# Presentation: 422167

## EHR-Laboratory Interoperability andConnectivity Specification (“ELINCS”) 

- EHR-Laboratory Interoperability andConnectivity Specification (“ELINCS”)
- Presentation to AHIC EHR Work Group
- February 22, 2006
- Jonah Frohlich,  California HealthCare Foundation
- Walter Sujansky,  Sujansky & Associates, LLC

## A national project sponsored by the  California HealthCare Foundation (www.chcf.org)
Motivation
Streamline the implementation of electronic data interfaces between labs and ambulatory EHRs
Expand the electronic delivery of laboratory results to clinicians in the office setting
Promote the adoption of EHRs among ambulatory-care providers
Initiated in February, 2005

- Motivation
- Streamline the implementation of electronic data interfaces between labs and ambulatory EHRs
- Expand the electronic delivery of laboratory results to clinicians in the office setting
- Promote the adoption of EHRs among ambulatory-care providers
- Initiated in February, 2005

- ELINCS Project Overview

**Notes:**
Purpose of this proposal:  
Background information on the v3.0 methodology for dynamic modeling
Proposal for a specific dynamic model for the ELINCS standard –> point of departure for working group discussion

## An implementation guide for the electronic reporting of lab results
Detailed specification of the format and coding of lab-result messages (based on HL7)
Detailed interaction rules for laboratory information systems and EHRs (based on HL7)
Based on requirements of varied stakeholders
EHR vendors, commercial labs, L.I.S. vendors, clinician users, government bodies, standards organizations
Balance of ideal requirements and practical capabilities => enable near-term adoption
Support for objective conformance testing

- Detailed specification of the format and coding of lab-result messages (based on HL7)
- Detailed interaction rules for laboratory information systems and EHRs (based on HL7)
- Based on requirements of varied stakeholders
- EHR vendors, commercial labs, L.I.S. vendors, clinician users, government bodies, standards organizations
- Balance of ideal requirements and practical capabilities => enable near-term adoption
*Support for objective conformance testing*

- ELINCS Project Goals

**Notes:**
Purpose of this proposal:  
Background information on the v3.0 methodology for dynamic modeling
Proposal for a specific dynamic model for the ELINCS standard –> point of departure for working group discussion

## ELINCS Use Case: Outpatient Lab Testing

- M.D.

- EHR

- Laboratory*

- ELINCS Use Case: Outpatient Lab Testing

*Order Generated by EHR;  Order received at Laboratory*

- * Hospital, Commercial, or Clinic

*Result Transmitted Electronically to EHR*

*Result Review/**Decision Support*

- Covered by ELINCS specification

**Notes:**
Although v3.0 storyboards are intended to be narrative descriptions of the healthcare scenarios, this more concise graphical description may serve our purposes.  When we begin to discuss certain details (such as the specific types of information that may be sent in result transmissions), it will be useful to add narrative descriptions to this diagram.

Also, please note that this is not intended to be an “interaction diagram” in the v3.0 sense.  This diagram just graphically depicts the workflow related to the ordering, performing, and reporting of a lab test in the ambulatory setting.

## Includes 
Standardized format and content of lab-result messages
Standardized interaction model for exchanging lab-result messages
Standardized coding of common tests (LOINC)
Excludes
Standardized format for lab orders
Transport technologies, encryption/authentication mechanisms, and message-routing services

- Standardized *format and content* of lab-result messages
- Standardized *interaction model* for exchanging lab-result messages
- Standardized coding of common tests (LOINC)
- Excludes
- Standardized format for lab orders
- Transport technologies, encryption/authentication mechanisms, and message-routing services

- Scope of ELINCS v1.0

**Notes:**
Purpose of this proposal:  
Background information on the v3.0 methodology for dynamic modeling
Proposal for a specific dynamic model for the ELINCS standard –> point of departure for working group discussion

## Multi-disciplinary technical working group
Membership by nomination and invitation

Consensus-based decision making
Discussion and consensus in work group
Public comment period to collect wider industry input
Thorough documentation of process

Guidance from external steering committee

- Membership by nomination and invitation
- Consensus-based decision making
- Discussion and consensus in work group
- Public comment period to collect wider industry input
- Thorough documentation of process
- Guidance from external steering committee

- ELINCS Development Process

**Notes:**
Purpose of this proposal:  
Background information on the v3.0 methodology for dynamic modeling
Proposal for a specific dynamic model for the ELINCS standard –> point of departure for working group discussion

## Technical Working Group Representation

_**Hospital L.I.S. Vendors**_
- GE Medical Technologies
- Misys

_**EHR Vendors**_
- AllScripts
- Emdeon (WebMD)
- e-MDs
- NextGen

_**Commercial Laboratories**_
- Ameripath
- LabCorp
- Quest Diagnostics

_**Government**_
- CDC
- CMS
- V.A.

_**Other Organizations**_
- American College of Physicians
- eHealth Initiative
- Indiana Health Information Exchange

**Notes:**
Purpose of this proposal:  
Background information on the v3.0 methodology for dynamic modeling
Proposal for a specific dynamic model for the ELINCS standard –> point of departure for working group discussion

## Jason DuBoisVice President, Government RelationsAmerican Clinical Laboratory Association (ACLA) 
Donald T. Mon, Ph.D.Vice President, Practice Leadership American Health Information Management Association (AHIMA) 

Charles ParisotChair, Standards and Interoperability WorkgroupEHR Vendor Association, HIMSS

Rod PiechowskiVice President, Technology Leadership National Alliance for Health Information Technology (NAHIT) 

Wesley RishelDirector at Large and Past ChairHealth Level 7 (HL7) 

John Tooker, M.D., M.B.A., F.A.C.P.Executive Vice President and Chief Executive OfficerAmerican College of Physicians (ACP) 

Patricia Wise, R.N., M.A., M.S.N.Director EHR Initiative, HIMSS

**Jason DuBois**Vice President, Government Relations_American Clinical Laboratory Association (ACLA)__ _
**Donald T. Mon, Ph.D.**Vice President, Practice Leadership _American Health Information Management Association (AHIMA)_
**Charles Parisot**Chair, Standards and Interoperability Workgroup_EHR Vendor Association, HIMSS_
**Rod Piechowski**Vice President, Technology Leadership _National Alliance for Health Information Technology (NAHIT)_
**Wesley Rishel**Director at Large and Past Chair_Health Level 7 (HL7)_
**John Tooker, M.D., M.B.A., F.A.C.P.**Executive Vice President and Chief Executive Officer_American College of Physicians (ACP)_
**Patricia Wise, R.N., M.A., M.S.N.**Director _EHR Initiative, HIMSS_

- Steering Committee

## Version 1.0 completed and published July 2005
Available at www.elincs.org
Version 1.0 pilots projects initiated Feb. 2006
Goal:  Reference implementations of ELINCS v1.0
5 grantees in California
Include physician groups, EHR vendors, and laboratories

- Available at _[www.elincs.org](http://www.elincs.org/)_
- Version 1.0 pilots projects initiated Feb. 2006
- _Goal_:  Reference implementations of ELINCS v1.0
- 5 grantees in California
- Include physician groups, EHR vendors, and laboratories

- ELINCS Status

**Notes:**
Purpose of this proposal:  
Background information on the v3.0 methodology for dynamic modeling
Proposal for a specific dynamic model for the ELINCS standard –> point of departure for working group discussion

## Brown & Toland Medical Group

Cedars-Sinai Medical Foundation

Southern Sierra Medical Clinic

- Cedars-Sinai Medical Foundation
- Southern Sierra Medical Clinic

- ELINCS Pilot Project Grantees

**Notes:**
Purpose of this proposal:  
Background information on the v3.0 methodology for dynamic modeling
Proposal for a specific dynamic model for the ELINCS standard –> point of departure for working group discussion

## Humboldt Del Note IPA

Redwood Community Health Coalition

- Redwood Community Health Coalition

- ELINCS Pilot Project Grantees

**Notes:**
Purpose of this proposal:  
Background information on the v3.0 methodology for dynamic modeling
Proposal for a specific dynamic model for the ELINCS standard –> point of departure for working group discussion

## ELINCS Pilot Project Timeline

**April**

**May**

**June**

**July**

**August**

**Sept.**

**Feb. 07**

- Project Kick-off

- ELINCS Testing
- Tool Released
- (Beta)

- Preliminary Results Available

- ELINCS v1.1
- (as required)

- Final Project Results and Evaluation

## CCHIT has proposed ELINCS v1.0 compatibility as a certification criterion for ambulatory EHR products in 2006/2007
ELINCS is working with CCHIT to support certification process

- ELINCS is working with CCHIT to support certification process

- ELINCS and CCHIT

**Notes:**
Purpose of this proposal:  
Background information on the v3.0 methodology for dynamic modeling
Proposal for a specific dynamic model for the ELINCS standard –> point of departure for working group discussion

## EHR includes all required data elements on the lab orders it generates
EHR can receive HL7 v2.4 result messages
EHR can recognize, parse and process the 3 ELINCS message types
EHR fulfills all receiver responsibilities
Sends acknowledgement messages 
Appropriately stores and displays information designated by CLIA

- EHR can receive HL7 v2.4 result messages
- EHR can recognize, parse and process the 3 ELINCS message types
- EHR fulfills all receiver responsibilities
- Sends acknowledgement messages
- Appropriately stores and displays information designated by CLIA

- What is ELINCS Conformance?

**Notes:**
Purpose of this proposal:  
Background information on the v3.0 methodology for dynamic modeling
Proposal for a specific dynamic model for the ELINCS standard –> point of departure for working group discussion

## ELINCS v2.0 (March 2006)
Standardized structure for microbiology results
LOINC coding for 95% most common tests
ELINCS Orders (2007 ?)
Standardized interaction and message format for electronic orders
ELINCS v3.0 (2008 ?)
SNOMED coding, units coding
Structured pathology reporting

- Standardized structure for microbiology results
- LOINC coding for 95% most common tests
- ELINCS Orders (2007 ?)
- Standardized interaction and message format for electronic orders
- ELINCS v3.0 (2008 ?)
- SNOMED coding, units coding
- Structured pathology reporting

- ELINCS Roadmap

**Notes:**
Purpose of this proposal:  
Background information on the v3.0 methodology for dynamic modeling
Proposal for a specific dynamic model for the ELINCS standard –> point of departure for working group discussion

## Version 2.0 is an extension of version 1.0
Addition, not replacement, of features
Backward compatibility
Version 2.0 is more complex and will take labs longer to implement
Version 1.0 has been proposed as an EHR certification criterion for 2006
Therefore...
Organizations can implement v1.0 now and v2.0 later

*Addition*, not replacement, of features
- Backward compatibility
- Version 2.0 is more complex and will take labs longer to implement
- Version 1.0 has been proposed as an EHR certification criterion for 2006
*Therefore...*
- Organizations can implement v1.0 now and v2.0 later

- ELINCS v1.0 and v2.0

**Notes:**
Purpose of this proposal:  
Background information on the v3.0 methodology for dynamic modeling
Proposal for a specific dynamic model for the ELINCS standard –> point of departure for working group discussion

## Following pilot implementations of v1.0, ELINCS will be transitioned to an appropriate organization
Ongoing implementation support for v1.0
Reference implementations of v2.0
Ongoing maintenance and enhancements
Health Information Technology Standards Panel
Do HITSP tasks include maintenance of implementation guides for health data interoperability?
ELINCS also in discussion with HITSP member organizations (including IHE)

- Ongoing implementation support for v1.0
- Reference implementations of v2.0
- Ongoing maintenance and enhancements
- Health Information Technology Standards Panel
- Do HITSP tasks include maintenance of implementation guides for health data interoperability?
- ELINCS also in discussion with HITSP member organizations (including IHE)

- ELINCS Long-Term Maintenance

**Notes:**
Purpose of this proposal:  
Background information on the v3.0 methodology for dynamic modeling
Proposal for a specific dynamic model for the ELINCS standard –> point of departure for working group discussion

## QuestionsCommentsFeedback

## ELINCS Format and Content:  Message Structure

**R**:  Required Always
**RE**:  Required if data available
**X**:  Not supported

- _ORU message type (HL7 v2.4) _

**Notes:**
Purpose of this proposal:  
Background information on the v3.0 methodology for dynamic modeling
Proposal for a specific dynamic model for the ELINCS standard –> point of departure for working group discussion

## ELINCS v1.0:  Lab Testing Data Model

- Lab Requisition  [Patient, Provider]

- OBR-2 Placer Order Number

- A. Reported Analyte [Path Report=Mild Atypia]

**Notes:**
Purpose of this proposal:  
Background information on the v3.0 methodology for dynamic modeling
Proposal for a specific dynamic model for the ELINCS standard –> point of departure for working group discussion

## ELINCS Format and Content:  Segment Structure

**RE**:  Required if data available
**O**:  Optional

- Example: _OBX_

**C**:  Conditional
**X**:  Not supported

- ELINCS Format and Content:  Segment Structure

**Notes:**
Purpose of this proposal:  
Background information on the v3.0 methodology for dynamic modeling
Proposal for a specific dynamic model for the ELINCS standard –> point of departure for working group discussion

## ELINCS Format and Content:  Field Definitions

- ELINCS Format and Content:  Field Definitions

**Notes:**
Purpose of this proposal:  
Background information on the v3.0 methodology for dynamic modeling
Proposal for a specific dynamic model for the ELINCS standard –> point of departure for working group discussion

## ELINCS Interaction Model:  Based on HL7 v3.0

- Order Fulfiller
- [ LIS ]

- Result Receiver
- [ EHR ]

*Result Available  (IN-3)*

- [ _MT-ORU-2_ ]

- ELINCS Interaction Model:  Based on HL7 v3.0

- 4. ReceiverResponsibilities

**Notes:**
This is part of an “interaction diagram” in the v3.0 sense.  Now the vertical bars represent communication roles within software applications.  For example, “Order Fulfiller” is one application role (among potentially many) that may be performed by an L.I.S. system.  

## ELINCS Interaction Model:  Supported Interactions

- Order Placer(EHR System)

- Order Fulfiller(L.I.S.)

- Result Receiver(EHR System)

*Order Fulfillment Request (IN-1)*

*[ “*_*Virtual Order Message”*_* ]*

*Result Confirm Response (IN-5)*

- [ _MT-ACK-1_ ]

- ELINCS Interaction Model:  Supported Interactions

- Result Confirm

**Notes:**
This is a straw man proposal for breaking out the typically reported events into distinct interactions.

As an alternative, we may choose to combine “Result in Progress” [preliminary result available] and “Result Complete” [final result available].
Also, we may wish to combine “Result Corrected” and “Result Nullify”.

## ELINCS Interaction Model:  Documentation

## Acknowledging receipt of lab messages 
Releases lab from need to resend message
Storing and displaying certain information 
Test cancellations
Identity of the lab performing the test
Required to assure labs of CLIA conformance(Clinical Laboratory Improvement Amendments)
Example:  Producer ID

- Releases lab from need to resend message
- Storing and displaying certain information
- Test cancellations
- Identity of the lab performing the test
- Required to assure labs of CLIA conformance(Clinical Laboratory Improvement Amendments)
- Example:  _Producer ID_

- EHR Receiver Responsibilities

**Notes:**
Purpose of this proposal:  
Background information on the v3.0 methodology for dynamic modeling
Proposal for a specific dynamic model for the ELINCS standard –> point of departure for working group discussion

## ELINCS Interaction Model:  Virtual Orders

- Order Placer(EHR System)

- Order Fulfiller(L.I.S.)

- Result Receiver(EHR System)

*Order Fulfillment Request (IN-1)*

*[ “*_*Virtual Order Message”*_* ]*

*Result Confirm Response (IN-5)*

- [ _MT-ACK-1_ ]

- ELINCS Interaction Model:  Virtual Orders

- Result Confirm

**Notes:**
This is a straw man proposal for breaking out the typically reported events into distinct interactions.

As an alternative, we may choose to combine “Result in Progress” [preliminary result available] and “Result Complete” [final result available].
Also, we may wish to combine “Result Corrected” and “Result Nullify”.

## EHR Responsibilities 
Include required data elements on all orders
Examples:  Requisition ID, Ordering Provider, Patient Name, Ordered Test IDs, etc....
Lab Responsibilities 
Record required data elements on the order
Store data elements during lifetime of the order
Include data elements in all ELINCS status/result messages
Example:  Ordered Test ID

- Include _required data elements_ on all orders
- Examples:  Requisition ID, Ordering Provider, Patient Name, Ordered Test IDs, etc....
- Lab Responsibilities
- Record required data elements on the order
- Store data elements during lifetime of the order
- Include data elements in all ELINCS status/result messages
- Example:  _Ordered Test ID_

- Virtual Order Message

**Notes:**
Purpose of this proposal:  
Background information on the v3.0 methodology for dynamic modeling
Proposal for a specific dynamic model for the ELINCS standard –> point of departure for working group discussion

## LOINC codes required for top 80% of tests (by frequency)
~ 100 tests;   Based on data from 3 large CA provider groups
Tests enumerated in ELINCS specification
Examples: 

- ~ 100 tests;   Based on data from 3 large CA provider groups
- Tests enumerated in ELINCS specification
- Examples:

- Standard coding for Common Tests

**Notes:**
Purpose of this proposal:  
Background information on the v3.0 methodology for dynamic modeling
Proposal for a specific dynamic model for the ELINCS standard –> point of departure for working group discussion