The growth in the rate of prescriptions written electronically is a huge success story. But at the Jan. 29 joint hearing of the federal HIT Policy Committee and HIT Standards Committee, attendees were reminded that sending structured lab data is a bigger challenge, in part due to the highly fragmented nature of the laboratory market.
Micky Tripathi, president and CEO of the Massachusetts eHealth Collaborative and chair of the policy committee’s information exchange work group,told the committees that a large percentage of lab results are still delivered by fax and paper. (Data provided by EHR vendor Cerner found that 90 percent are delivered by paper and fax, and 10 percent through HL7 interfaces). Information from vendor AthenaHealth found that of the lab data sent to its system, 599 labs (76 percent) send results with proprietary codes and only one lab (24 percent) sends LOINC-encoded results.
He noted that market fragmentation is one hindrance to progress on electronic transactions. Seven percent of labs are done by physician office labs, 33 percent by commercial labs, and 60 percent by hospital labs. Fragmentation may be increasing, Tripathi said, as hospitals increase lab business to offset revenue decreases in other areas. The fragmentation makes it difficult to generate collective action for a national lab network such as Surescripts has created for e-prescribing, he noted, and he expressed concern that meaningful use Stage 2, the only force driving standardization, may not provide enough of a spur to the industry to change.
ONC is currently surveying a random sample of 14,000 clinical laboratories, including 2,729 hospital-based labs, to better understand their capacity to electronically exchange lab information. Topics include the volume of test results sent electronically, adoption of standards, current systems, and barriers and facilitators for exchange. ONC plans to use the findings to monitor progress and develop policies that promote the exchange of structured test results among laboratories and ordering providers.
As part of that project, the state of Oregon did a census of its labs. A presentation on its web site notes that over half of the respondents currently send electronic test results, yet adoption of LOINC and later versions of HL7 was very low. Awareness of the ONC’s lab interface implementation guide (S&I) was almost non-existent. “Hospital labs are unlikely to send electronic lab results to providers outside of their organization without an existing business relationship,” the presentation noted.
Other barriers the Oregon survey found:
• Labs have little incentive to devote resources to HIE projects outside of their own organizations and customers.
• Despite some clarification from CMS and ONC, labs remain concerned about the CLIA (Clinical Laboratory Improvements Amendments) regulation implications of Direct Exchange.
• Laboratory information system vendors do not support a seamless workflow for Direct result delivery.
• Awareness and use of current standards remains low.
On the plus side, “pressure from providers is expected to make labs’ preference for point-to-point result reporting unsustainable,” the presentation noted. The technical and regulatory barriers posed by CLIA and CAP accreditation will be addressed, and MU Stage 2 added hospital reporting of labs to outside providers to the list of menu items.
Are there things ONC could or should be doing beyond what is in meaningful use Stage 2 to encourage a more rapid change to electronic delivery of lab results?