Which Comes First - The EMR or LIS?

As the push for Electronic Medical Records increases and provider groups assess their need for an EMR system, a question emerges: If your practice is shopping for an EMR yet still has no LIS, which should come first?

By Kerry Foster

In today's world of advanced healthcare technology, the push for Electronic Medical Records (EMRs) intensifies. Since President Bush's State of the Union address in 2004 where he said, "By computerizing health records, we can avoid dangerous medical mistakes, reduce costs and improve patient care," the demand for integrating technology into healthcare has increased.

In a 2005 survey conducted for Orchard Software, a laboratory information system (LIS) company, nearly 20 percent of the 600+ clinics and physician-groups interviewed were planning on shopping for an EMR system within the next year, another 16 percent the following year, and another 12 percent the year after that.

So how does this all relate to the laboratory? The successful implementation of an EMR system hinges on the existence of a fully functioning and integrateable LIS. For laboratory managers who have been put off time and time again for the investment of an LIS, the onset of the implementation of an EMR system may be just the opportunity needed to trigger the purchase of an LIS.

Numerous reasons exist for the investment of an LIS to manage the flow of clinical data generated by a moderately complex laboratory running multiple analyzers–the reduction of transcription errors, an increase in reimbursements due to automated medical necessity checking and insurance rules for order routing, the elimination for costly paper storage, instantaneous access to both present and historical results and simplifying the maintenance of QC for inspections. However, if your clinic or practice is considering an EMR, you now can present an even stronger case for an LIS.

Presenting Your Case

First, consider the role of the EMR system. "Initially, early generations were primarily concerned with the elimination of paper and the consolidation of patient information into an electronic format; however, as we proceed into the future, EMRs will be used to track a patient's progress and manage treatment protocols," says Rob Bush, Founder and President of Orchard Software. With 60 to 70 percent of the clinical data flowing from the laboratory into the EMR, Bush concludes, "Without historical lab results, how can you easily track a patient's progress?

"The role of the laboratory is more profound and complex than just generating a test," he continues. "Today's laboratory is responsible for managing how and where that test is generated and how the clinical results are presented, delivered and stored as consumable electronic and numeric data through interfaces. Paper results are not a useable form of data and will inhibit the advancement of patient care and protocol management."

"While most doctors agree that information technology will bring changes to their practices and clinics, how to get from point A to B isn't obvious to them," adds Simeon Schwartz, MD, president of Westchester Medical Group in White Plains, NY. "They would like to believe that whatever they did today they can do tomorrow."

Westchester Medial Group is an 85 doctor multi-specialist practice that has been growing 15 to 20 percent per year. An early adopter, Dr. Schwartz saw how the use of information technology would drive down his overhead costs. He installed his Orchard Harvest LIS in June 1999 and was doing 700,000-800,000 tests per year with only 2.5 FTEs and one supervisor. "We used IT and completely automated our lab and eliminated all the paper," he explains. "And it's not hard to see the return on investment when you are spending $10,000 to automate a $2 million lab."

Dr. Schwartz installed his GE Centricity EMR system in September 2002 and states, "While being more expensive than my LIS, again, I saw the return on our investment for the EMR and was able to utilize Computerized Physician Order Entry [CPOE]. I knew that it took a physician the same amount of time to write out a paper requisition as it would to put the order directly into the EMR. Again, we reduced numerous FTEs for manual order entry, not to mention the reduction of errors. The physician orders the lab test in the EMR and attaches the diagnosis code. The order then goes into my Orchard LIS. When the patient arrives at phlebotomy, the order is checked for coding and routing, and out comes the appropriate bar code labels for our lab or Quest. We eliminate pre-analytical errors and manual entry, and accessioning takes no more than 20 seconds per patient."

Dr. Schwartz has Quest reference lab interfaced directly to Orchard's Harvest LIS. This way only one interface is needed to the EMR system, and it allows him to take advantage of Harvest LIS's diagnosis code screening and test routing capabilities. Plus, it gives the lab total control over the order, reporting of results back into the EMR and quality control.

Recommendations

To other providers facing EMR and LIS decisions, Dr. Schwartz says, "Technology is an easy win. Put the Physician Practice Management system in first for scheduling and billing and follow that up with the LIS and an interface between them. This affects a smaller group of people in the practice and helps people see the benefits, giving organizational credibility for IT and the EMR. Your initial investment is less, too, and you are building up a history of lab results to dump into the EMR when it comes online."

Valerie Torre, lab manager for Crystal Run Healthcare, Middletown, NY, agrees. Crystal Run is a seven site multi-specialty physician group with about 150 providers, offering everything from primary care to advanced medical subspecialty services. They have two core laboratories doing over 1 million tests per year.

"We were lucky," Torre says. "Our managing partner, Hal D Teitelbaum, MD, is a visionary. Crystal Run is very customer-focused; he saw the value of being able to offer multiple services to the patient all under one roof. He also saw the need for growth and how technology and going electronic would sustain that growth and make it efficient."

Torre begins, "First of all, labs are regulated, and anybody running a lab is getting inspected regularly. And for this reason alone, I can't imagine pulling all my data for inspections without having an LIS. It saves time, interfaces reduce transcription errors and maintains all your QC data with the click of a mouse.

"Nationwide," she continues, "there is a tech shortage and labs have to do more with less and you have to automate your lab as much as possible. In the long run, an LIS is a good investment."

Another important reason Crystal Run uses Harvest LIS is the rules-based technology for automatically splitting orders, giving them the ability to route orders based on a patient's HMO or insurance coverage. "Some HMOs require us to use a certain lab to be reimbursed or keep them from billing our patient. The LIS does the routing automatically and keeps us from doing tests in-house when we should have sent it out to another lab. In this way the LIS helps avoid costly errors and decreases patient dissatisfaction. It saves so much time having to look up a patient's insurance information and the corresponding test numbers for the appropriate reference lab.

"The LIS also has rules for deferred or future orders which allow us to provide better patient care," Torre adds. "The providers are notified via e-mail when a patient fails to return samples collected at home. This gives them the opportunity to follow up with the patient immediately. Putting in the LIS first seems to be the most logical way to go. We felt like the lab staff was more willing to take on the challenge of an LIS, and unlike others in the practice, we were already using electronic equipment (the analyzers)."

Torre adds that installing the LIS first didn't disrupt the workflow of providers. Initially, they could still have their paper charts, but for the lab, once approved, all data is stored electronically.

Getting Results

When Crystal Run went live with the Next Gen EMR system, the doctors had already begun to see the advantages of information technology. It also immediately populated the EMR with two years of historical lab results.

"For the first six months, we let the providers complete paper requisitions, and the lab entered the orders manually into the EMR," Torre recalls. The EMR feeds orders to Harvest LIS, the LIS processes the orders. Results, whether from Crystal Run's labs or outside reference labs, are interfaced back into Harvest LIS. Harvest LIS then populates the EMR with approved results and physicians are notified in the EMR when results are released from Harvest LIS. She notes, "We do have a few tests done in outside labs not interfaced to the LIS, and in those cases, we have to scan the document and attach it to the patient's file in the EMR. These are only done on low-volume tests."

Torre says providers use laptops wheeled in on carts when they see their patients, and at hand is immediate access to meds, previous encounters and lab results. "Technology is one of the tools we use to provide better patient care."

Bruce Friedman, MD, professor of Pathology at the University of Michigan Medical School, adds, "The purchase of an EMR and an LIS are two separate purchases, but both should be shopped for at the same time. While implementing the LIS first provides you with a low-cost chance to get your feet wet in information technology, you want to be sure that the EMR you select will work seamlessly with the LIS."

Dr. Friedman suggests that when shopping, ask for your LIS and EMR vendors to provide a list of reference sites where the interface between the two is already working.

Bush agrees and suggests that you make sure your LIS is up and running smoothly before tackling the bigger task of interfacing the LIS to the EMR and integrating it into your practice's workflow. "When an IT manager puts together the master plan, he should consider installing the LIS first because it is a quick win and takes substantially less time than the full implementation of the EMR system, not to mention the experience of utilizing the EMR by the providers is greatly enhanced from day one. Your chance for acceptance is much greater, for until 100 percent of laboratory information can be delivered electronically to the EMR, paper records will still exist, and if a provider knows the electronic file is incomplete, he'll be obligated to check the paper charts."

On the Horizon

As for the future, with molecular and genetic testing on the horizon, the data produced in the lab environment will become even more critical to patient care. Bush concludes, "The integration of systems uniquely designed to enhance individual departments and functions is the future healthcare IT. The information generated and compiled by the laboratory and its associated reference labs will become increasingly important to the diagnosis and treatment process, and the electronic delivery of these results to the EMR is imperative to how providers use that data to improve patient care."

Kerry Foster is director of Marketing, Orchard Software, and is an ADVANCE vendor advisory board member.

Advantages of an LIS First

• Less initial capital outlay with the LIS than the EMR.

• Easier to implement, affecting only one department instead of the entire practice.

• Laboratory results account for nearly 60 to70 percent of the data stored in the EMR, and without the LIS's past and future results must be manually entered into the EMR, making it more likely that transcription errors will occur.

• Scanning results is possible; however, historical data is not available in a numerical format for easy comparison or data mining.

• CPOE and result review in the LIS is an easy task and eases the providers' transition to the EMR.

• Historic laboratory results are generated ahead of the EMR and more easily populated into the EMR system.

Overall Benefits of an Integrated EMR and LIS

• Paper charts and storage costs are greatly reduced, if not eliminated.

• Physical overhead is reduced, such as paper, copying equipment and supplies, and on-site and off-site storage.

• Human resources are reduced, better utilized or redeployed, as there is no more chasing charts, copying paper records, scanning documents or manual entry.

• Transcription errors are eliminated.

• Improved operational efficiency with immediate access to files and records by authorized personnel, and no more phone tag.

• Improved patient care and risk management through access to all patients' historical data, standardized protocols, pharmacy management and regulatory compliance.

• Increased reimbursements through proper E&M and diagnosis coding and test routing.