meaningful use in the laboratory - executive war college · 2017. 4. 2. · clinical information...

© 2011 Sunquest Information Systems, Inc.

Meaningful Use in the LaboratoryMeaningful Use in the Laboratory

Kelly Feist, VP MarketingSunquest Information Systems


TopicsTopics

What is Meaningful Use?Meaningful Use and the LaboratoryWhat’s Next?


What is ARRA?What is ARRA?

On February 17, 2009, President Barack Obama signed into law the American Recovery and Reinvestment Act of 2009 (ARRA) as an economic stimulus package providing investment in the nation's infrastructure, employment, transportation, education and other fields.


HITECHHITECH

Health Information Technology for Economic and Clinical Health Act

Incentivize the adoption of computerized health records:– Improve outcomes– Facilitate access– Simplify Care and Reduce medical errors– Reduce healthcare costs


What is What is ““Meaningful UseMeaningful Use””

HITECH defines Meaningful Use as:

The use of Certified Electronic Health Record technology in a meaningful way.

24 Criteria or “Modules” are measures of Meaningful use in first stage

Incentives $2M+$200*total discharges

– Medicare


StageStagess


Meaningful Use TimelineMeaningful Use Timeline

02/17/2009ARRA signed into law

06/18/2010IFR for temporary EHR certification released

10/03/2010Initial certification bodies authorized by ONC

11/10/2010ONC FAQ Guidance: all to be certified

05/2011Incentive payments expected to begin

10/01/2012Last day for eligible providers to begin 365-day window to demonstrate Meaningful Use EHRs in fiscal year 2012 —for payments 2012-2015

12/30/2009CMS issues NPRM outlining provisions governing Medicare and Medicaid incentive programs including a proposed definition for the central concept of “Meaningful Use” of EHR technology

07/28/2010Final Rule for the CMS incentive programs and ONC adoption standards published in Federal Register

10/24/2010NIST updates and scripts to be used for certification

07/03/2011Last day for eligible providers to begin 90-day window to demonstrate Meaningful Use EHRs in fiscal year 2011 —for payments 2011-2014

2015Penaltiesbegin


Certified TechnologyCertified Technology

Certification required to use a technology to meet any or all of the 24 criteria– Functional requirements

– Plus Requisite Privacy and Security Modules

– Includes Encryption, Authentication, and Integrity modules

Comprehensive v. Modular– Modular may allow clients to leverage current technology

Must use it in a Meaningful Way


Hospital Path (Medicare)Hospital Path (Medicare)

Obtain certified technology– Must have a financial obligation to certified technology for all 24

Implement and Use Technology, first year– Must demonstrate meaningful use (14 core +5 menu) for 90 days

in 1st year• May defer demonstration of 5 criteria

• Last day to begin 90 day for FY2011 start is July 3, 2011

Apply to CMS to demonstrate the above:– Register and attest + submit evidence of above

Implement and Use Technology, on-going– Must demonstrate meaningful use of all for 365 days in second

year+


Inpatient CriteriaInpatient CriteriaCoreRecord patient demographicsRecord vital signs/chart changesMaintain current and active diagnosesMaintain active medication listMaintain active allergy listRecord adult smoking statusProvide patient clinical summariesProvide electronic health information copy on demandGenerate and transmit prescriptions electronically(Eligible Providers only)Use computerized physician order entry for drug ordersImplement drug-drug/drug-allergy interaction checksBe capable of electronic clinical information exchangeImplement one clinical decision support ruleProtect patient data privacy and security

MenuImplement drug formulary checksGenerate patient lists by conditionIdentify patient-specific education resourcesPerform medication reconciliation between care settingsProvide summary of care for transferred patientsSend care reminders to patients (Eligible Providers Only)Provide timely patient electronic access to health information (Eligible Providers Only)Record Advanced Directives (Hospitals Only)Incorporate Lab Results as Structured DataPublic Health Reporting*

The final rule requires eligible professionals and hospitals to choose at least one public health objective from the set of menu objectives, which include submitting one of the following:Immunization InformationSyndromic Surveillance DataReportable Electronic Laboratory Results (Hospitals only)

At this time, New York State is not testing the syndromic surveillance objective.


Laboratory Specific CriteriaLaboratory Specific Criteria

170.302 (h) – Incorporate laboratory test results

170.306 (g) – Reportable laboratory results

Privacy/Security Meaningful Use Modules including:

• 170.302(p) – Emergency Access• 170.302(q) – Automatic Log-Off• 170.302(r) – Audit Log• 170.302(s) – Integrity• 170.302(t) – Authentication• 170.302(u) – General Encryption• 170.302(v) – Encryption when Exchanging

Electronic Health Information


170.302 (h) Incorporate Laboratory Test Results170.302 (h) Incorporate Laboratory Test Results

The capability for the EHR Module to electronically receive clinical laboratory test results in a structured format, display such results in human readable format and incorporate results to a laboratory order or patient record.

Receive in a structured format (like HL7 or LOINC)

Display the results

Incorporate results into health record


170.306 (g) Reportable Lab Results170.306 (g) Reportable Lab Results

The capability for the EHR Module to electronically record, retrieve, and submit laboratory test results containing LOINC codes in HL7 v2.5.1 format to public health and other agencies.

LOINC-encoded

Laboratory test result data

HL7 v2.5.1 format

Implement interface to public health agency


WhatWhat’’s next? Minimal Impact on Lab s next? Minimal Impact on Lab

Submit reportable lab data

For EH make Stage 1 core. For EP make lab reporting menu.

Mandatory test. For EHs, submit if accepted and as required by law. For EPs, ensure that reportable lab results are submitted to public health agencies either directly or through their performing labs (if accepted and as required by law).Include complete contact information (e.g., patient address, phone and municipality) in 30% (EH) of reports.

Provide summary of care record (50%) Move to Core

Summary care record provided electronically for 80% of transitions and referrals

Stage 1 Final Rule Proposed Stage 2 Proposed Stage 3 Comments

Incorporate lab results as structured data (40%)

Move current measure to core, but only where results are available

90% of lab results are stored as structured data in the EHR and are reconciled with structured lab orders, where results and structured orders available


SunquestSunquest’’s Stage 2 Commentss Stage 2 Comments


Test Code LOINC code

GLU 1234-5

GLU 1234-6

Validation Table

Test Code LOINC code

GLU 1234-5

Ex 1234-8

Translation Table

1 – Create Validation and Translation Tables for tests associated to flag appropriate reportable results

2 – Expand Validation and Translation Tables to all tests and batteriesImplement LOINC enablement of HIS Results interface

Ex 1234-8

Ex 1234-9

Ex2 1235-1

Ex3 1235-2

Ex3 1235-3

Ex2 1235-1

Ex3 1235-3

3 – Implement LOINC enablement of other interfaces as needed

SunquestSunquestLabLab

Privacy/SecurityPrivacy/Security

LOINCHub

PublicHealth

HIS

RefLab

What About Standard Nomenclature?What About Standard Nomenclature?


PROPRIETARY AND CONFIDENTIAL 17

Why do LOINC & Reportable Results belong Why do LOINC & Reportable Results belong in the Lab?in the Lab?

The test dictionary is maintained in the Laboratory system– You don’t want to duplicate that and maintain it in two locations

LOINC is mainly a Lab vocabulary– It will be utilized in the Lab and in interfaces from the Lab

The Laboratory system should be capable of sending the LOINC-coded data where you need it

Makes sense vs. swiss-army-knife comprehensive EHR approach

Outreach?


Legislation Since 2009Legislation Since 2009

March 2010: Healthcare Reform Act– Patient Protection and Affordable Care Act– Healthcare and Education Reconciliation Act

March 2011: Affordable Care Act– Updating the delivery model– Not yet updating the payment structure– Will success vary based on who manages the ACO

• Hospital?• Providers?


The Evolution of a Care Delivery ModelThe Evolution of a Care Delivery Model

HITECH Act: financial incentives for investment in information technologies.

Meaningful Use: Drive interoperability and integration to promote clinical decision support leading to changes in the delivery of care

Accountable Care Organization: Build integrated care delivery networks accountable for the care of a population of patients.


Accountable Care OrganizationAccountable Care Organization

ACO: defined by CMS as “an organization of health care providers that agrees to be accountable for the quality, cost, and overall care of Medicare beneficiaries who are enrolled in the traditional fee-for-service program...”


Lab Is Central To Patient DiagnosticsLab Is Central To Patient Diagnostics

21

Patient

Patient

Patient

Patient

Patient

Patient

PatientPatient

H

LARGE HOSPITALLABS

Academic &Research Centers

CommunityHospitals

Clinic Labs

PhysicianOffice

SurgicalCenter “Minute

Clinic” “MinuteClinic”

SurgicalCenter

PhysicianOffice

“MinuteClinic”

SurgicalCenter

PhysicianOffice

ReferenceLabs

PhysicianOffices

Lab Is A Strategic AssetLab Is A Strategic Asset

Patient

Patient

Patient

Patient

Patient

Patient

Patient

Patient

Integrates Vital Data

Contributes to 70% of Diagnostic Decisions (1)

Meets Pay-for-Performance and Joint Committee Quality Measures

Ensures Patient / Physician Satisfaction

Pioneers Predictive and Personalized Medicine

Leads the Convergence between Clinical and Anatomic Pathology

Patient

(1) Source: “The Value of Laboratory Screening and Diagnostic Tests for Prevention and Health Care Improvement”, The Lewin Group, Inc.


Common Among Successful Delivery Models? Common Among Successful Delivery Models?

involvement of primary care physicians,engagement of sufficient specialty physicians,coordination of care throughout the health systemaccess to patient information and performance data

commitment to control costsEmploy evidence-based medical practicesalignment of financial incentives,focused attention on the management of chronic illnesses,deliver care in ambulatory settings wherever possible patient-centered culture at all levels.

Advance Vol. 20 • Issue 4 • Page 29, Joe Miles


Meaningful Use Requires Laboratory ResultsMeaningful Use Requires Laboratory Results

Laboratory data constitutes 70% of patient’s medical record

Laboratory data critical to decisions that affect patient care

Laboratory testing/pathology services typically cost only 2¢ to 3¢ of every healthcare dollar!

Lab Test data influences 70-80% of healthcare decisions


ACOACO’’s Represent an Opportunity for the Labs Represent an Opportunity for the Lab

Lab is already an important and primary integrator of clinical information within the care continuumOutreach: more care will be delivered in ambulatory settings in the ACO modelConnectivity to community-based providers is keyPathologists offer a unique and necessary clinical interpretive skill set to that can help deliver improvements in care outcomesThe lab is uniquely positioned to offer insight into CPOE order set creation and use of clinical decision support to determine care protocolsThe Lab is a leader in combining IT and lean processes to deliver cost and productivity efficiencies


OrderSpecimen Collection/Management

Accessioning and Planning Analysis Results and

Reporting

Clinical Workflow? Or “manufacturing” workflow that delivers a clinical product?

Laboratory Workflow


Patient Safety Is At The Forefront Patient Safety Is At The Forefront Of Healthcare PrioritiesOf Healthcare Priorities

26

Patient Safety is One of Nation’s Most Pressing Healthcare ChallengesPatient Safety is One of Nation’s Most Pressing Healthcare Challenges

Failure Type Occurrence (2)

X Failure to ask stated name and match to wristband 57%

X Failure to match wristband ID with blood bag label 24%

X Failure to match wristband data with request form 46%

X Failure to check results of compatibility testing and expiration 27%

Failure to do ALL 4 correctly 75%

Eliminating preventable medical errors is key to improve quality of care and hold down healthcare costs

− Only 25% of blood test procedures are performed correctly across all four key steps

− 1/400 units administered to wrong patient

Nursing shortage is expected to intensify as baby boomers age and the need for healthcare growsNursing shortage, combined with an increasing workload, poses a direct threat to the quality of care (and potentially an increase in errors)

U.S. Registered Nurse Supply vs. Demand (’000) (1)

Supply

Demand

(1) Source: U.S. Department of Health and Human Services. (2) Source: Novis et al. Arch Path Lab Med 2003; 127: 541.

Negative payment incentives, industry initiatives like ASHP2015, and professional standards (e.g. CAP target benchmarks, Joint Commission safety and quality goals) are all driving patient safety as a top priority for hospitals

“Never Events” effective October 2008, Medicare does not reimburse for care related to:

− Object inadvertently left in after surgery

− Air embolism− Blood incompatibility− Catheter associated urinary tract

infection− Pressure ulcer (decubitus ulcer)

− Vascular catheter associated infection− Surgical site infection-mediastinitis

(infection in the chest) after coronary artery bypass

− Graft surgery− Certain types of falls and trauma


Process Changes Improve SafetyProcess Changes Improve Safety

Batch collectionsCalling/paging for Stats– Generic patient labels

Lab generated label printing

• Visual patient identification

Real time listsAutomatic real time notificationBedside label printing

Visual and electronic identification (Patient bar coded armband)

OldOld NewNew


Extend Process Changes Into the FieldExtend Process Changes Into the Field

Outreach Advantage Mobile Manages:

• Courier Routing

•Dispatch

•Tracking and Stats

•Specimen Management in the field


Significant Return on InvestmentSignificant Return on Investment

Reduce specimen collection timeProductivity Benefit Support Pre Post Diff

Time spent traveling to/from lab /hour/day (mins) 15 6 9 # of phlebotomists 12 12 Hourly cost per phlebotomist 21.70$ 21.70$ Time spent on specimen receipt /hour/day (mins) 10 - 10 # of lab techs 35 35 Hourly cost per lab tech 31.00$ 31.00$ Annual Benefit 464,322$ 49,164$ 415,159$

Validation of Key Assumptions

# of phlebs - Reduced phlebotomist FTE by 4 or 10% (Hospital H), reduced FTE by 3 (Hospital K).

Benefit Calculation

Time spent traveling to/from lab - Reduced travel time from 15 minutes per hour to 5 (Hospital B). 50-60% of time spent on traveling reduced to 10-15% and time per collection reduced from 40 minutes to 15 (Hospital H). Reduced travel time by 60% in the ED (Hospital J).

With Collection Manager labels can be printed right at the bedside so no time is spent traveling back and forth for labels. It can also immediately notify when a new test request comes in, eliminating the need to check-in with the lab, and once the specimen bar code is recorded in the device the specimen is automatically received into the LIS.

Time spent on specimen receipt - 10-20 minutes an hour spent on manual receipt eliminated (Hospital B). 3-5 minutes per test eliminated (Hospital H).

Reduce specimen collection time.


Increase ED capacity by reducing TATRevenue Benefit Support Pre Post Diff

# of ED patients per day 80 80 - Average LOS per patient (in minutes) 220 210 10 New capacity created - # of added patients possible 4 % of new capacity captured 10.0%Average charges per patient in the ED 1,896$ 1,896$ Annual Benefit 55,363,200$ 55,626,834$ 263,634$


Average charges per patient - Average charges per ED visit $1,896 (Consumer Health Ratings Study).

Benefit CalculationIncrease emergency department capacity by reducing TAT.

Average LOS per patient - Reduced average LOS in the ED by 10-20 minutes a person, CM accounts for 50% of this (Hospital J).

With Collection Manager the risk of mislabeled specimens is significantly reduced or eliminated, as the device can be used to scan a wristband and print a set of labels to identify “draw and hold” collections prior to the order being placed in the LIS. Once the order is placed specimens can quickly be sent to lab.




Optimize courier efficiencyCost Savings Benefit Support Pre Post Diff

Cost to maintain courier fleet a month/per vehicle 160$ 144$ 16$ # of vehicles in fleet 100 100 Monthly costs of taxis/outside couriers 10,000$ -$ Annual Benefit 312,000$ 172,800$ 139,200$


Benefit Calculation

Monthly costs of taxis/outside couriers - $10K a month spent on cabs and outside couriers eliminated (Lab D).

Optimize courier efficiency. Outreach Advantage allows you to optimize your courier routes. In addition, with the system’s ability to provide real-time updates on the status and location of each courier, they can be efficiently redeployed when needed for STAT calls, eliminating the need for outside taxis.


Does This Look Familiar?Does This Look Familiar?


Workflow Automation OpportunitiesWorkflow Automation Opportunities

• Receipt of “Foreign Specimens” into the lab without the need to re-label

• Prospectively plan and route samples through the lab to optimize capacity and decrease turnaround time

Evolution of the LIS into a Resource Planning Solution?


• Decrease the possibility of errors resulting from the re-labeling process

• More than simply tracking the progress of a sample through the lab

• Prospective routing and expanded capacity provide opportunities to drive additional profitable revenue

Evolution of the LIS


Reduce time spent handling outside samplesProductivity Benefit Support Pre Post Diff

# of outside samples w/foreign ID received a month 50,000 50,000 - Average time spent handling these (mins/sample) 5 1 4 Lab tech FTE costs per hour 31.00$ 31.00$ -$ Other re-labeling costs (labels, printing, etc)/mth 1,000$ -$ 1,000$ Annual Benefit 1,562,000$ 310,000$ 1,252,000$


Benefit CalculationReduce time spent by lab technicians dealing with outside samples and manually re-labeling them to be recognized by their lab.

Sunquest Lab’s Advanced Accessioning lets you receive outside samples with a barcoded identifier already affixed, and gives you the ability to read that code (the "Foreign CID") into the system and utilize it as the Sunquest Container ID. Average time spent handling outside samples - Currently 5-10 minutes per outside sample

when received into the lab (Industry Benchmark).

Increased Productivity Delivers ROIIncreased Productivity Delivers ROI


Reduce manual intervention required by techsProductivity Benefit Support Pre Post Diff

# of tests per month 500,000 500,000 - Time spent manually handling specimens (mins) 5.0 3.5 1.5 Lab tech hourly FTE costs 31.00$ 31.00$ Annual Benefit 1,550,000$ 1,085,000$ 465,000$


Benefit CalculationReduce manual intervention required by techs to walk specimens from station to station.

With SMART, based on pre-defined criteria a specimen can be placed on the track, be received in the LIS, be pre-processed as needed, including complex aliquot instructions, and centrifuging, put on the instrument, processed and results acquired all without a tech looking at it.

Time spent manually handling specimens - Time spent handling specimens reduced by 30% resulting in ability to increase volume by 30% with no added FTE(Hospital B). Time spent walking specimens from station to station reduced from 3-4 minutes to 0 and time to enter specimens into the system reduced from 5 minutes to 0 (Hospital F).

Increased Productivity Delivers ROI Increased Productivity Delivers ROI


Increase lab capacity by reducing TATRevenue Benefit Support Pre Post Diff

# of tests run per month 500,000 500,000 - Current TAT (in minutes) 45 32 14 New capacity created - # of new tests possible 214,286 % of new capacity captured 1%Average revenue per added test 40.00$ 40.00$ Annual Benefit 240,000,000$ 241,028,571$ 1,028,571$


Benefit CalculationIncrease lab capacity by reducing TAT.

Route optimization logic determines each container’s optimal path through accessioning, processing, and testing workstations, getting it to the workbenches more quickly where staff can quickly locate containers, view instructions, conduct testing and generate reports. Current TAT (in minutes) - TAT per specimen reduced from 30 minutes to 2 (Hospital B), TAT

reduced by 30% and capacity increased by 40% (Hospital F).Average revenue per added test - Average revenue per test $50 - $80 (Hospital B), $40 - $80 (Hospital F), average hospital revenue per patient $2,800 (RedOrbit News 2007).

Capacity Enables Revenue GenerationCapacity Enables Revenue Generation


Looking to the FutureLooking to the Future……..What should we be thinking about?

– Clinical Decision Support• During the ordering process• During the interpretation of results

– Quality Measures• Reportable metrics • Outcomes and quality reporting


Thank You!Thank You!

[email protected]

meaningful use in the laboratory - executive war college · 2017. 4. 2. · clinical information...

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