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Will the Federal Government’s Newly “Aggressive” Agenda Bring True Lab Results-Based Interoperability?

March 13, 2013
by Mark Hagland
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Robin Raiford believes that one element in the federal healthcare agenda for 2013 could dramatically improve patient care delivery

A number of important news developments took place at HIMSS13, the annual HIMSS Conference, sponsored by the Chicago-based Healthcare Information & Management Systems Society, and held March 3-7 at the Ernest N. Morial Convention Center in New Orleans. One of the more important developments was the announcement by Marilyn Tavenner, R.N., acting administrator of the Centers for Medicare & Medicaid Services (CMS), that the federal agencies supervising healthcare—CMS, its parent agency, the Department of Health and Human Services (HHS), and the healthcare IT-focused agency under its aegis, the Office of the National Coordinator for Health IT (ONC), were pushing a very “aggressive” agenda around healthcare IT during 2013.

One area that has proven to be particularly challenging has been how to incorporate clinical laboratory results into the flow of electronic health records (EHRs) in a way that is practicable and sustainable. As HCI’s Senior Contributing Editor David Raths noted in a blog report on Feb. 4, “[A]t 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.”

Raths quoted Micky Tripathi, president and CEO of the Massachusetts eHealth Collaborative and chair of the HIT Policy Committee’s Information Exchange Work Group, who noted at that meeting the large percentage of lab results still delivered via fax and paper. Tripathi had cited survey data from the Watertown, Mass.-based AthenaHealth that found an extremely low percentage of lab results being conveyed electronically using LOINC-encoded results (based on the Logical Observation Identifiers Names and Codes, or LOINC standard).

This week, HCI Editor-in-Chief Mark Hagland spoke with Robin Raiford, R.N., research director for the IT Strategy Council at the Washington, D.C.-based Advisory Board Company, about federal healthcare officials’ aggressive policy push, as announced at HIMSS13. Below are excerpts from that interview.

Were you at the HIMSS Conference session at which Marilyn Tavenner articulated the federal government’s overall healthcare strategy on Wednesday morning, March 6, based on the announcement that had just been released that morning about that same strategy?

I wasn’t at the Tavenner session, but I have seen the HHS announcement, and I went to a subsequent town hall Thursday with Farzad [Farzad Mostashari, M.D., national coordinator for health IT]. That was a packed session on Thursday.

Robin Raiford, R.N.

What is your perspective on the level of “aggressiveness” of CMS and ONC in terms of their announced policy agenda for 2013? Do you believe that they are putting just the right level of pressure on healthcare providers right now, or perhaps too much or too little pressure?

I think they’re making their point clearly. And way back in the day when Tony Trenkle was speaking for the government, they said, we don’t have to put all the MU ornaments on one Christmas tree. And they also said they were interested in sharing the benefits of MU with non-acute care, and that was a good intention, though most of those organizations don’t yet have EHRs. But the big news was if they’ve decided to manipulate CLIA [the federal Clinical Laboratory Improvement Amendments of 1998] for the labs. One of the things that CMS kind of controls is the CLIA clinical lab regulations. And so a while back, they said, yes, you’re going to have to put in the director and address of the place that did the lab into the EHR, and you have to put that into your lab system so the lab system could send it to the EHR, and that was kind of a big thing.

But the other thing is that the EHR could absorb this coded lab value via the LOINC standard. So if they require labs to include the code, that’s what should happen, because that’s been a missing link. We often get asked, can our lab send the public health reporting? Well, they could get certified as an EHR module, but the intent is that it’s supposed to come out of the EHR. Well, their labs didn’t have to comply with that, but if they changed the regs [based on a newly aggressive policy agenda this year], that would be big. So for example, what if you had the horrible bug MRSA, someone might code it as “M_R_S_A,” and someone else might type in “M.R.S.A.” And no amount of standardization [of information systems] is going to work unless you have coded values. That’s why that area could prove to be a major development.

There are some potentially large public health and biosurveillance implications of this, if the federal healthcare agencies do end up pushing the industry towards LOINC-based coded lab results, then?

Yes, definitely. For one thing, you could begin to analyze lab results more broadly, across whole communities and regions. For example, with lab values coded in LOINC-based format, you could trend information on an individual lab tests on specific patients, and could trend that information more broadly and determine whether a particular disease outbreak trend is going up or down. And Farzad was very clear during the town hall last Thursday; he said over and over again, we’re going to use every policy lever we have. And in the HHS announcement, they had mentioned the lab as well. The lab piece is mentioned in question number 10 in the RFI [the request for information that Ms. Tavenner and Dr. Mostashari announced that on March 6 the government was sending out to the industry--see p. 15 of the RFI here, which discusses the potential for direct patient access to lab results based on modifications to the CLIA regulations].

It seems that the implications for improving patient care might be very broad, if LOINC-based lab results communications could flow automatically into EHRs.

Yes, because right now, hospitals and EPs [eligible providers under the HITECH Act] are required to include patient problems, meds and allergies in EHRs. And problem lists, medications, and allergies are all very important information. But the ready availability of patients’ baseline lab results are the keys to the kingdom.

Overall, is it your feeling that federal officials including Ms. Tavenner and Dr. Mostashari are pushing down at about the right level on the levers of their power and influence to compel change in healthcare?

I do think they are, yes. I think they need to push [healthcare reform and meaningful use], because people don’t just do this on their own. There was a very interesting documentary on CNN last night about quality in healthcare. That documentary looked at some of the issues around both cost and quality in healthcare. What’s clear is that people need to be pushed to change healthcare for the better, because we’ll be bankrupted otherwise. And before the election, President Obama said, the purpose of government is to get people to do things they could not do on their own; and I would add, the purpose is also to get people to do things they would not do on their own. And frankly, I think it’s appalling that some people are going to wait until the very last minute in 2014 to move forward on meaningful use. And I’m a big Obama fan, but I just think this is where healthcare has to go.

The plain reality is that when you have a set amount of money to take care of individuals, quality and prevention naturally come to the fore; I discovered this in doing some research on Indian/Native American healthcare delivery in Arizona and Alaska. In those situations, they’re working with limited funding, and yet they consistently deliver quality care. Another example of how healthcare delivery has to be reconsidered has to do with the most innovating healthcare organizations, many of which have salaried-physician models. For example, I didn’t know until recently that the doctors at the Cleveland Clinic were salaried; that’s their business model, and it really makes sense.

I also believe strongly in patient engagement, and recently made public comments to the HIT standards and policy committees around what can be done to engage patients. In those comments, I said that what’s needed is to create some kind of patient experience or excellence award; HealthGrades has just created a precedent for that, with their Outstanding Patient Experience Award recipients. What's particularly interesting is that, of the 311 recipients of that award, over 150 of them are also meaningful-user hospitals.

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