporting processes. We also examined the impact of health information exchange (HIE) enhancement methods that attempt to improve completeness. The laboratory data were heterogeneous in their completeness. Fields identifying the patient and test results were usually complete. Fields containing patient demographics, patient contact information, and provider contact information were suboptimal. Data processed by the HIE were often more complete, suggesting that HIEs can support improvements to existing public health reporting processes.

Reducing missed laboratory results: defining temporal responsibility, generating user interfaces for test process tracking, and retrospective analyses to identify problems

Researchers have conducted numerous case studies reporting the details on how laboratory test results of patients were missed by the ordering medical providers. Given the importance of timely test results in an outpatient setting, there is limited discussion of electronic versions of test result management tools to help clinicians and medical staff with this complex process. This paper presents three ideas to reduce missed results with a system that facilitates tracking laboratory tests from order to completion as well as during follow-up: (1) define a workflow management model that clarifies responsible agents and associated time frame, (2) generate a user interface for tracking that could eventually be integrated into current electronic health record (EHR) systems, (3) help identify common problems in past orders through retrospective analyses.

Investigating the semantic interoperability of laboratory data exchanged using LOINC codes in three large institutions

LOINC codes are seeing increased use in many organizations. In this study, we examined the barriers to semantic interoperability that still exist in electronic data exchange of laboratory results even when LOINC codes are being used as the observation identifiers. We analyzed semantic interoperability of laboratory data exchanged using LOINC codes in three large institutions. To simplify the analytic process, we divided the laboratory data into quantitative and non-quantitative tests. The analysis revealed many inconsistencies even when LOINC codes are used to exchange laboratory data. For quantitative tests, the most frequent problems were inconsistencies in the use of units of measure: variations in the strings used to represent units (unrecognized synonyms), use of units that result in different magnitudes of the numeric quantity, and missing units of measure. For non-quantitative tests, the most frequent problems were acronyms/synonyms, different classes of elements in enumerated lists, and the use of free text. Our findings highlight the limitations of interoperability in current laboratory reporting.

LIMS USER ACCEPTANCE TESTING

Laboratory Information Management Systems (LIMS) play a key role in the pharmaceutical industry. Thorough and accurate validation of such systems is critical and is a regulatory requirement. LIMS user acceptance testing is one aspect of this testing and enables the user to make a decision to accept or reject implementation of the system. This paper discusses key elements in facilitating the development and execution of a LIMS User Acceptance Test Plan (UATP).

Electronic interchange of lab test orders and results between laboratories reduces errors and gives full traceability

Introduction of electronic lab test ordering and reporting corresponding results between laboratories when exchanging special tests for analysis in service labs, instead of manual paper based workflow, have reduced the fault rate by a factor 10 and reduced reporting time by 2 days compared to the manual workflow. Retyping orders and results into different IT systems is not longer needed as all 9 different labsystems in more than 60 laboratories are using the same standards and procedures resulting in full interoperability. The solution, challenges, implementation process and outcome is described in the paper.

Terminology modeling for an enterprise laboratory orders catalog

Laboratory test orders are used in a variety of clinical information systems at Partners HealthCare. At present, each site at Partners manages its own set of laboratory orders with locally defined codes. Our current plan is to implement an enterprise catalog, where laboratory test orders are mapped to reference terminologies and codes from different sites are mapped to each other. This paper describes the terminology modeling effort that preceded the implementation of the enterprise laboratory orders catalog. In particular, we present our experience in adapting HL7's "Common Terminology Services 2 - Upper Level Class Model" as a terminology metamodel for guiding the development of fully specified laboratory orders and related services.

[Laboratory alert value reporting by the clinical laboratory at an academic medical network]

BACKGROUND

An alert value is a result suggesting that the patient is at imminent danger unless appropriate remedial actions begin promptly. Report of alert values (AV) by the clinical laboratories has taken special relevance in recent years due to its contribution to patient's care.

AIM

To report results of AV informed during 2007 within the Health Network of the Pontificia Universidad Católica de Chile.

MATERIAL AND METHODS

Analysis of AV recorded in a centralized database of the laboratories of the health network, between January and December, 2007.

RESULTS

Total number of AV was 5.366, which represented 0.3% of total examinations and corresponded mainly to the clinical chemistry area. Potassium levels generated the higher number of AV detected, followed by positive blood cultures. Eighty two percent of AV corresponded to hospitalized patients. The greater number of AV was reported to intermediate and intensive care services. Thirty two percent of AV was informed to the physician or professional in charge of the patient within 5 minutes of obtaining the results and 79% within 30 minutes.

CONCLUSIONS

To obtain a real impact on patient management, it is fundamental to shorten the lapse between the obtainment of tests results and the warning, supported on appropriate computerized systems, and to spread the procedure to all personnel involved in patient's care.

The reference change value: a proposal to interpret laboratory reports in serial testing based on biological variation

BACKGROUND

A proposal to calculate and use the reference change value (RCV) as an objective guide for interpreting the numerical results obtained in clinical laboratory serial testing is introduced in this study.

METHODS

A database showing the results of a compilation of 191 publications on biological variation and including information on a number of analytes provided the standardized criterion based on biology for calculating the RCVs.

RESULTS

For each of the 261 analytes included in the study, the RCV was determined using Harris's formula, replacing analytical imprecision with the desirable specification of analytical quality based on half the within-subject biological variation at 95% probability levels. The result is a guide for a common criterion to identify clinically significant changes in serial results.

CONCLUSIONS

The RCV concept is an approach that can be offered by laboratories to assess changes in serial results. The RCV data in this study are presented as a point of departure for a widely applicable objective guide to interpret changes in serial results.

[Compliance with laboratory requirements regarding the secondary use of clinical specimens and laboratory data]

Clinical specimens as well as associated laboratory data (values and images) have been utilized to assure the overall quality of laboratory testing systems, including the evaluation of assay performance, individual analysis for the diagnosis and safety of patients, and education of medical laboratory technologists. Such secondary uses of clinical specimens and laboratory data require compliance with regulations and guidelines concerning ethical and social issues. We formulated an internal rule regarding the secondary use of specimens and laboratory data in our clinical laboratory, according to the view of the Japan Society of Laboratory Medicine (2002), and implemented it. Because a profound consideration of personal information and any conflict of interest has been recently emphasized in Japan, we have revised our internal rule. It is important to continue discussions on these ethical and social issues and observe the regulations and guidelines for the laboratory-based uses of post-assay specimens and data.

The development of a highly constrained health level 7 implementation guide to facilitate electronic laboratory reporting to ambulatory electronic health record systems

Electronic laboratory interfaces can significantly increase the value of ambulatory electronic health record (EHR) systems by providing laboratory result data automatically and in a computable form. However, many ambulatory EHRs cannot implement electronic laboratory interfaces despite the existence of messaging standards, such as Health Level 7, version 2 (HL7). Among several barriers to implementing laboratory interfaces is the extensive optionality within the HL7 message standard. This paper describes the rationale for and development of an HL7 implementation guide that seeks to eliminate most of the optionality inherent in HL7, but retain the information content required for reporting outpatient laboratory results. A work group of heterogeneous stakeholders developed the implementation guide based on a set of design principles that emphasized parsimony, practical requirements, and near-term adoption. The resulting implementation guide contains 93% fewer optional data elements than HL7. This guide was successfully implemented by 15 organizations during an initial testing phase and has been approved by the HL7 standards body as an implementation guide for outpatient laboratory reporting. Further testing is required to determine whether widespread adoption of the implementation guide by laboratories and EHR systems can facilitate the implementation of electronic laboratory interfaces.

Using the e-Chasqui, web-based information system, to determine laboratory guidelines and data available to clinical staff

13% of all drug susceptibility tests (DSTs) performed at a public laboratory in Peru were duplicate. To determine reasons for duplicate requests an online survey was implemented in the e-Chasqui laboratory information system. Results showed that 59.6% of tests were ordered because clinical staff was unaware of ordering guidelines or of a previous result. This shows a benefit of using a web-based system and the lack of laboratory information available to clinical staff in Peru.

LIS--connecting the pieces. When it comes to laboratory information systems, the debate is between interoperability and best of breed

Lab directors usually choose best of breed. CIOs usually choose enterprise solutions. An integrated LIS may really be just interfaced. KLAS LIS Perception Report is planned for November.

Standardization of terminology in laboratory medicine II

Standardization of medical terminology is essential in data transmission between health care institutes and in maximizing the benefits of information technology. The purpose of this study was to standardize medical terms for laboratory observations. During the second year of the study, a standard database of concept names for laboratory terms that covered those used in tertiary health care institutes and reference laboratories was developed. The laboratory terms in the Logical Observation Identifier Names and Codes (LOINC) database were adopted and matched with the electronic data interchange (EDI) codes in Korea. A public hearing and a workshop for clinical pathologists were held to collect the opinions of experts. The Korean standard laboratory terminology database containing six axial concept names, components, property, time aspect, system (specimen), scale type, and method type, was established for 29,340 test observations. Short names and mapping tables for EDI codes and UMLS were added. Synonym tables were prepared to help match concept names to common terms used in the fields. We herein described the Korean standard laboratory terminology database for test names, result description terms, and result units encompassing most of the laboratory tests in Korea.

Integration of scanned document management with the anatomic pathology laboratory information system: analysis of benefits

Electronic document management systems (EDMSs) have the potential to improve the efficiency of anatomic pathology laboratories. We implemented a novel but simple EDMS for scanned documents as part of our laboratory information system (AP-LIS) and collected cost-benefit data with the intention of discerning the value of such a system in general and whether integration with the AP-LIS is advantageous. We found that the direct financial benefits are modest but the indirect and intangible benefits are large. Benefits of time savings and access to data particularly accrued to pathologists and residents (3.8 h/d saved for 26 pathologists and residents). Integrating the scanned document management system (SDMS) into the AP-LIS has major advantages in terms of workflow and overall simplicity. This simple, integrated SDMS is an excellent value in a practice like ours, and many of the benefits likely apply in other practice settings.

[The expectations for the third generation clinical laboratories in Japan]

The author expressed his hopes and expectations for third generation clinical laboratory schemes or systems in Japan. The history of development of the clinical laboratory in Japan can be classified three generations after the Second World War, the first generation (1945-1975), the second generation (1970-2005) and the third generation (2001-). The third generation clinical laboratory can be called "the clinical laboratory for the 21st century". The author advised some suggestions for the clinical laboratory for the 21st century. The main advice of the author is as follows: 1) The necessity of professional physicians of clinical laboratory medicine in hospitals. 2) The necessity of standardization and holding nationwide common reference values of main clinical laboratory tests. 3) The realization of a network of high-grade laboratory tests between all clinical laboratory divisions of the national university hospitals.

Managing transferability of laboratory data

Considerable attention has been focused on definition and enhancement of the analytical quality in laboratory testing over the past decades. Advances in laboratory technology and computer informatics have allowed a major sense of confidence with the analytical phase and more efforts should now be focused on extra-analytical areas of improvement, that should further strengthen the link between cost effectiveness and clinical outcome. Deduction and implementation of common reference intervals, to be possibly shared by a regional network of clinical laboratories, appear so far a crucial step to increase efficiency and harmonization. With the experience gained from External Quality Control exercises and with the consensus of several contributory laboratories, this process is underway in Italy. Quality performances resulting from widespread implementation of common reference intervals and longitudinal comparison of patient's data, will allow clinical laboratories to accomplish with a major transferability, amplifying health benefits and meeting increasing health systems demand.

Clinical Governance and Laboratory Medicine: is the Electronic Medical Record our best friend or sworn enemy?

This review attempts to address the question: is the Electronic Medical Record (EMR) our best friend or sworn enemy in the context of Clinical Governance and Laboratory Medicine? It provides a brief overview of the history and development of Clinical Governance before going on to define an EMR. It considers how EMRs could assist in delivering quality care in laboratory medicine. A number of outstanding issues regarding EMRs and electronic health records (EHRs) are identified and discussed briefly before the author provides a brief outlook on the future of clinical governance and EMRs in laboratory medicine.

The California Clinical Data Project: a case study in the adoption of clinical data standards for quality improvement

The California Clinical Data Project is a statewide initiative to remove barriers to the widespread and effective use of information technology to improve chronic disease care. The project is a case study in the development and widespread adoption of clinical data standards by varied and often competing stakeholders. As an initial step, the project defined precise data standards for the batch reporting of pharmacy claims data and laboratory results data. These uniform standards facilitate the flow of existing electronic clinical information into disease registries and electronic health record systems. Pharmacy and lab results data now are being exchanged electronically with this standard among the largest health plans, medical groups, and clinical laboratories participating in California's pay-for-performance programs. Lessons from this project may apply to the development and adoption of data standards for other states and locales and for the emerging national health information infrastructure.

Automated reporting of GFR--coming soon to a laboratory near you!

BACKGROUND

Serum creatinine concentration is an unreliable and insensitive marker of chronic kidney disease (CKD). To improve CKD detection, Australasian guidelines have recently recommended that laboratories calculate and report an estimated glomerular filtration rate (eGFR) using the Modification of Diet in Renal Disease (MDRD) formula with every request for serum creatinine concentration.

OBJECTIVE

This articles aims to provide timely information to health professionals about how to appropriately interpret and act upon eGFR reports. It also discusses the treatments shown to reduce renal and cardiovascular risk in CKD patients, and the indications for nephrologist referral.

DISCUSSION

The accuracy and precision of eGFRs are reasonable in most adults in whom calculated values are ENTITY lt 60 mL/min/1.73 m2. However, eGFRs should be interpreted with caution in some settings (particularly patients with eGFRs ENTITY gt 60 mL/min/1.73 m2 and children). Automatic laboratory reporting of eGFR will enhance early detection of CKD, allow the timely institution of appropriate reno- and cardio-protective therapies, and better inform decisions regarding the prescription of renally excreted medications.