CAP TODAY Pathology/Laboratory Medicine/Laboratory Management
Raymond D. Aller, MD, and Hal Weiner
Lab test data in the EMR: why what you see may not be reality
Blind faith is seldom the solution. And it’s definitely not the answer when it comes to accepting the capabilities of your hospital’s electronic medical record system.
The health care reform law’s insistence on EMRs places a new burden on laboratory professionals, requiring them to make sure that lab results aren’t displayed in a way that’s ambiguous, confusing, or incomplete, says Teresa Darcy, MD, medical director for clinical laboratories, University of Wisconsin Hospital and Clinics. “It’s a very proactive approach for the lab and not always comfortable for pathologists,” she continues. “But if we don’t act, who will?”
For instance, Dr. Darcy says, laboratorians need to consider that lab results from the EMR may be read by patients or physicians at other institutions years from now. As a result, test names that seem unambiguous now, such as a PSA, may need to be described more explicitly to avoid confusing clinicians in the future. “We assume that if it’s not a free PSA, it’s total PSA,” she says. “But a year from now, that may not be true.”
In an Executive War College presentation earlier this year, titled “The Lab Hitchhiker’s Guide to the Pitfalls and Opportunities in the Handling of Lab Test Data in the EHR,” Dr. Darcy identified a number of areas where EMRs are not ideally suited to handling lab data. Other, as yet unidentified, trouble spots may exist as well, Dr. Darcy cautioned in an interview with CAP TODAY. Therefore, laboratorians should spend as much time as possible looking for problems in patient records in their institution’s EMR system. “Constantly scan the record for issues,” she advises. “Then recommend changes to make it safer.”
Labs should not only notify their information technology departments about problems, but work with the IT department to communicate issues to their EMR system vendor, she says. Sometimes the IT department can’t fix the problem, and it will be up to the vendor to redesign the record.
Dr. Darcy explained in her War College presentation how the following EMR display components can sabotage lab data.
Data flags. Data that are flagged by the laboratory information system are treated by the EMR as an abnormal result, Dr. Darcy says. Problems can occur when results are not flagged, or when text, which cannot be flagged, is sent instead of data. For example, a lab that sent a written finding of a carcinoma to a clinician later found that EMR software classified the carcinoma finding as “normal” because there was no flag on it.
Comment field. Pathologists might think the EMR system’s comment field would be an ideal place to highlight specifics of laboratory findings, Dr. Darcy says, but clinicians tend not to look at these comments because most EMR systems require extra clicks to reach the comment field. One physician even accused Dr. Darcy of hiding lab results because they were noted in the comment field. Clinicians don’t want to dig down three or four levels to get to the comments, she says.
Decimal points and commas. Some EMR systems don’t align data along a decimal point or use commas. Others remove commas and decimal points from the data. “When you’re looking at a lot of numerical data, your mind assumes that the data in a column will be justified on the decimal point and that if the number sticks out farther to the left, it’s bigger than another number,” Dr. Darcy says. “Also, a lot of EMRs don’t let you put commas in numbers, so you may misread a level. Your eye is looking for a comma. That drives the eye crazy when we’re looking at a lot of data.” Case in point: Once, while looking at tumor markers, Dr. Darcy says, a clinician reported glancing at a record and thinking the level was 2,200 when it was 22,000.
Proportional spacing. The use of proportionally spaced fonts, which have long been preferred over monospaced fonts because they are easier to read, also may create a problem in EMR systems. With the former, letters take up different amounts of horizontal space. The problem is that some proportionally spaced fonts don’t leave enough room for combinations of wider characters in some EMR fields, such as in the field for nurses’ initials, Dr. Darcy says.
12- versus 24-hour clock. If the same clock type isn’t used consistently throughout a patient’s record, it can cause safety issues, Dr. Darcy says. For example, a test may be performed at 8 PM but, at a glance, the clinician may think it was performed at 8 AM. One vendor’s EMR software uses an AM/ PM clock and a 24-hour clock at different places in the same system, she notes. Medical institutions that use one type of clock for their outpatient facility and another for their inpatient facility are also inviting errors, she adds.
Scale. EMR software can automatically create charts or other graphics to display data, which is viewed as a boon to busy clinicians. The problem is if the software uses a scale that is out of proportion to the range of possible results, Dr. Darcy says. In such instances, data may be displayed incorrectly or crammed together at the top or bottom of a graph. Dr. Darcy’s lab has barred the use of its vendor’s automated charts in some situations “because they’re not showing the normal range of results.”
When it comes to incorporating lab results into EMR systems, Dr. Darcy says, the train has left the station. And problems that seem minor now may snowball over time as patients accumulate years of data and as health care entities increasingly exchange patient records electronically. If labs don’t act now to resolve these problems, she adds, “We’re going to be sorry down the road that we didn’t take the time to do it right.”
LOINC and SNOMED to join terminologies
The Regenstrief Institute and International Health Terminology Standards Development Organisation have signed a long-term agreement under which they will link their global health care terminologies—Logical Observation Identifiers Names and Codes and SNOMED Clinical Terms, respectively.
The nonprofit organizations reported in a joint release that “it makes sense to work together to limit duplication of effort and focus limited resources on enhancements that serve the practical needs of the growing number of users of LOINC and SNOMED CT.”
By aligning how the two terminologies represent the attributes of laboratory tests and some types of clinical measurements, the collaboration will provide a common framework within which to use LOINC and SNOMED CT.
The organizations are committed to the agreement for at least 10 years. They initially will focus on laboratory testing and basic clinical measurements, and then expand into other areas of mutual interest. Over the past few years, IHTSDO and Regenstrief have worked together on shorter-term and smaller-scale projects.
Regenstrief Institute, 317-630-6083 IHTSDO, +45 36 44 87 36
NovoPath offers remote hosting support for anatomic pathology system
NovoPath has introduced a remote hosting option for its NovoPath anatomic pathology system. The new offering allows users to purchase NovoPath AP software and select the HIPAA-compliant remote hosting provider of their choice. NovoPath will work with the provider to install its software so that it supports a virtual private network or Internet access locally at the user’s lab.
Customers can lease and control their own dedicated off-site server. “This is a terrific offering for smaller labs and users with minimal IT support, as well as almost any lab that expects significant growth but is unable to pre dict future needs given today’s rapidly evolving medical environment,” says Wally Soufi, CEO of NovoPath.