[Slide 1]{.underline}

**State and Regional Demonstration Projects: Laboratory Exchange**

Scott Young, MD

Director for Health Information Technology

March 21^st^, 2006

[Slide 2]{.underline}

**Today's Focus**

Lab Exchange Experience and Challenges

Planning; Utah

Initial Implementation; Tennessee

Experienced; Indiana

[Slide 3]{.underline}

**Today's Discussion**

Ark State and Regional Demonstration, SRD, Projects laboratory exchange
experience

Complexities and challenges confronting SRD's

How SRD laboratory exchange experience may help to advance
recommendations to the Community

[Slide 4]{.underline}

**State and Regional Demonstrations**

Five-year State-based contracts

> Help States develop secure statewide networks to use health IT to
> communicate and share information
>
> Ensure privacy of health information
>
> Make an individuals' health information more available to health care
> providers

FY O 4: Five State or State-based contracts totaling 25 million dollars
over five years

Colorado

Indiana

Rhode Island

Tennessee

Utah

Fall 2005: Ark gave the Delaware Health Information Network, DHIN, 4.7
million dollars over the next four years to build a statewide health
information system

[Slide 5]{.underline}

**Ark SRD Projects: Goals**

Enable information and communication technologies to allow clinicians
access to patient information at the point of care

Develop a health information exchange that connects the systems of
various local health care providers for better care coordination

Plan, develop, implement, and evaluate a patient indexing system that
allows public and private health care providers to share patient data

Build and evaluate a State-based regional data sharing and
interoperability service that links health care organizations across
counties

Expand and refine an existing statewide network that conveys patient
information electronically

[Slide 6]{.underline}

**Utah Health Information Network; UHIN**

Goal: Move health care into EDI

Fact: Majority of health care still uses paper

Fact: Need to move to formatted messages

Objectives:

> Create an evolutionary EDI path that allows paper, via PDF, but
> encourages user to migrate to formatted files: HL7, NCPDP, et cetera

Ensure that these exchanges can be used for both clinical and
administrative purposes; easier and more economical

[Slide 7]{.underline}

**UHIN: Send Lab Data**

Create an easy, low-cost, effective way to SEND lab results from
hospitals, physicians, and others

> Strategy: add functionality to an existing free UHIN tool, UHINT, so
> that it can:
>
> Pick up a standardized HL7 file or a PDF file
>
> Mail it securely to the appropriate receiver; EG, payers, other
> providers, hospitals, et cetera
>
> Allows for PDF so that anyone can send lab results, for clinical
> purposes or as claim attachment

[Slide 8]{.underline}

**UHIN: Receive Lab Data**

Create an easy, low-cost, effective way to RECEIVE lab results from
labs, hospitals, and others

> Strategy: add functionality to an existing free UHIN tool, UHINT, so
> that it can:
>
> Retrieve, park, view, and print HL7 and PDF messages
>
> Allows for PDF so that anyone can receive lab results, for clinical
> purposes or as claim attachment

[Slide 9]{.underline}

**UHIN: Integration with EMR**

Users with an EMR can send and receive formatted or PDF messages

Users without an EMR can send PDF's and receive formatted or PDF
messages

Objectives:

> Demonstrate the value of these exchanges to the participants slash
> community at large
>
> Focus initially on resolving the workflow issues rather than the
> technology

[Slide 10]{.underline}

**The Tennessee Ark Demonstration**

Structure and Environment

> Hospital-based initiative designed to create a utility to inform
> clinical practice
>
> Live system: 12 hospitals feeding data
>
> Three counties, 1 million people; plus 250,000 from adjacent States
>
> High uninsured and Medicaid population
>
> Complex delivery and insurer climate
>
> Active telemedicine and E-prescribing initiatives

[Slide 11]{.underline}

**Tennessee: Today and Tomorrow**

Today

> Consumers can see their clinical provider and receive some laboratory
> tests. They can log onto a provider system and view the results within
> hours

Tomorrow

> A consumer may receive their tests at a wider range of clinical
> settings; EG, a rural pharmacy?
>
> They can log onto a provider or a bank, question mark, system and see
> their results, their interpretation, and their charges

Future Challenge

> Generalizing current organizational-specific approaches

[Slide 12]{.underline}

**Tennessee: Charge from Stakeholders**

Explore Rio and hospital-based opportunities currently available.

Explore governance and financing approaches in successful Rio models,
Ark Rio contracts, and NHIN sites

Identify key components of a patient driven, easy to use, secure
authorization process

Consider Opt-in versus Opt-out Patient Choices

[Slide 13]{.underline}

**Tennessee: Hospital-based Opportunities**

Hospital data feeds fairly easy to develop

Primary challenge: translate data into appropriate standard forms

Best accomplished if one does not expect the hospital to do the
programming

Standardizing some core elements is essential for comparison and use;
EG, 45 key labs to LOINC

Standardizing all lab values initially may not be cost effective prior
to demonstrating value

Problem is simplified because the associations with patient identifiers
are straightforward

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**Tennessee: Governance and Financial Models**

ROI model: Return found on the quote, margins, unquote

ROI not just financial but quality and efficiency

Paradox: Announcement accelerated some point-to-point initiatives

Establishing formal governance and relationships is essential

Distribution of fees relative to the value conferred is expected to be
low

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**Tennessee: Technology, Data Sharing, and Opt-out**

Hybrid technology: logically decentralized but physically centralized

Data-sharing agreement is based on the Connecting for Health Framework;
Markle Foundation

Patients will initially be able to "opt-out" at the institutional level

Created an infrastructure that allows scaling of these issues through
practitioners

Infrastructure for direct consumer access is not yet envisioned

[Slide 16]{.underline}

**Tennessee: Lessons Learned**

Possession of patient data should not confer a competitive advantage

Data exchange can be evolutionary and does not have to be expensive

Technologies can be inclusive and create markets

Addressing major impediments to regional data exchange is essential for
any advanced use of health information technology. Examples:

Trust and confidentiality

Use limitations and specifications

Governance

Federated identity management

Authorization approaches

[Slide 17]{.underline}

**Tennessee: Next Steps**

Laboratory exchange emulating Commission for Systemic Interoperability's
vision for prescription drug histories

Standard approaches to patient identification allowing reliable
integration of data

Standard approaches to information representation

Means of identifying, authenticating, and authorizing access

Public safeguards for the inevitable errors

Strengthening communication between patient and care provider while
creating more efficient markets

[Slide 18]{.underline}

**Indiana: State and Regional Demo**

Evolving from the Indiana Network for Patient Care, INPC, with funding
by Ark slash NLM

Created by Regenstrief Institute

Operational for 10 years

Population base: 1.7 million

150 HL7 message feeds

Almost a billion structured observations; EG, lab results or vital signs

Approximately 80 million results added annually

Over 30,000 clinical results delivered daily

All data coded using LOINC codes

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**Indiana: Architecture**

Federated data model, centrally managed

Data standardized as received

Deterministic patient matching

At the center of a circle is a book labeled Concept Dictionary. To the
left of the book is a rotary ticket rack labeled Global Patient Index;
to the right is another labeled Global Provider Index. Just inside the
circle is a ring of icons that might be CPU's. Starting from the right
and moving clockwise, they are labeled Wishard Health Services,
Community, IUMG SC, Saint Francis, VA, Public Health, Saint Vincent,
IUMG PC, MMG, and Clarian Health Partners. Near the Wishard Health
Services icon, a lightning bolt projects from the circle to another CPU,
labeled OTH. The VA icon looks faded. Near the Clarian Health Partners
icon is a set of tiny picture icons labeled Radiology, Laboratory, ADT,
Pharmacy, Transcription, and something corresponding to a caduceus. An
arrow that appears to be labeled Real-time HL7 points from these icons
to Clarian Health Partners. Overlapping this area is a small circle full
of tiny words so clustered that one cannot expect to make sense of them.

[Slide 20]{.underline}

**Indiana:** Laboratory Fragmentation

  ----------------------- ----------------------- -----------------------
  Type                    Indianapolis MSA        Statewide

  Hospital                31                      214

  Regional                24                      102

  National                1                       2

  Reference               3                       3

  Public Health           4                       13
  ----------------------- ----------------------- -----------------------

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**Indiana: Complexities**

Fragmentation of market; many labs to deal with

Significant number of important labs are performed in physician offices

Typical laboratory has 5,000 unique results

Poorly structured messages from laboratories

Results messages and test catalogues don't contain enough information to
map them to standard codes

No two laboratories use the same codes

Laboratories change codes frequently

Laboratories often don't retain results on line more than 60 days;
varies

Completely mapping a single laboratory requires approximately 6 person
months

[Slide 22]{.underline}

**Indiana: Mapping Approach**

Accumulate large sample of laboratory result messages

Build database

Clean-up units

Evaluate lab terms: quote, analyze name words, unquote

Use Relma to generate first pass

Edits slash error checks: iterative review

Tool for checking specimen and units

Lessons

> Limit effort to one lab section at a time and limit to focus expertise
>
> Chemistry and hematology are easiest; microbiology and blood bank most
> difficult

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**Indiana: Good News**

Nearly every laboratory is automated

Essentially every laboratory system can generate outbound HL7 messages

LOINC is fairly comprehensive

Relma facilitates mapping process

Centralized mapping works; decentralized mapping does not work

[Slide 24]{.underline}

**Indiana: Docs-for-Docs Clinical Messaging**\
An inexpensive bridge to the EMR

Docs-for-Docs delivers clinical results including laboratories to
clinicians in real time: minutes

Routing based on providers listed in message

> Every data source uses their own provider ID's so providers have to be
> mapped to a single identifier

Consistent report format across all sources

Replaces all other delivery; data source funds

Accommodates paper based practice workflows

Three delivery options

> Secure Inbox requires only an Internet connection, PC, and browser in
> the provider's office
>
> Delivery into provider's EMR
>
> Facsimile delivery for those without Internet

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**Trends and Options**

Paper-based offices are going to continue to constitute a significant
portion of the health care landscape

> Adopt policy levers to promote electronic exchange of lab orders and
> results
>
> Formally adopt a standardized image format
>
> Promote the creation slash adoption of standardized inexpensive, less
> than 100 dollars, tools for physicians to securely send and receive
> standardized labs electronically; not fax and not e-mail
>
> The achievement of this exchange results in offices reorganizing
> workflows around EDI instead of phone, fax, e-mail, et cetera. This
> step is often underrated but is critical towards EHR migration.

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**Trends and Options**

Lack of standards for formatted messages

> Consider adopting E-links as the standard for lab order and result
> messages; current version may not be adequate for HIE
>
> Promote assistance for creating crosswalks between the plethora of
> proprietary lab codes and the appropriate LOINC's
>
> Assist LOINC with developing appropriate codes and with developing
> workshops to help the health care community learn how to use these
> codes correctly and uniformly

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**Trends and Options**

Interoperability; lack of Rio standards

> Convene or recognize core group of Rios, preferably Rios who are
> actually in production operation at this time, to discuss and adopt a
> suite of Rio-standardized messages
>
> Recognize that lab exchange is not exclusively clinical; may encompass
> public health or administrative info
>
> Recognize the need to exchange labs using identical formats and codes
> regardless of how the destination is going to use them

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**Enabling Factors**

Lab system vendors provide standardized HL7 outbound interfaces

> Minimal cost, less than 5,000 dollars
>
> E-links-HIE
>
> Option for LOINC codes

Drive Adoption of LOINC

Adopt a federated authentication model for providers; EG, Connecting for
Health

[Slide 29]{.underline}

**Summary**

Rios are a viable strategy option to promote the electronic exchange of
lab results and data

Ark is supporting a core group of Rios currently exchanging lab data

A series of policy discussions and decisions need to be made to fully
realize Rios capability in this arena

SRD's offer opportunity to evaluate alternative strategies where
consensus has not yet emerged

[Slide 30]{.underline}

**Ark: Agency for Healthcare Research and Quality: Advancing Excellence
in Health Care; www.ahrq.gov**

For additional information, please contact Scott Young, MD

syoung@ahrq.gov