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Know your LIS Vendors: Implementing ELR at the front line Raymond D. Aller, M. Know your LIS Vendors: Implementing ELR at the front line Raymond D. Aller, M. D. , Sue May, MT(ASCP), *Heather Capel, BS, Sue Lee, MT(ASCP), *John Piraino Automated Disease Surveillance Section Acute Communicable Disease Control Program Los Angeles County Department of Public Health and *Atlas Public Health 28 August 2008 Los Angeles County Department of Public Health

A bit about LA County’s experience ELC/NEDSS system (v. CMR) launched 2000 ELR operational A bit about LA County’s experience ELC/NEDSS system (v. CMR) launched 2000 ELR operational 2002 Since 2005, steady growth in number of labs and transactions Data arrives via a variety of mechanisms Now covers communicable diseases, STD TB has not yet programmed their system to accept HL 7 ELR transactions Lead has separate system Does not include cancer, other reports 28 August 2008 2 Los Angeles County Department. of Public Health

Labs and EDs connected 28 August 2008 3 Los Angeles County Department. of Public Labs and EDs connected 28 August 2008 3 Los Angeles County Department. of Public Health

Growth of ELR volume 28 August 2008 4 Los Angeles County Department. of Public Growth of ELR volume 28 August 2008 4 Los Angeles County Department. of Public Health

Ways of categorizing and prioritizing ELR candidates Volume of reports – Remember to include Ways of categorizing and prioritizing ELR candidates Volume of reports – Remember to include all diseases – Report volume >< case volume Your Public Health lab Experience with sending ELR Eagerness LIS platform 28 August 2008 5 Los Angeles County Department. of Public Health

What about PH labs? A unique set of testing types – – Clinical Environmental What about PH labs? A unique set of testing types – – Clinical Environmental Newborn screening Etc. A unique set of regulations (e. g. , Calif. PHLT licensure) Sometimes a name does make a difference – LIMS tend to originate in pharmaceutical, research, industrial settings – LIS tend to have come from the clinical realm – Several installations of “LIMS” in the PH space have been problematic • E. g. , one widely purchased product lacks a patient table… it can handle specimens, but tying them to a patient is a “custom” modification 28 August 2008 6 Los Angeles County Department. of Public Health

Report volume Collate data from multiple programs – (CD, STD, TB, HIV, etc. ) Report volume Collate data from multiple programs – (CD, STD, TB, HIV, etc. ) Paper reporting rate greatly underestimates what you will get electronically Smallest volume labs should be reporting via web page – not investing thousands of dollars for ELR to transmit 3 reports per month… But sometimes… highest volume reporters “aren’t interested” … a note about this later in the talk… 28 August 2008 7 Los Angeles County Department. of Public Health

Your Public Health Lab A number of factors support doing this one early – Your Public Health Lab A number of factors support doing this one early – Volume of reportables – Community labs – “talk to us after you have your own connected” But PHL LIS’s vary in capability Surprisingly, there may be political barriers 28 August 2008 8 Los Angeles County Department. of Public Health

Experience with sending ELR Your local labs and hospitals, likely won’t have experience National Experience with sending ELR Your local labs and hospitals, likely won’t have experience National labs – Lab. Corp, Quest, Mayo, ARUP – do Therefore, the nationals are a good place to start Not all of them are equally ready – e. g. – Different LIS’s in different regions – Legacy central LIS 28 August 2008 9 Los Angeles County Department. of Public Health

Eagerness Dealing with large volume Enthusiasm for creating a technological solution Without enthusiasm, it Eagerness Dealing with large volume Enthusiasm for creating a technological solution Without enthusiasm, it won’t happen But even with enthusiasm, need to assess the return on investment… – An anecdote 28 August 2008 10 Los Angeles County Department. of Public Health

LIS platform – what LIS’s are out there? Source: CAP Today survey, November of LIS platform – what LIS’s are out there? Source: CAP Today survey, November of each year Some vendors tend to be in small labs, who likely would be using web page entry Some install in a variety of labs, but may have relatively few in sizable accounts Many labs have been using the same software for 10 -15 years, and it is no longer being actively marketed (therefore, isn’t listed in the November survey) Our classification is based on a variety of data sources; you should verify specifics with the vendor and PH jurisdiction receiving these feeds 28 August 2008 11 Los Angeles County Department. of Public Health

Vendors ELR serving larger and PH labs: Sunquest, SCC/Soft, M/Mgmt ELR in a few Vendors ELR serving larger and PH labs: Sunquest, SCC/Soft, M/Mgmt ELR in a few sites: Aspyra/CCA, Clinical Information Systems, Clinical Software Systems, Clinlab, Multidata, Orchard, Seacoast ELR, unknown capability: GE, Mc. Kesson, Noemalife (Italy), Quality Software Systems ELR not yet installed: Antek, e. Tele. Next, Fletcher-Flora, Hex, Impac, Medi. Solution, Netlims, Omnitech, Psyche, Star. LIMS No ELR: Comp. Pro. Med, Computer Service and Support, CPSI, Custom Software Systems, Lab. Soft, Med. Com, Schuyler, Siemens Can only produce full HL 7 dump: Cerner, Meditech Status of Cerner Health. Sentry? 28 August 2008 12 Los Angeles County Department. of Public Health

Levels of ELR functionality in the LIS Level 6 Level 5 Level 4 – Levels of ELR functionality in the LIS Level 6 Level 5 Level 4 – Antimicrobials, orders Level 3 – Filtering, LOINC and SNOMED translation – Sunquest, SCC Level 2 – Filtering only – Quest LA Level 1 – dump of all results, HL 7 format - Meditech Level 0 – incapable of even producing HL 7 dump Filtering a separate issue from format (HL 7 vs. flat file) 28 August 2008 13 Los Angeles County Department. of Public Health

How is clinical lab data conveyed to public health? s. FTP, VPN, Hypersend, SCP, How is clinical lab data conveyed to public health? s. FTP, VPN, Hypersend, SCP, At. C, etc. LIS+ – extract reportables, apply LOINC/SNOMED RHIO LIS – HL 7 of all results PH ELR System Provider-Lab Link Edge server – Filtering, translation 28 August 2008 14 Los Angeles County Department. of Public Health

We got lucky …. Our large publicly owned hospitals, our public health lab, and We got lucky …. Our large publicly owned hospitals, our public health lab, and a number of our largest private hospitals all run the same LIS: Sunquest The County already has a contract with Sunquest, so we could issue a direct purchase order for the LIS-to-PH interface software Our own PH lab was the alpha site for the SQ interface software (originally intended in 2002 to connect to the Cal State ELR system…) 28 August 2008 15 Los Angeles County Department. of Public Health

But what about the other LIS suppliers? Census of largest labs serving LA County: But what about the other LIS suppliers? Census of largest labs serving LA County: – – National – specific connection for each Meditech – 2 flavors – only HL 7 dump Cerner – 2 flavors – HL 7 dump being created One or a few sites each: Soft, Mc. Kesson (2 flavors), Siemens For HL 7 dump-only sites, our contractor (Atlas) built middleware/edge server software (PHIL), our HRSA/HPP grant funded hardware in each hospital’s data center Even for dump-only, beware the HL 7 version (2. 3. 1/2. 3. z and above!) – “Our company doesn’t have an HL 7 standard interface – it has a (vendor name) standard interface!” 28 August 2008 16 Los Angeles County Department. of Public Health

The address/phone number problem… LIS’s often don’t send this – – – Interface configuration… The address/phone number problem… LIS’s often don’t send this – – – Interface configuration… In a different part of the hospitals’ I/S In the billing system Lab never received it – especially for reference labs – It isn’t entered until a couple of days later – Etc etc Various approaches …. 28 August 2008 17 Los Angeles County Department. of Public Health

Interesting formatting issues Microbiology report as blob What’s efficient for the laboratorian may not Interesting formatting issues Microbiology report as blob What’s efficient for the laboratorian may not be easy to parse (the dashpiece issue) The elusive “abnormal” flag (OBX-8) 28 August 2008 18 Los Angeles County Department. of Public Health

How did we encourage labs? Full-time recruiter for over a year Reimbursed hospitals for How did we encourage labs? Full-time recruiter for over a year Reimbursed hospitals for costs of – LIS vendor interface software and installation – Edge server, where necessary Constant and consistent attention With these efforts, now have over 25 hospitals “in the queue” – Installed LIS interface software – Installed edge servers – Extracted reportable codes, created LOINCSNOMED conversions. 28 August 2008 19 Los Angeles County Department. of Public Health

For partners who are not eager… State after state is now mandating ELR California For partners who are not eager… State after state is now mandating ELR California AB 2658, signed 1 Aug 08 Sometime after 1 Jul 09, labs must submit PH reports electronically (except HIV) Labs receiving incomplete patient data may report name of requesting provider Applies to out-of-state labs 28 August 2008 20 Los Angeles County Department. of Public Health

Looking toward the future Complex groupings of lab results – e. g. , hepatitis Looking toward the future Complex groupings of lab results – e. g. , hepatitis – LFT’s De-identified: – Antimicrobial susceptibility results – on ALL isolates – All lab orders (for syndromic patterns) – Result patterns Other 28 August 2008 ideas? 21 Los Angeles County Department. of Public Health

By the way – let’s not forget: Surgical pathology to the tumor registry Automated By the way – let’s not forget: Surgical pathology to the tumor registry Automated transfer of tumor diagnoses to the cancer registry – a type of ELR First automated transfer of SNOMED-coded diagnoses: 1977 … it has taken a LONG time for others to pick up this model. Recent projects to make this a more widespread practice: NAACCR volume 5 2007 Complicated by the one-blob-of-text model of surgical pathology reporting A whole lecture in itself. 28 August 2008 22 Los Angeles County Department. of Public Health

Two different categories of data Findings in large populations Identified disease cases Tumor diagnoses Two different categories of data Findings in large populations Identified disease cases Tumor diagnoses Coroner’s cases Public Health Disease Surveillance Syndromic Case reports from Infection control practitioners, nurses physicians, others v. CMR ELR Emergency department chief complaints Lab orders ELR RODS Diagnostic laboratory findings Over the counter medications ELR Antimicrobial results 28 August 2008 23 Los Angeles County Department. of Public Health

How do I get my lab connected? Talk with your local public health department How do I get my lab connected? Talk with your local public health department – Are they ready to receive data? – What format/coding do they want? – In the US, we are moving toward standardization on HL 7 version 2. 5. 1 Talk with the vendor of your lab’s Laboratory Information System – How to install their public health interface module? – Does it match the specifications of your local PH? – Or do they have a way of sending out all results in HL 7 2. 3. 1+ 28 August 2008 24 Los Angeles County Department. of Public Health

Questions? Follow up? Raymond D. Aller, M. D. raller@ph. lacounty. gov I look forward Questions? Follow up? Raymond D. Aller, M. D. [email protected] lacounty. gov I look forward to hearing from you. 28 August 2008 25 Los Angeles County Department. of Public Health