Skirting the pitfalls of merging lab results

Some institutions have realized the need for better policies when quality issues have surfaced from unstandardized additions of outside laboratory test results to the EHR. At Barnes-Jewish Hospital in St. Louis, where Ronald Jackups Jr., MD, PhD, is chief medical information officer for laboratory informatics, obstetrics and oncology lab results may sometimes be entered by nonlaboratory staff—medical assistants, for example—who transcribe from a hard copy the patient brings from an outside lab.

“Our hospital system has recognized the harm caused by unstandardized reporting of tests, even just naming conventions, and is building a steering committee made of lab administrative and IS leaders to work on the tests with the highest impact, starting with basic metabolic panel and CBC,” Dr. Jackups wrote on the API listserv. “What convinced them of the importance was when the hospital transitioned to an Epic EHR, and physicians complained they couldn’t pick the right name among the 12-plus options for the same test.”

If the system could be built from scratch, Dr. Jackups believes an established nomenclature, like LOINC, might be a solution. “But we’re not starting from scratch,” he wrote, “and such a wholesale change could have dramatic short-term consequences.” In addition, what’s good for an LIS may not be good for the computerized physician order entry system. “For instance, it may make more sense to call the PF4/hepatitis Ab test something like ‘HIT screen’ in your CPOE, since physicians may prefer to know the clinical function of the test rather than the actual name.”

On the other hand, when multiple hospitals’ information systems have to come together in an institutional merger, it can sometimes raise awareness of and attention to the comparability of laboratory tests. When Amanda G. Blouin, MD, PhD, was assistant director of validation for the laboratories at Mount Sinai Hospital in New York, multiple LISs fed directly into a single EHR. After Mount Sinai merged in 2013 with Beth Israel, St. Luke’s, and Roosevelt hospitals, she helped implement middleware between the LISs to fit the needs of the enterprise. Dr. Blouin, now an assistant director in the Department of Laboratory Medicine at Memorial Sloan Kettering Cancer Center, says the merger of labs and outreach produced opportunities not only to save money and shorten turnaround time but also to standardize testing.

Mount Sinai had an Epic EHR; the other hospitals had other EHRs. The merger led to a consolidation of testing performed at Mount Sinai, “but we weren’t integrating with their EHRs,” she tells cap today. “The interface was LIS to LIS. So from the clinician’s view, the display of results didn’t change, as if they originated from their own LIS to their EHRs.”

How did the management ensure comparability of results during the merger? Some tests were not moved over to Mount Sinai, Dr. Blouin says. “One reason we were successful was we did a deeper dive into exactly the differences among the tests.” By meeting with physician groups that were heavy users of a test, the management found some tests with a specific population and methodology that required much higher sensitivity than what Mount Sinai was offering. “So those tests weren’t moved over.”

During the building of an integrated health system, doctors may not be fully aware their lab results are coming from different labs, she says. “But now I think they’re more attuned to that. It’s one of the reasons clinicians try to follow trends” of results within a particular test method, rather than focus on individual test results. For tumor markers, for example, it is essential that the patient is tested by the same method over time, she says. “That’s something that clinicians who deal with tumor markers frequently would understand, but clinicians who don’t typically order that kind of test might not.”

The dream that an EHR could offer patients a portable medical history is limited by the fact that lab results do not conform to the model of integration across an entire system, Dr. Blouin says. “For portability of lab results, we have to ensure portability of performance understanding—that physicians understand why these tests may not be equivalent. That can be through clinician education, but maybe at the laboratory level, too, we need to have a better understanding of performance correlations between different tests.”

As director of clinical pathology for Children’s Health medical centers in Dallas and Plano, Tex., Hung S. Luu, PharmD, MD, is the “informatics point person” for the department, he says. Dr. Luu has completed an integration of the system’s Epic EMR and Cerner LIS to handle testing performed by Quest and LabCorp. “A few years ago, I oversaw implementation of an interface with Quest and LabCorp where their information could flow into our EMR and post to the lab results section, without going through Cerner.”

Because the Quest and LabCorp results effectively bypass the laboratory IT management, “we consciously chose not to ‘own’ the results,” he says, meaning his laboratory doesn’t manage the interface. Not owning the results was important for his department, he says, because he has no oversight of Quest or LabCorp. “Anytime something is wrong—for example, a lab result is a critical value that is not communicated to the physician, or something got lost and a test could not be performed—our lab would be getting the calls from the physician when we didn’t draw the patient, we didn’t process the specimen, and we certainly didn’t perform it. That’s why we chose a deliberate separation between those results and the results we draw.”

It’s not only an issue of quality but also of staff resources. “We don’t get the revenue from those tests and that would be an invisible source of added work for us,” Dr. Luu says. If his laboratory were someday to be evaluated for efficiency and found to be doing fewer tests per medical technologist, “we wouldn’t be able to tell them, ‘Well, that’s because our resources are going toward having to manage all these LabCorp/Quest issues.’”

With reference testing, the situation is somewhat different, he explains. “Where I have leverage is that we have authority over whom to choose for a referral lab if we want to send it out to ARUP or Mayo or Quest.” But with the LabCorp/Quest tests, “the choice isn’t really ours. It’s the physician placing the order for the patient. We never see the patient or handle the specimen.”

Like Dr. Rogers’ institution, Children’s Medical Center Dallas has many transplant patients from out of town, and often its clinic staff enter those patients’ community hospital test results into its EMR manually. But to keep errors down, “we help them set up QC programs, where a certain percentage of the results have to be audited to make sure what we entered reflects the true results.”

To augment quality control with the LabCorp/Quest arrangement, “We would have somebody look at the test menus to decide which tests could go on the same line as our internal test result. We said, ok, CBCs and certain chemistry tests are pretty comparable, no matter the methodology and which lab performs them, so those can post to the same line on the record,” allowing results to be trended. Other tests, like albumin, often have different methods. “So we were not comfortable allowing those to post to the same line.” Different reference ranges for the same test present another problem, he says, and there is an ongoing effort to harmonize results across institutions.

Although it’s necessary to rely on some reference testing, “We try to limit the number of labs we have to deal with,” Dr. Luu says, “because if a patient comes in and gets a lab from ARUP and next week that goes to Mayo, are they useful to compare to each other? Or if you go today to a hospital and they tell you you have a low platelet count and the next day at a different ED they say you’re normal, that isn’t very useful to you. Where, really, is the truth?”
For comparison purposes, keeping tabs on the mean values at the hospital campuses’ on-site labs is part of the routine.

“Since QC is performed daily by the medical technologists, after a month all those QC points are accumulated for an internal report for pathology. And each month when I review those reports, we’re not only making sure all points are within an acceptable range, but also we’re looking at the average mean for each instrument on each campus and checking whether there may have been ‘drift’ in lab results at one campus versus the other campus.”

Because the on-site labs share common instrumentation, with the same administration and policies and procedures, “our labs are pretty closely aligned. If we buy an instrument, it will be at both labs.” He believes this practice has allowed the system to avoid some variation problems such as for tests like HbA1c, which may produce results that are one or two percent different, depending on the instrument. However, Dr. Luu notes, even in huge systems, patients aren’t necessarily going to visit multiple sites in the course of an illness. “They’re likely to have one site and return to that site for follow-ups. So it may not be as imperative that results at one campus match results at another.”

His institution uses the prefix “OSH” to indicate that a lab result is from outside the hospital. Is it enough for clinicians to appreciate the complexities of variations in the source of testing? “OSH is a pretty common convention, but I’m not sure that most clinicians understand the exact nuances of it,” he says.

“That is our biggest worry, and why we probably bend over backward to flag things and make sure to try to impress upon them that the results are from an outside facility and the internal lab probably doesn’t have any control over the quality. For the most part, clinicians, if they see a lab result posted in the EMR, typically just assume it has been vetted by the local lab and there’s no difference.” From a lab director’s standpoint, however, “there’s no worse feeling in the world than having to be responsible for something and then have no ability to implement what you think is important” to assure its quality, Dr. Luu says.

As complex as the informatics quandaries are now, even thornier issues lie ahead for laboratories worried about merging lab results. “We are rapidly moving into a time when patients will have increasing numbers of home-generated lab tests and other health data, such as vital signs or exercise data,” Bruce Levy, MD, associate chief medical informatics officer with Geisinger Health System, wrote on the API listserv. “We are studying how to best incorporate this type of data as well. I believe the solutions for these related issues should be consistent.”

While merging lab results is an area of advocacy for Dr. Luu, he knows that many laboratory directors prefer to sidestep choosing between two positions that may appear untenable and avoid the subject whenever possible. “I don’t really know what is the right answer. Is it that we keep everything separate and never draw anything that will be performed outside? Or do we bite the bullet and form a partnership, so we somehow have a hand in making sure all the results are accurate?” These are questions that laboratories and health systems must face, he says. “I don’t think we’re ever going to get to a solution without talking about it. Ignoring it, while it might be comfortable in the short term, is not a long-term solution.”
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Anne Paxton is a writer and attorney in Seattle.