laboratory information is a key driver of evidence - based clinical care and medical decision analysis .
timely ( turnaround - time based ) availability of this information at the point of service is crucial in an increasingly complex medical environment .
furthermore , the ability to mine for data in order to monitor the health of condition - specific populations and to meet the call for quality reporting relies on a sophisticated repository system that is accessible and flexible , yet secure and in compliance with regulatory requirements .
a well - integrated laboratory information system ( lis ) is part of the bedrock of a successfully implemented electronic medical record ( emr ) .
laboratory data are said to account for the bulk ( around 70% ) of data stored in any given emr . such laboratory data populating an emr include both quantitative results ( i.e. numerical values ) and qualitative information ( e.g. formatted pathology reports that contain predominantly text ) .
optimal use of laboratory data in the emr requires careful consideration of electronic laboratory result formatting and display in the emr .
the meaningful configuration of laboratory data is critical to the success of the burgeoning emr technology . with laboratory data included in the emr
, users can begin to benefit from decision support tools that capitalize on this data ( e.g. lab - drug - related e - alerts ) . in its current state
, emrs can display laboratory data in the form of tables , spreadsheets , group listings , or graphs .
this allows users to rapidly search , view , sort and pool laboratory information to support trend analyses and their clinical decision making process .
however , to best serve the user , electronic laboratory data need to be flexible and customizable .
our aim was to determine all the various ways in which laboratory data get utilized by clinicians in our health system 's emr .
all the laboratory data from our different liss ( sunquest version 6.2 , copath plus version 3.1 , mediware hcll ) are transmitted electronically in hl7 and/or rtf format to the enterprise emr ( millennium v2007.13 , cerner corporation ) .
the enhanced view version of the emr provides both a table of contents menu and a labeled ( tab ( electronic folder ) ) layout that together facilitate viewing of all result types .
currently , there are discrete menu bars within the emr for all results ( including vital signs , radiology , pharmacy information , and laboratory results ) , laboratory results only , microbiology results , and anatomical pathology reports . to account for the complexity of the medical record
, there is a drop down menu that provides nearly three dozen custom flowsheets based on specialty and/or administrative needs .
not only are data presented for discursive viewing , but also they are linked to a defined set of rules and internal feeds that generate decision support alerts , trigger automated health maintenance reminders , and can be used to populate clinical notes and emr - generated letters .
the authors were involved in the customization and maintenance of several tools within their enterprise emr over a 5-year period . during this time period , the aforementioned electronic menus , tabs , flowsheets and subsections within the emr were explored to determine how clinicians utilize laboratory data .
the results of the authors ' experience from observations , training , user feedback , and management of issues related to laboratory data in the emr are described .
all the laboratory data from our different liss ( sunquest version 6.2 , copath plus version 3.1 , mediware hcll ) are transmitted electronically in hl7 and/or rtf format to the enterprise emr ( millennium v2007.13 , cerner corporation ) .
the enhanced view version of the emr provides both a table of contents menu and a labeled ( tab ( electronic folder ) ) layout that together facilitate viewing of all result types .
currently , there are discrete menu bars within the emr for all results ( including vital signs , radiology , pharmacy information , and laboratory results ) , laboratory results only , microbiology results , and anatomical pathology reports . to account for the complexity of the medical record
, there is a drop down menu that provides nearly three dozen custom flowsheets based on specialty and/or administrative needs .
not only are data presented for discursive viewing , but also they are linked to a defined set of rules and internal feeds that generate decision support alerts , trigger automated health maintenance reminders , and can be used to populate clinical notes and emr - generated letters .
the authors were involved in the customization and maintenance of several tools within their enterprise emr over a 5-year period . during this time period ,
the aforementioned electronic menus , tabs , flowsheets and subsections within the emr were explored to determine how clinicians utilize laboratory data .
the results of the authors ' experience from observations , training , user feedback , and management of issues related to laboratory data in the emr are described .
both clinical and anatomical pathology laboratory data in the emr were utilized by clinicians in five distinct ways [ table 1 ] , viz . , within flowsheets , their personal inbox ( emr messaging ) , with decision support tools , in the health maintenance tool , and when incorporating laboratory data into their clinical notes and letters .
laboratory data presented as a flowsheet is similar to a spreadsheet with columns and rows .
data within small preset cells ( that do not autosize to fit the result ) may cause results to be hidden or truncated .
hidden data require users to perform an additional right - hand click to display this information . nevertheless , this is often the default format of many emrs .
default settings frequently require customization for each user , which means training of the users is required .
depending on the number of results and time range selected , users may need to scroll down and across the screen in order to view all results .
data may be missed when rapidly scanning large tables . looking over many blank cells without
results in this format can be easily sorted ( e.g. by specified date range ) . by arranging laboratory data into a list or group of tests
, users can rapidly view all the results obtained for a given day on their patient .
specialty flowsheets ( e.g. diabetes , heart failure , hiv infection view ) can be customized to group relevant laboratory results [ figure 1 ] to assist in disease - specific management .
for example , physicians providing care in the acute hemodialysis unit select the renal flowsheet for immediate viewing of salient results .
data can then be selected for graphical display of trends across custom timeframes . in the ambulatory setting , ready access to condition - specific flowsheets assists in the surveillance of preventive and maintenance measures necessary both for optimal patient care and quality reporting .
for example , the hiv infection flowsheet displays relevant routine laboratory results ( e.g. complete blood count , metabolic panel ) , related results ( annual std screening , hepatitis antibody status ) and hiv - specific results ( t - cell subsets , hiv rna viral load assays ) .
printing laboratory results in draft format from flowsheets may fail to incorporate pertinent data ( e.g. reference ranges ) .
screenshot showing portion of an hiv flowsheet in the emr with laboratory data in a table format for laboratory tests that are ordered by health care providers in the ambulatory setting , results not only post to the flowsheet in the patient 's chart , but also get routed using the emr messaging system to the ordering provider 's inbox .
however , this requires that the correct provider is identified to be notified . within the inbox
, these results are stratified into three categories : normal , abnormal , and critical .
for example , each result needs to be individually opened in order to see if it is normal or abnormal .
the critical results folder is highlighted in red and duplicates direct telephone alerting to the ordering clinician .
the delivery of results to the inbox allows the clinician to track those results that were recently ordered .
the results arrive as they are statused and can be acted upon in a timely fashion as determined by the ordering clinician .
results within an inbox can be endorsed , deleted , forwarded , and/or set up to be handled by a proxy .
laboratory data in our emr have also been used in the design of rules and alerts that are fundamental to clinical decision support .
specifically , certain laboratory results have been associated with medication order entry so as to generate drug - related alerts that interrupt workflow .
for example , ordering a potentially nephrotoxic drug in the emr triggers the automated scanning of laboratory results ' tables for creatinine values .
if appropriate ( e.g. there is an abnormal creatinine value ) , an interruptive alert is sent to the clinician recommending a drug dose reduction .
on the other hand , the posting of a high potassium result yields a non - intrusive message that is sent to the ordering clinician 's inbox if he / she ordered a medication known to raise the risk of hyperkalemia .
also , when laboratory values undergo post hoc modification or updating in the lis , an alert message is sent to the provider 's emr inbox notifying him / her of this changed result [ figure 2 ] . although critical laboratory test results are electronically reported to providers ' inboxes , as a redundant mechanism , laboratory personnel still make telephone calls and/or page providers to verbally communicate such critical results .
screenshot of a user 's emr inbox messages showing an automated e - alert informing them that a potassium result was modified from 11 to 3.5
mmol / l an added advantage of an enterprise emr is that data can be accessed as well as fed to a variety of care enhancement tools . in our emr laboratory information
gets posted not only to flowsheets , but also to a health maintenance tool that is customized and based upon the latest clinical practice guidelines .
for example , pap test results , lipid panel findings , and glucose test results all populate this health maintenance tool [ figure 3 ] once they are transmitted to the emr .
this assists the clinicians in their efforts to perform comprehensive preventative care in a timely fashion .
moreover , the health maintenance tool is used to assist in the monitoring and tracking of disease - specific testing .
we have linked results of biannual hemoglobin a1c and annual urine evaluation for microalbumin , low - density lipoprotein ( ldl ) , and creatinine to the diabetes mellitus module within the health maintenance tool .
similar modules have been designed to effectively manage patients with heart failure , cerebro and peripheral vascular disease , and coronary artery disease .
screenshot of the emr health maintenance view populated with pending expectations for the user to act on we found that many clinicians incorporate laboratory results , often without the accompanying data elements ( units , reference ranges , comments ) , into their clinical notes .
for example , the author of an inpatient progress note can select relevant values ( e.g. white blood cell count , blood uea nitrogen ( bun)/creatinine ) to populate their note . an electronic consultation request within the emr
can also be generated to include laboratory values that are germane to the question at hand , and thus expedite the consultant 's ability to discern the details of the clinical case .
moreover , laboratory data were also included within emr - generated letters to patients [ figure 4 ] .
letter templates that reside in the emr foster quick , yet complete , communication with patients , and they include laboratory results . while numerical results ( e.g. a lipid panel ) get automatically entered into such letter templates , they are associated with clear explanations from the clinician along with additional advice and treatment targets . in addition , these ad hoc letters have served as laboratory requisitions for follow - up testing when required . in such cases , clinicians simply included the specific test requested and an associated diagnostic code to facilitate billing .
example of an emr - generated letter by a physician to his / her patient including laboratory results and interpretation comments for the patient
laboratory data presented as a flowsheet is similar to a spreadsheet with columns and rows .
data within small preset cells ( that do not autosize to fit the result ) may cause results to be hidden or truncated .
hidden data require users to perform an additional right - hand click to display this information . nevertheless , this is often the default format of many emrs .
default settings frequently require customization for each user , which means training of the users is required .
depending on the number of results and time range selected , users may need to scroll down and across the screen in order to view all results .
results in this format can be easily sorted ( e.g. by specified date range ) . by arranging laboratory data into a list or group of tests
, users can rapidly view all the results obtained for a given day on their patient .
specialty flowsheets ( e.g. diabetes , heart failure , hiv infection view ) can be customized to group relevant laboratory results [ figure 1 ] to assist in disease - specific management .
for example , physicians providing care in the acute hemodialysis unit select the renal flowsheet for immediate viewing of salient results .
data can then be selected for graphical display of trends across custom timeframes . in the ambulatory setting , ready access to condition - specific flowsheets assists in the surveillance of preventive and maintenance measures necessary both for optimal patient care and quality reporting .
for example , the hiv infection flowsheet displays relevant routine laboratory results ( e.g. complete blood count , metabolic panel ) , related results ( annual std screening , hepatitis antibody status ) and hiv - specific results ( t - cell subsets , hiv rna viral load assays ) . printing laboratory results in draft format from flowsheets may fail to incorporate pertinent data ( e.g. reference ranges ) .
screenshot showing portion of an hiv flowsheet in the emr with laboratory data in a table format
for laboratory tests that are ordered by health care providers in the ambulatory setting , results not only post to the flowsheet in the patient 's chart , but also get routed using the emr messaging system to the ordering provider 's inbox . however
, this requires that the correct provider is identified to be notified . within the inbox
, these results are stratified into three categories : normal , abnormal , and critical .
for example , each result needs to be individually opened in order to see if it is normal or abnormal .
the critical results folder is highlighted in red and duplicates direct telephone alerting to the ordering clinician .
the delivery of results to the inbox allows the clinician to track those results that were recently ordered .
the results arrive as they are statused and can be acted upon in a timely fashion as determined by the ordering clinician .
results within an inbox can be endorsed , deleted , forwarded , and/or set up to be handled by a proxy .
laboratory data in our emr have also been used in the design of rules and alerts that are fundamental to clinical decision support .
specifically , certain laboratory results have been associated with medication order entry so as to generate drug - related alerts that interrupt workflow .
for example , ordering a potentially nephrotoxic drug in the emr triggers the automated scanning of laboratory results ' tables for creatinine values .
if appropriate ( e.g. there is an abnormal creatinine value ) , an interruptive alert is sent to the clinician recommending a drug dose reduction . on the other hand ,
the posting of a high potassium result yields a non - intrusive message that is sent to the ordering clinician 's inbox if he / she ordered a medication known to raise the risk of hyperkalemia .
also , when laboratory values undergo post hoc modification or updating in the lis , an alert message is sent to the provider 's emr inbox notifying him / her of this changed result [ figure 2 ] . although critical laboratory test results are electronically reported to providers ' inboxes , as a redundant mechanism , laboratory personnel still make telephone calls and/or page providers to verbally communicate such critical results .
screenshot of a user 's emr inbox messages showing an automated e - alert informing them that a potassium result was modified from 11 to 3.5 mmol / l
an added advantage of an enterprise emr is that data can be accessed as well as fed to a variety of care enhancement tools . in our emr laboratory information
gets posted not only to flowsheets , but also to a health maintenance tool that is customized and based upon the latest clinical practice guidelines .
for example , pap test results , lipid panel findings , and glucose test results all populate this health maintenance tool [ figure 3 ] once they are transmitted to the emr .
this assists the clinicians in their efforts to perform comprehensive preventative care in a timely fashion .
moreover , the health maintenance tool is used to assist in the monitoring and tracking of disease - specific testing .
we have linked results of biannual hemoglobin a1c and annual urine evaluation for microalbumin , low - density lipoprotein ( ldl ) , and creatinine to the diabetes mellitus module within the health maintenance tool .
similar modules have been designed to effectively manage patients with heart failure , cerebro and peripheral vascular disease , and coronary artery disease .
screenshot of the emr health maintenance view populated with pending expectations for the user to act on
we found that many clinicians incorporate laboratory results , often without the accompanying data elements ( units , reference ranges , comments ) , into their clinical notes . for example , the author of an inpatient progress note can select relevant values ( e.g. white blood cell count , blood uea nitrogen ( bun)/creatinine ) to populate their note .
an electronic consultation request within the emr can also be generated to include laboratory values that are germane to the question at hand , and thus expedite the consultant 's ability to discern the details of the clinical case .
moreover , laboratory data were also included within emr - generated letters to patients [ figure 4 ] .
letter templates that reside in the emr foster quick , yet complete , communication with patients , and they include laboratory results . while numerical results ( e.g. a lipid panel ) get automatically entered into such letter templates , they are associated with clear explanations from the clinician along with additional advice and treatment targets . in addition , these ad hoc letters have served as laboratory requisitions for follow - up testing when required . in such cases , clinicians simply included the specific test requested and an associated diagnostic code to facilitate billing .
example of an emr - generated letter by a physician to his / her patient including laboratory results and interpretation comments for the patient
as we discovered , laboratory data in our emr were being utilized by clinicians in a number of ways .
the positive and negative features of utilizing the laboratory data in different emr tools are summarized in table 1 .
it should be noted , however , that our findings are based upon the evaluation of a single institution 's proprietary emr ( cerner millennium ) , with certain tools specific to this emr .
while it is acceptable to have laboratory results within an emr be displayed in several ways , these data should not be permitted to be edited by users . allowing laboratory results viewed within an emr to be customized , as was evident in our emr with different flowsheets , meets the needs of many users and specialties . rather than force all users to view data in the same manner , such customized screens ( dynamic displays , dashboards , or flowsheets ) can be created .
moreover , countless test results on a computer screen can be distracting and is a waste of time for busy users to search through .
honing into these flowsheets hides distracting test results that are not relevant to the clinical scenario or decision - making process on the screen for users . by collating only relevant data and focusing attention on important data , customized displays
because printing laboratory results directly from the emr in draft format may not incorporate pertinent data , for medicolegal purposes users are required to use an alternate medical record publishing ( mrp ) format .
laboratory tests that are ordered and resulted during a hospital encounter post to the results flowsheet .
this fits well into the traditional workflow of the hospital - based clinician . in this practice setting , the flowsheet is routinely viewed in the midst of hospital rounds and is accessible when required . for laboratory orders that are ordered in the ambulatory setting , while results still post to the flowsheet ,
they have been found to be most helpful to users when they are also sent to the clinician 's emr inbox . new or outstanding lab results for review are displayed in the inbox . in this way , the emr provides added value by decreasing the risk of a lost or overlooked result .
furthermore , the clinician is afforded the opportunity to both review the relevant data and electronically immediately document any necessary action taken . utilizing the emr messaging system
thereby facilitates a paperless environment , eliminating the need to also deliver printed pathology reports to patients ' providers .
the emr messaging system has several other advantages such as displaying new or updated chart information for sign off and facilitating communication ( e.g. send reminders , request information , forward instructions ) among clinical colleagues .
however , poorly formatted inboxes may cause important results to be missed . given the potential for medicolegal liability of missing results in one 's inbox , there is some concern about relying solely on an emr messaging system .
clinical decision support systems allow the emr to more actively contribute to the clinical care process .
available data suggest that decision support tools not only improve the efficiency of patient care ( e.g. lower the misuse of tests ) , but also may enhance outcomes ( e.g. reduce the incidence of adverse events ) .
these tools can also support mundane administrative duties ( e.g. automated coding ) and promote best - practices ( e.g. practice guidelines and protocols ) .
they can include alerts ( e.g. pop - up screens ) , reminders , calculators , order sets , and embedded educational content in the emr .
alerts may be interruptive ( i.e. an action is required by the user ) or non - interruptive ( i.e. no user action is needed ) .
alerts may certainly be a hindrance when they interrupt user workflow and with overuse they may result in " alert fatigue " causing users to ignore , delete , or override them .
modified , abnormal and/or critical laboratory results within the lis can even be used to trigger a timely message to automatically alert clinicians via a cell phone , pager , e - mail , or the emr inbox . at our institution
, we also invested in building more complex emr tools that link laboratory data and information about medications .
they may generate at the time of online order entry or trigger when laboratory data are resulted . linking laboratory results and pharmacy data
has been shown to help with drug choices ( e.g. laboratory - based indications and contraindications ) , drug dosing ( e.g. renal or hepatic values , blood level - guided adjustments ) , drug monitoring ( e.g. laboratory signals of toxicity ) , and broader quality improvement ( e.g. surveillance for unrecognized toxicity ) .
computer - based reminders to prompt physicians to implement preventive and other services have been available since the late 1970s .
studies have reported improvements in the delivery of preventive services ( e.g. vaccination ) using automated reminders . by virtue of the automated delivery of results to a health maintenance tool , the clinician is afforded a highlighted alert that particular testing is either imminent or past due .
laboratory data such as pap test results posted to the health maintenance tool in our emr were used to generate reminders , prompting physicians to perform a pap test on their patient if indicated .
unfortunately , researchers have shown that many clinicians neither pay attention to these reminders nor do they even regularly review the health maintenance needs of their patient before the clinical encounter .
perhaps what is required is not just a tool to remind providers of needed preventive services , but a system to ensure optimal delivery of preventive services . as a result of this study
, it was apparent that clinicians frequently cut and paste or " pull " laboratory data from the " source of truth " into their clinical notes and letters .
this cut and paste mechanism can be utilized by clinicians to quickly summarize other clinical data ( e.g. radiology interpretations ) in addition to laboratory data .
the ability to pull laboratory data into clinical documentation certainly enhances communication , not only between referring and consulting physicians , but also between the clinician and the patient .
this feature , however , is not without risk , as it has the potential for users to misreport data if incomplete or incorrect data are pasted or moved . guidelines ( e.g. clia 493.1109 standard ) exist regarding the specific data elements that should be incorporated in laboratory reports . when appropriate , laboratory reports ( i.e. paper and potentially electronic ) are required to include the following data elements : unique patient identification , name and address of the performing laboratory , report date , test(s ) performed , specimen source , result , units of measure , reference range as determined by the laboratory performing the test , and information regarding specimen(s ) that do not meet acceptability criteria .
all of these additional data elements , although present in the emr , are not included when clinicians cut and paste laboratory data into their notes and letters .
users need to be aware of the data they are omitting . according to the college of american pathologists ( cap ) checklist question gen.41067 ( does an individual meeting cap laboratory director qualifications review and approve the content and format of paper and electronic patient reports at least annually ? ) , the laboratory director must approve the content and format of laboratory patient reports , including computer screen images , to ensure that they effectively communicate patient test results .
pathologists should assume responsibility for the data supplied by their laboratory that get cut and pasted into clinical emr notes and letters , and accordingly , should have a role in the design and/or utilization of this feature in their emr . in summary , flexible electronic laboratory data in the emr have many advantages .
users can view , sort , and pool lab information to support trend analysis and clinical decision making .
laboratory data can also be used to trigger clinical decision support systems such as alerts and reminders .
future studies could survey clinicians to better assess their needs and determine which tools they find most valuable .
it may also be of interest to compare and contrast similar tools in other emrs .
pathologists need to start participating more actively in the creation of many of these emr tools in order to support the appropriate utilization of laboratory information in the emr .
 background : laboratory data account for the bulk of data stored in any given electronic medical record ( emr ) . 
 to best serve the user , electronic laboratory data needs to be flexible and customizable . 
 our aim was to determine the various ways in which laboratory data get utilized by clinicians in our health system 's emr.method:all electronic menus , tabs , flowsheets , notes and subsections within the emr ( millennium v2007.13 , cerner corporation , kansas city , mo , us ) were explored to determine how clinicians utilize discrete laboratory data.results:laboratory data in the emr were utilized by clinicians in five distinct ways : within flowsheets , their personal inbox ( emr messaging ) , with decision support tools , in the health maintenance tool , and when incorporating laboratory data into their clinical notes and letters . 
 
 conclusions : flexible electronic laboratory data in the emr hava many advantages . 
 users can view , sort , pool , and appropriately route laboratory information to better support trend analyses , clinical decision making , and clinical charting . 
 laboratory data in the emr can also be utilized to develop clinical decision support tools . 
 pathologists need to participate in the creation of these emr tools in order to better support the appropriate utilization of laboratory information in the emr . 
INTRODUCTION
METHOD
EMR Design
EMR Evaluation
RESULTS AND DISCUSSION
Flowsheets
Inbox Results (EMR Messaging)
Decision Support Tools
Health Maintenance Tool
Clinical Notes and Letters
CONCLUSIONS