CEO SUMMARY: Only about 180,000 U.S. physicians have adopted electronic medical record (EMR) systems over the past 14 years—mostly in larger medical groups. Now experts believe as many as 60,000 physicians per year will begin to adopt EMRs because of new federal incentives funded by the stimulus bill passed early last year. This is a major development and requires a response by every clinical lab and pathology group practice, since physicians will need their lab provider to enable electronic lab test ordering and lab test reporting for their EMRs.
PHYSICIAN ADOPTION OF ELECTRONIC MEDICAL RECORDS (EMR) SYSTEMS is expected to skyrocket during the next 36 months as a direct result of new federal incentives. This will be an opportunity for clinical labs and pathology groups that move nimbly to offer LIS-to- EMR interfaces to their client physicians.
“The opportunity exists because EMR adoption and LIS-to-EMR interfaces have a hand-to-glove relationship,” stated Pat Wolfram, an expert in EMR integration. “Once a physician group implements an EMR into its practice for the first time, it immediately wants its laboratory to electronically populate the patient’s EMR record with the laboratory test results.
“Now, to qualify for recently-introduced federal financial incentives, physi- cians must also order lab tests within their EMRs,” he said. “Physicians will need the lab’s help to put both EMR lab results and lab orders in place.
“In recent years, we have seen that the clinical laboratories which do this best gain competitive advantage,” he continued. “These labs do better at retaining existing clients while increasing the number of new physician clients for their lab testing outreach program.”
Wolfram is Vice President of Marketing & Customer Services for Ignis Systems Corporation, a company in Portland, Oregon, that provides EMR integration between physicians and labs and other providers. He made these comments last week during THE DARK REPORT’S special audio conference “New Opportunities for Your Laboratory’s LIS-EMR Interface: How to Profit From the ‘Big Wave’ About to Hit Healthcare.”
Changing Doc’s Use Of IT
“EMR adoption is absolutely the biggest thing happening in the way ambulatory physicians use information technology,” observed Wolfram. “Since Congress passed the bill last year that funded $17 billion in incentives to encourage physicians to implement an EMR, demand for our services has increased each month.
“Keep in mind that the terms EMR and EHR (electronic health record) are often used interchangeably,” he noted. “That can be confusing. For purposes of our discussion today, my analysis and recommendations deal with the category of systems known as ambulatory medical record systems.
“It helps to understand the numbers which will drive this surge in physician demand for EMRs,” he continued. “Estimates place the current number of physicians with EMRs in their offices at between 150,000 and 180,000. These are primarily larger groups, usually with 15 or more doctors in the practice, or a collection of affiliated practices. It has taken 14 years to achieve this number of EMR users.
“If the federal stimulus package achieves its goals of 90% adoption by 2015, that means 360,000 physicians that do not have EMRs today will install EMRs,” he continued. “That averages out to be about 60,000 new doctors using EMR systems each year between now and 2015.
“This rapid uptake of EMRs by physicians will put a major stress on laboratories, for an obvious reason,” stated Wolfram. “Almost all EMRs today utilize interfaces with providers of laboratory tests. When done right, the LIS-to-EMR interface supports computerized physician order entry from within the EMR and electronically feeds the laboratory test results back into the EMR. Thus, the nation’s labs will have to scramble if they are to support 60,000 physicians during their EMR adoption process each year.
Trump Card For Laboratories
“The good news is that laboratories have a trump card to play with physicians preparing to implement an EMR for the first time,” he observed. “Each physician can qualify for federal incentives that can be as much as $44,000 per doctor over several years, so long as the EMRs in use meet ‘meaningful use’ requirements. Lab test ordering and lab test resulting are currently requirements of the ‘meaningful use’ criteria.
“These requirements were published by the Office of the National Coordinator for Health Information Technology (ONC) on December 30, 2009,” said Wolfram. “The published requirements are currently in a 60-day comment period that ends March 15, 2010. It is expected that the published requirements will become final in May 2010.
“There are several things about meaningful use that pathologists and laboratory executives should understand so they can meet the needs of their client physicians in the most appropriate manner,” said Wolfram. “I am going to primarily address the incentive program offered by Medicare. Medicaid has slightly different criteria governing the financial incentives it offers for EMR adoption.
“To qualify for incentive payments, the adopted EMR must be certified by one of the certification committees, such as the Certification Commission for Healthcare Information Technology (CCHIT),” he added. “Next, the physician is to use that electronic medical record in the care of his or her patient population in a meaningful way. Once the physician achieves the objectives required by the government, he or she can apply for the incentive payment.
“The ONC has defined 28 functions (as presented on the CCHIT checklist) that the EMR must support and the physician must use,” Wolfram explained. “Laboratory testing is named in three of the defined uses within a qualified EMR.
“The first of these is computer physician order entry (CPOE), where a physician uses an EMR to order laboratory tests, imaging studies, referrals, and/or medications,” he noted. “The second is electronic receipt of laboratory test results directly into the EMR.
“The third criteria of meaningful use involving laboratory testing is a somewhat new function,” continued Wolfram. “In cases where a public health agency requires the physician to submit a laboratory test report, the EMR must be capable of electronically transmitting these lab reports directly to the public agency.
“During the first stage of the government’s EMR incentive program, this capability only needs to be proven,” he stated. “It does not need to be performed in a production environment. That will probably be a requirement of stage two or stage three ‘meaningful use.’
“Those are the meaningful use criteria that most involve laboratories. But it is cash from the government that catches the attention of physicians,” offered Wolfram. “Federal payments will come in three stages.
“In stage one, if a physician adopts an EMR and, for 2011 (during next year), can prove that it is being used in a meaningful way, he or she can get a reimbursement check for as much as $18,000 from Medicare. If the physician proves that same meaningful use in 2012, he or she can get an additional $12,000,” he noted.
“The threshold goes up in stage two, which begins in 2013,” explained Wolfram. “A different level of meaningful use will be applied at that time. Because government officials have not released this information yet, we don’t know what these later rounds of meaningful use requirements will be.
“The bar gets raised again in stage three, which is in 2015,” he added. “Lab managers and pathologists should anticipate that, in stage three of the federal EMR adoption incentive program, every point of patient care throughout a healthcare system would involve use of a common medical records repository. The ambulatory EMR would contribute to this repository, as would other clinical systems throughout the care network where a patient receives care.
“These same clinical systems would have access to this common medical record to read or retrieve the full clinical profile of the patient,” speculated Wolfram. “The goal is to nurture and encourage further integration of care pathways and the information technology that providers use to view a complete electronic health record for an individual patient.
“Having laid the groundwork for the coming wave of EMR adoption, let’s take a closer look at the requirements that are specific to laboratory testing,” he noted. “How the EMR handles receipt of lab test results is a good starting point.
“It won’t be enough for the EMR to simply interface with—and accept lab testing results from—the LIS,” said Wolfram. “It will be required that 50% of the lab results accepted into the EMR be at the numeric structured level. In its simplest form, this means the specific values of, say, a cholesterol test must be presented in a database location in the EMR in a way that allows for trending, reporting, and to trigger care protocols.
“Next, there are specific requirements for lab test ordering within the EMR,” he added. “For the function of computerized physician order entry (CPOE), over 80% of the orders in the ambulatory environment must be entered by the physician directly inside the EMR.
“In practical terms, we know that means a substantial number of orders placed by the physician would be lab tests. It will be impossible for most physicians to demonstrate that 80% of their orders are being placed within the EMR unless clinical laboratory tests are included. Lab directors will need to deal with this issue when developing the LIS-to-EMR integration for a physician who is adopting an EMR.
“Bear in mind that the requirement calls for the physician to order via the computer, but it does not require that the order be transmitted electronically to your lab—at least not in stage one,” he said. “The physician can satisfy the requirement by printing the lab test request on paper and sending that paper to the laboratory.
“However, there are good workflow and operational efficiency reasons to make the EMR lab order an electronic one,” added Wolfram. “Perhaps the best reason is that returned lab results will have the needed identifiers (patient and provider) to guarantee a match to the right EMR chart and notification to the right provider in the medical group practice.
“Similarly, as part of the stage one requirements for reportable lab submissions, the lab report does not need to be submitted to a public health agency, but it simply has to be proven that the EMR is capable of this function,” Wolfram said. “Thus, the physicians’ practice only needs to prove that its EMR can submit the report to the agency if that community has a public health agency that can receive this type of data.”
Wolfram has specific recommendations for laboratories that want to be effective at helping client physicians adopt EMRs. “One function that is almost mandatory is that the laboratory deliver a simple and efficient lab test results interface with the EMR,” advised Wolfram.
“What we see in the marketplace is that about 90% physician EMRs go live with a laboratory interface in place that electronically delivers lab results into the EMR,” he commented. “If the new EMR becomes operational without this automatic data feed for lab tests results, the doctors will ask for this capability very quickly. In our experience, we’ve learned EMRs do not go live and are not used by doctors unless lab results are there.
“Historically, ordering lab tests within the EMR occurs at later phases of the EMR adoption cycle,” observed Wolfram. “But with the current requirements for mean- ingful use, lab ordering will happen sooner.
Reason For Late Adoption
“There are two primary reasons for late stage adoption of lab ordering within the EMR,” he explained. “The first is ease-of- use. Ordering tests within an EMR is a significant workflow change for a practice when compared to the much simpler function of electronically accepting and reviewing lab results. Second, the setup required to install the lab’s test codes and ordering rules into the EMR ordering libraries, along with compliance and other related ordering rules (ABNs and AOEs, for example) requires significant effort. Some EMR products in the marketplace today are better at this than others.
“As more and more of your practices evaluate EMRs, you can partner with them to understand the value of EMR-to-Lab integration and to make it part of the acceptance criteria,” he said. “Then, help them evaluate whether the EMR can sup- port your lab ordering rules and how to accomplish the LIS-to-EMR integration setup. It’s often not prioritized as a critical element in their EMR evaluation, but it should be.”
THE DARK REPORT calls attention to the fact that this multi-year period of widespread adoption of EMRs by the nation’s physicians is a once-in-a-lifetime market opportunity for clinical labs and pathology group practices. More than half of the nation’s 700,000 physicians will become EMR users between now and the end of 2015.
Once a physician group embeds a laboratory’s LIS-to-EMR interface into its EMR product, it becomes more difficult and time-consuming to switch to a new laboratory provider. This is an important reason why clinical laboratories and pathology group practices should want to be competent and deft at supporting the physicians’ EMR implementation process.
At a time when the physician group is investing considerable time and money to make an EMR a reality, the local laboratory can demonstrate its competence and ability to support the physicians’ “meaningful use” of their EMR system. Recent experience demonstrates that labs that do this earn great loyalty from their client physicians.