10 Years of Electronic Test Ordering and Reporting:The Florida Experience

Susanne Crowe, MHABureau of Public Health Laboratories (BPHL)

APHL Annual MeetingJune 3, 2018

Objectives

• Describe Florida Electronic Test Ordering and Reporting

• Describe challenges and successes• Discuss future directions

Jacksonville – Established 1903

Tampa – Established 1910

Miami – Established 1914

Florida’s Public HealthLaboratories

BPHL – By the Numbers

Pre-2007 Information Systems • Massachusetts General Hospital Utility Multi-

Programming System (MUMPS) system (1995-2007)

• Several partial implementations between 2000-2005 (LabLynx, LITS Plus, BOLIMS)

• Electronic data transfer was by text or flat file

2007-LIMS Implementation

• 2007 The Bureau of Public Health Laboratories implemented LabWare Laboratory Information Management System (LIMS)

• All clinical testing except for HIV and Newborn Screening (NBS)

• Phased implementation

2007-LIMS Implementation

• Initially no Electronic Ordering (ELO)• 2-D Barcode county health department Health

Management System (HMS)

• Electronic Laboratory Reporting (ELR)• Health Level Seven International (HL7)• Extensive testing with providers and epidemiology

Electronic Laboratory Reporting (ELR)

HL7 Standards• Florida Department of Health

• Currently using 2.5.1 Messages

ELR Messages

• HL7 Messages• Created by the LIMS• Data Integration Team forwards to ELR Database• Messages are retrieved by various systems

• Multiple templates• ELR 2.5.1 messages• Biological Threat (BT) messages/LIMS• Public Health Laboratory Interoperability Project

(PHLIP) messages

Electronic Reporting-LabWare

Jacksonville

Miami

Tampa

Citrix Servers Data Integration

Team (Mirth, Cloverleaf)

67 Counties (HMS)

STD (Prism)

Epi (Merlin)

Env Health

CDC

ELR Database

LabWare

Electronic Reporting to Centersfor Disease Control and Prevention (CDC)

• Foodborne Microbial Diseases• Modified the HL7 message to include a flag for

organisms of interest to the DFBMD at CDC • Data Integration Team creates CSV files for

reporting to the CDC• In production

• Influenza reporting to the CDC• Via AIMS

ELR Challenges

• Stakeholder Cooperation• Testing!• Retrieving results from system rather than calling

lab• Educating staff

• Up front work before implementing new analyses• Getting all the required codes- 2009 H1N1

• Awareness when correcting reports- not just paper!

ELR Benefits

• Results go out electronically within an hour after release

• Reduces turnaround time• Eliminates need to mail/fax additional reports

to program offices (TB, STD, etc…)• Providers can ‘opt-out’ from receiving paper

results• “Greener Operation”

Electronic Laboratory Ordering (ELO)

Electronic Laboratory Ordering

• Implemented in 2008• Receive Electronic Laboratory Orders for clinical

laboratory tests• Eliminates the need for paper requisitions• Originally HMS (county health system) order• Now generated by third party vendor (Change

HealthCare)• Same message going to Quest for ELO

LabWare ELO Workflow• Provider generates order• Provider affixes barcode label to sample• Order sent as HL7 message through the Data

Integration• Data Integration performs any needed

translations• Data Integration deposits ELO in the incoming

HL7 table • When sample arrives at lab, barcode on sample

is scanned to link with ELO• Lab accession number is assigned

Samples with ELO Labels

Scan Tube ID On Sample

Assign Laboratory Accession Number

Electronic Ordering-LabWare

Jacksonville

Miami

Tampa

Citrix Servers

Data Integration Team

(Mirth, Cloverleaf)

67 Counties (HMS)

Hospital

Hospital

LabWare

Challenges with ELO

• Project timeline• Test Data

• Testing updates• Regression testing

• Provider errors• Orders not sent• Identifying sending clinic

Benefits of ELO

• Reduces accessioning errors (correct test ordered!)

• Eliminates patient demographic entry errors• Reduces turnaround time• Expedites triage of samples (no unwrapping/re-

wrapping, copying, etc…)• Eliminates need for paper requisitions

• “Greener”

Other ELO/ELR Projects

• Pan Flu Project- data exchange between PHL (Florida and Texas)

• ELO/ELR exchanged with non-county health department providers

• Baycare• Working with LabWare to create standard

template• HIV System

Newborn Screening (NBS)

ELO/ELR Newborn Screening

• Based on National Library of Medicine (NLM) NBS Guide

• Currently in production with 1 hospital system• 6 Hospitals• 400-500 samples per week

• Card label contains minimal essential information

NBS CardPre-Printed kit # = Order ID

ELO Newborn Screening

• Hospital system generates HL7 ELO• ELO is converted to flat file by Data Integration

Team • Flat file is placed in table in database• Order is retrieved when the kit ID is scanned

Electronic Ordering-NBS

NBS Lab

NBS Servers

Hospital

Hospital

Hospital

HL7Flat File

Kit IDScanned

Data Integration Team

(Mirth, Cloverleaf)

ELR Newborn Screening

• When results are reported, NBS Software generates a flat file

• Data Integration Team converts file to HL7 ELR message

• ELR message sent back to hospital• Includes a PDF of paper report

Electronic Reporting-NBS

NBS Lab

NBSServers

Data Integration Team

(Mirth, Cloverleaf)

Hospital

Hospital

Hospital

HL7 & PDF

Flat File & PDF

NBS ELO/ELR Challenges

• ELO requires a lot of work on part of ordering provider

• Competing priorities

• NBS Software vendor not compatible with HL7• Testing issues

• Provider verifying what is received• CLIA

• New disorders• Incomplete information

ELO/ELR Benefits

• Eliminates data entry errors in lab • Decreased turnaround times• Results can automatically go into patient record

NBS Web Portal

• Third party vendor• Currently in production

• One hospital: 100-125 samples per week• One birthing center: 3-5 samples per week

• Additional sites scheduled or in validation phase• Card comes with label with minimal essential

information

Web Portal Ordering-NBS

NBS Lab

NBS Servers

Web Portal

Hospital

Hospital

Hospital

Kit IDScannedFlat File

Web Portal Benefits

• Limited investment for providers• Eliminates data entry errors in lab • Decreased turnaround times• Ability to make fields mandatory (hard stops)

Other Lessons Learned

ELO ELR Lessons from Zika

• Staff time to enter/approve/release results in LIMS• Staff time to enter and review demographics in

LIMS• Quality Assurance

• Measures to ensure work was done in a timely manner

• ELO or Web Portal would be beneficial!• Incomplete or illegible requisitions• Time for data entry• Multiple providers wanted copies of results

ELO ELR Lessons from Zika

• Results to LRN Results Messenger • Epidemiology approval of orders• Epidemiology review of positive results before

release

Future Projects

• Continue to expand ELO/ELR LabWare• Continue to expand hospitals using NBS Web Portal• LabWare Web Portal • Web Portal-ELR Hybrid• Chemical Threat

Questions?

Thank you!Susanne Crowe, MHADirector, Bureau of Public Health Laboratories - Jacksonville Email: Susanne.Crowe@flhealth.gov904-791-1550