Pathology Informatics and Enterprisewide EMR Projects: First Steps

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Pathology Informatics and Enterprise-wide EMR
Projects First Steps

• Walter H. Henricks, M.D.
• Director, Laboratory Information Services
• The Cleveland Clinic Foundation
• henricw_at_ccf.org

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Objective of Presentation

• Describe implications and opportunities that EMR
  efforts hold for pathologists and laboratories

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Outline of Presentation

• Electronic Medical Record (EMR) - description and
  current status
• Relevance of EMR to pathologists and laboratories
  - first steps
• Case study - CCF
• Future directions

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Electronic Medical Record (EMR) Working
Definition

• Record of electronically maintained information
  about a patients lifetime health status and
  health care that integrates all aspects of an
  individual's health, management of acute illness
  and injury, management of chronic illness, health
  maintenance and prevention that also
• integrates information from multiple sources
• provides clinical decision support
• serves as primary source of information for
  patient care IOM, 1991 Trace DA, Andrew WE,
  1999

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Electronic Medical Record (EMR)Terminology

• Computer-based Patient Record (CPR)
• Computerized Patient Record (CPR)
• Electronic Medical Record (EMR)
• Computerized Medical Record (CMR)
• IOM designation

• Computerized Health Record (CHR)
• Electronic Health Record (EHR)
• Virtual Health Record (VHR)
• Virtual Patient Record (VMR)
• Marietti C, 1998

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Spectrum of the EMR
Electronically imaged paper documents of
medical record
Electronic record system built by transcription
or direct entry. In essence, a digital chart
usually text-based

• Complete electronic record plus
• decision support
• clinical alerting
• practice guidelines
• structured data and vocabularies

IOM, 1991 Sujanski WV, 1998 Trace DA, Andrew WF,
1999 Kuhn KA, Giuse DA, 2001
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Electronic Medical Record (EMR)Distributed Nature

• Clinical information system(s)
• E-mail
• Personal Digital Assistants (PDAs)
• Alpha pagers
• PACS

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Expected Benefits of EMR Implementation

• Decreased costs
• Reduced errors
• Increased quality of care
• Increased efficiency of processes

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Computer-based Physician Order Entry (POE)

• POE is proving to be one of the most important
  components of EMRs
• POE has potential to decrease costs, reduce
  errors, increase efficiency, and improve care
• Tierney WM et al, 1993 Sittig DF and Stead WW,
  1994 Chin HL and Wallace P, 1999 Bates DW et
  al, 2001
• POE directly affects pathology
• 32 of hospitals had POE (1998) only 4.9
  required its use Ash JS et al, 1998

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Lack of Widespread Deployment of EMR Systems

• Sites that have started EMR installation
• 2000 29
• 1999 32
• Sites that have fully operational EMRs
• 2000 12
• 1999 11
• HIMSS survey, 2000

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EMR and POEBarriers and Problems

• Integration and standardization of multiple data
  sources
• Human-computer interaction and data input
• Workflow and process design
• Data structure requirements
• Return on investment
• Vendor mergers and acquisitions
• Trace DA, Andrew WF, 1999 Kuhn KA, Giuse DA,
  2001 Weiner M et al, 1999 Murff HJ and Kannry
  J, 2001

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POE ImplementationPhysician satisfaction

• Physician satisfaction is a crucial determinant
  of success of POE
• Perceptions correlating with user satisfaction
• ordering performed in a straightforward manner
• consistent terminology
• Problems perceived with POE
• excess work for simple orders
• increased number of tests ordered
• increased errors in order entry
• Lee F et al, 1996 Chin HL and Marshall PD,
  1998 Weiner M et al, 1999 Murff HJ and Kannry
  J, 2001 Overhage M et al, 2001

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EMR Relevance to Pathology

• The laboratory will in all likelihood be held
  responsible for all aspects of laboratory
  testing, from order entry through result
  distribution, whether or not it participated in
  development of all systems and procedures
  involved.

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EMR Issues of Relevance to Pathology

• Stewardship of pathology data and integration
  into EMR
• Electronic order entry (POE)
• Structured pathology data for EMR
• Opportunity to be integral to success of
  institutions strategic project

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EMR Relevance to PathologyStewardship of
Pathology Data

• Pathology/laboratory data comprise majority of
  data in current EMRs
• 70/70 rule Becich MJ, 2000
• 94 of Mayos EMR database is lab data
• Forsman R, 2000
• When pathology data are transferred to or
  replicated in another record, there are patient
  care and regulatory implications for the
  laboratory

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EMR Relevance to PathologyStewardship of
Pathology Data

• Questions to assess
• Are the lab data in the EMR a true copy of the
  lab database (source of truth)?
• Is the display of lab results adequate (at least)
  to support appropriate clinical decision making?

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EMR Relevance to PathologyStewardship of
Pathology Data

• CAP accreditation checklist
• Has the laboratory documented the accuracy and
  consistency of laboratory results (reference
  ranges and appropriate comments) across all
  computer interfaces with external systems (LISs,
  HISs, and others)? (Phase II)

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EMR Relevance to PathologyStewardship of
Pathology Data

• Areas meriting particular attention
• Result comments
• Critical results flags
• Drug peak and trough identification and timing
• Addenda and amended reports, corrected results
• Other methods/systems of results distribution
• Additional clinical systems
• E-mail
• PDAs

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Stewardship of Lab Data in Distributed EMR at CCF

• Pathology results sent to four clinical systems
• Interface to Pharmacy system in progress
• AP and CP results distributed via e-mail to
  subscribing physicians
• At least 20 LIS person-hrs / week spent on
  interface issues and validation
• Regular documentation of accuracy of patient
  results in all receiving systems (including
  e-mail)

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Stewardship of Lab Data in Distributed EMR at CCF

• Physician tickler file for overdue lab results
• Laboratory IT team was instrumental in
  determining appropriate time interval for
  clinician notification of test results not
  received
• Central IT project team unaware of important
  details project required careful analysis, even
  to individual test level
• Next phase EMR synchronized to physician PDAs -
  will display of lab data be appropriate?

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EMR Relevance to PathologyElectronic Provider
Order Entry (POE)

• POE screens and sequences analogous to paper
  requisitions
• Benefits to laboratory of electronic orders
• Legibility
• Completeness
• Clinical history
• Regulatory requirements (e.g. CLIA)
• Correctness
• Compliance

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EMR Relevance to PathologyElectronic Provider
Order Entry (POE)

• Implications for laboratories of poor POE process
  design
• Incorrect orders
• Incomplete orders
• Increased phone calls
• Frustration with lab testing process
• Compliance problems
• Pitfalls
• Future orders
• Duplicate orders
• Cancelled orders

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EMR Relevance to PathologyElectronic Provider
Order Entry (POE)

• Need for improvement in order entry processes
  exists
• Most common reasons for errors cited by
  laboratories having the highest order entry error
  rates were
• inability to interpret poor physician handwriting
• information incorrectly ordered into computer by
  nonlaboratory staff
• Valenstein P and Meier F, 1999

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EMR Relevance to PathologyElectronic Provider
Order Entry (POE)

• Clinical information is critical for correct
  pathologic interpretations and diagnoses on
  specimens Marques M and McDonald JM, 2000
• e.g. presence of clinical history increased the
  diagnostic accuracy of pathologists in bronchial
  brush specimens Raab SS et al, 2000
• POE procedures must be designed to provide
  necessary clinical information to the laboratory

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Pathology Role in Electronic Order Entry at CCF -
Microbiology Example

• Certain microbiology tests or procedures are
  performed only on certain specimen types
• Active participation by LIS group drove design of
  improved HIS order entry screens and processes
  aimed at preventing erroneous or incomplete orders

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Role of Pathology in EMRElectronic Orders for AP
at CCF

• Goals
• Ensure proper handling and correct interpretation
  of irreplaceable specimens by providing for
  complete and legible requisitions, clinical
  information, and special requests
• Add AP (cytopathology, surgical pathology) orders
  to EMR
• Lay the groundwork for electronic AP orders
  interface for future version of APLIS

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Electronic Orders for AP at CCF
Barcoded requisition with specimen to lab
AP Order
Case accessioned
HIS
APLIS
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Electronic Orders for AP at CCFKey Project
Components

• Screen design
• Data fields and terminology
• Sequential drop-down lists
• Required fields
• Multiple physician capability
• Multiple specimen parts
• Requisition design
• Content and layout
• Barcoded information

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Electronic Orders for AP at CCFResults and
Experience

• Non-operating room submitting locations
• Requisition deficiencies audited
• Cytopathology - absent LMP
• Surgical Path - illegible handwriting, absent
  clinical history, absent requesting location
• 37 decrease in cytopathology deficiencies
• 65 decrease in surgical pathology deficiencies

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Electronic Orders for AP at CCFResults and
Experience

• Buy-in, training, and education of persons
  involved in process were just as important as
  technical steps
• Close collaboration among pathology, central IT,
  and clinical representatives were key to success
• Pathology involvement prevented inadequate order
  entry processes from being implemented.

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EMR Relevance to PathologyElectronic Provider
Order Entry (POE)

• Electronic order entry systems must take into
  account OIGs Compliance Program
• Specific areas of concern include
• Automated test panels
• Diagnosis codes (medical necessity, ICD-9)
• Advanced Beneficiary Notices
• Information and choice are keys to
  compliance-conscious POE systems
• Graziano C, 1999

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EMR Relevance to PathologyStructured Data for EMR

• Data models, structured data, and standardized
  codes and vocabularies are necessary to compare
  data from disparate sources or systems and
  required for computer-based decision support
  tools
• By understanding LOINC and SNOMED, pathologists
  and laboratories can determine relevance of them
  to their institutions and promote their use in
  EMR where appropriate.

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EMR Relevance to Pathology Strategic
Opportunities

• EMRs are high stakes initiatives, and
  participation is an opportunity to be an integral
  part of the success of a strategic project
• Participation will set the groundwork for crucial
  roles in future efforts that will include
  enhanced decision support, guideline development,
  and other advanced EMR features
• Political power accrues to those subunits of an
  organization best able to solve the strategic
  problems of an organization Friedman, BA 1990

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EMR Relevance to PathologyNext Steps

• Suggested pathologist-led decision support
  projects relating to EMR
• Develop order entry systems that physicians will
  actually use an that facilitate appropriate
  testing
• Ensure that the right information in the right
  form is available to physicians at the right time
  and place
• Design displays that more effectively convey the
  clinical significance of laboratory values
• Integrate laboratory results across the continuum
  of inpatient and ambulatory care for individual
  patients so that trends are readily seen

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EMR Relevance to PathologyNext Steps (contd.)

• Suggested pathologist-led decision support
  projects relating to EMR
• Work toward communication mechanisms for
  clinicians to acknowledge that they have seen
  (and will take into account) each et of
  laboratory results
• Participate in development of systems that
  facilitate the implementation and continuation of
  clinical guidelines and testing protocols and
  evaluate their outcome.
• Connelly DP and Aller RD, 1997
• CAP Foundation Conference on Outcomes and
  Accountability in Pathology

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EMR Relevance to PathologyFuture Directions

• Multimedia EMR has been defined to include
  integration of textual, numeric, imaging, and
  signal-based components of the patient record
  into a coherent representation Lowe HJ, 1999
• Published preliminary data have examined the
  roles of anatomic pathology images in the
  MEMR Crowley RS et al, 2000

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EMR Issues of Relevance to Pathology

• Stewardship of pathology data and integration
  into EMR
• Electronic order entry (POE)
• Structured pathology data for EMR
• Opportunity to be integral to success of
  institutions strategic project

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Role of Pathology in EMRSummary

• The EMR is in various states of development
• Installation of an EMR has implications for
  pathology with respect to test ordering and
  stewardship of laboratory data
• Initial EMR efforts represent an opportunity for
  pathology to empower pathology within
  organizations and to lay the groundwork for more
  extensive computer-based patient care.

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References

• 1. Trace DA, Andrew WF. CPR systems Lessons
  Learned. Advance for Health Information
  Executives 1999Feb57-63.
• 2. Marietti C. Will the real CPR/EMR/EHR please
  stand up? Healthcare Informatics 19981576-81.
• 3. Sujansky WV. The benefits and challenges of
  an electronic medical record much more than a
  "word-processed" patient chart. West J Med
  1998169176-183.
• 4. Kuhn KA, Giuse DA. From hospital information
  systems to health information systems. Method
  Inform Med 200140275-287.
• 5. Dick RS, Steen EB (eds). The computer-based
  patient record An essential technology for
  health care. Institute of Medicine, Committee on
  Improving the Patient Record. Washington
  National Academy Press, 1991.
• 6. Eleventh annual HIMSS leadership survey.
  Healthcare Information and Management Systems
  Society. Chicago, IL, 2000.
• 7. Ash JS, Gorman PN, Hersh WR. Physician order
  entry in U.S. hospitals. Proc AMIA Symp
  1998235-239.

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References

• 8. Tierney WM, Miller ME, Overhage JM, McDonald
  CJ. Physician inpatient order writing on
  microcomputer workstations effects on resource
  utilization. JAMA 1993269379-383.
• 9. Sittig DF, Stead WW. Computer-based physician
  order entry the state of the art. J Am Med
  Informatics Assoc 19941108-123.
• 10. Bates DW, Cohen M, Leape LL, Overhage JM,
  Shabot MM, Sheridan T. Reducing the frequency of
  errors in medicine using information technology.
  J Am Med Inform Assoc 20018299-308.
• 11. Chin H, Wallace P. Embedding guidelines into
  direct physician order entry simple methods,
  powerful results. Proc AMIA Symp 1999221-225.
• 12. Weiner M, Gress T, Thiemann DR, Jenckes M,
  Reel SL, Mandell SF, Bass EB. Contrasting views
  of physicians and nurses about an inpatient
  computer-based provider order-entry system. J Am
  Med Inform Assoc 19996234-244.
• 13. Murff HJ, Kannry J. Physician satisfaction
  with two order entry systems. J Am Med Inform
  Assoc 20018499-509.

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References

• 14. Marshall PD, Chin HL. The effects of an
  electronic medical record on patient care
  clinician attitudes in a large HMO. Proc AMIA
  Symp 1998150-154.
• 15. Overhage JM, Perkins S, Tierney WM, McDonald
  CJ. Controlled trial of direct physician order
  entry effects of physicians' time utilization in
  ambulatory primary care internal medicine
  practices. J Am Med Inform Assoc 20018361-371.
• 16. Lee F, Teich JM, Spurr CD, Bates DW.
  Implementation of physician order entry user
  satisfaction and self-reported usage patterns. J
  Am Med Inform Assoc 1996342-55.
• 17. Becich MJ. Information management moving
  from test results to clinical information. Clin
  Lead Manage Rev 200014296-300.
• 18. Forsman R. The electronic medical record
  Implications for the laboratory. Clin Lead Manage
  Rev 200014292-295.
• 19. Valenstein P, Meier, F. Outpatient order
  accuracy a College of American Pathologists
  Q-probes study of requisition order entry
  accuracy in 660 institutions. Arch Pathol Lab
  Med 19991231145-1150.

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References

• 20. Marques MB, McDonald JM. Defining/measuring
  the value of clinical information. Clin Lead
  Manage Rev 200014275-279.
• 21. Raab SS, Oweity T, Hughes JH, et al. Effect
  of clinical history on diagnostic accuracy in the
  cytologic interpretation of bronchial brush
  specimens. Am J Clin Pathol 200011478-83.
• 22. Graziano C. With online test orders,
  consider compliance. CAP Today 2000145-6.
• 23. Connelly DP, Aller RD. Outcomes and
  informatics. Arch Pathol Lab Med
  19971211176-1182.
• 24. Lowe HJ. Multimedia electronic medical
  record systems. Academic Medicine
  199974146-152.
• 25. Crowley RS, Gadd CS, Naus G, Becich M, Lowe
  HJ. Defining the role of anatomic pathology
  images in the multimedia electronic medical
  record - a preliminary report. Proc AMIA Symp
  2000161-165.