What Criteria Does The Centers For Medicaid And Medicaid Services Use To Compare Ehrs

J Pathol Inform. 2011; 2: 7.

"Meaningful use" of electronic wellness records and its relevance to laboratories and pathologists

Walter H. Henricks

Center for Pathology Information science, Pathology and Laboratory Medicine Constitute, L21, Cleveland Clinic, 9500 Euclid Avenue, Cleveland, OH 44195, USA

Received 2010 Dec 8; Accepted 2010 Dec 31.

Abstruse

Electronic health records (EHRs) have emerged equally a major topic in health intendance and are central to the federal regime's strategy for transforming healthcare delivery in the Us. Recent federal actions that aim to promote the use of EHRs hope to accept significant implications for laboratories and for pathology practices. Under the HITECH (Health Data Engineering science Economic and Clinical Wellness) Human action, an EHR incentive program has been established through which private physicians and hospitals can qualify to receive incentive payments if they accomplish "meaningful apply" of "certified" EHR technology. The rule also establishes payment penalties in future years for eligible providers who have non met the requirements for meaningful use of EHRs. Meaningful employ must be accomplished using EHR engineering science that has been certified in accordance with functional and technical criteria that are set forth a regulation that parallels the meaningful use criteria in the incentive plan. These actions and regulations are important to laboratories and pathologists for a number of reasons. Several of the criteria and requirements in the meaningful use rules and EHR certification criteria relate straight or indirectly to laboratory testing and laboratory information management, and future stage requirements are expected to impact the laboratory too. Furthermore, every bit EHR uptake expands, there will be greater expectations for electronic interchange of laboratory data and laboratory information system (LIS)-EHR interfaces. Laboratories volition demand to be enlightened of the technical, operational, and business organization challenges that they may face equally expectations for LIS-EHR increment. This newspaper reviews the important contempo federal efforts aimed at accelerating EHR utilize, including the incentive program for EHR meaningful utilize, provider eligibility, and EHR certification criteria, from a perspective of their relevance for laboratories and pathology practices.

Keywords: Electronic health records, federal regulations, laboratory information management, laboratory information systems, meaningful apply

INTRODUCTION

Electronic health record (EHR) systems are at present a major topic in wellness intendance. Use of EHRs in dr. practices and in healthcare organizations directly impacts the communication and direction of laboratory information in patient care, particularly reporting of laboratory results and examination club management. More pointedly, recent federal legislation and resultant regulations that aim to promote the use of EHRs promise to accept substantial direct and indirect implications for laboratories and for pathology practice.

EHRs are central to the goals that the federal authorities has identified for improving healthcare:[1]

• Amend quality, safety, and efficiency of healthcare and reduce health disparities.

• Appoint patients and families in their healthcare.

• Meliorate coordination of healthcare.

• Improve population and public health.

• Maintain privacy and security of health information.

• Reduce costs.

A minority of the physicians and healthcare organizations have fully implemented EHRs. Recent information from the CDC/National Middle for Health Statistics bespeak that 25% of the role-based physicians are using at least a "basic" EHR system, and only x% are using a fully functional EHR.[2] In the about recent Healthcare Information Management Systems Order (HIMSS) Leadership Survey,[three] 22% of the healthcare organizations reported in 2010 that they had a fully operational electronic medical record across their entire organisation (up from 17% in 2009), although only five% reported that they had not yet begun to programme for electronic medical record implementation.

In recent months, the federal government has enacted regulations and programs in guild to accelerate the implementation of EHRs by healthcare providers and healthcare organizations. This paper reviews the important recent federal efforts promoting EHR use, including regulations on EHR meaningful use and EHR certification criteria, and explores their relevance for laboratories and pathology practices.

LEGISLATIVE AND REGULATORY BACKGROUND

The American Recovery and Reinvestment Act of 2009 (ARRA), enacted in February 2009, included several provisions that in aggregate comprise the Wellness Data Technology Economic and Clinical Health Act, or "HITECH Act." The HITECH Human action includes a number of provisions aimed at improving healthcare quality, safety, and efficiency through promotion of health it (HIT), notably EHRs, and through greater electronic exchange of health data. There are other aspects of the HITECH Deed also, including modifications to the HIPAA regulations; these other provisions are out of the scope of this paper, and the reader is referred elsewhere.[4]

A chief goal of the HITECH Deed is to foster meaningful employ of certified EHR technology. Two contempo, related major regulations have implemented the HITECH Deed. Most significantly in this regard, the HITECH Act called for establishment of an incentive payment program for eligible professionals (eastward.g., physicians) and eligible hospitals that achieve "meaningful use" of qualified EHRs and interoperable HIT. To define and to implement this incentive program, in July 2010, Centers for Medicare and Medicaid Services (CMS) issued a Final Rule entitled Medicare and Medicaid Programs; Electronic Wellness Record Incentive Program (42 CFR Parts 412, 413, 422, et al).[5] The HITECH Act too required the Secretary of Wellness and Homo Services (HHS) to prefer an initial gear up of standards, implementation specifications, and certification criteria for EHRs, forth with establishing a certification program for EHRs. To meet these requirements, in July 2010, the Office of the National Coordinator for Health Information technology (ONC) in the Section of Health and Human Services published a Final Dominion entitled Health It: Initial Set of Standards, Implementation Specifications, and Certification Criteria for Electronic Health Tape Technology (45 CFR Part 170).[half dozen] The relationships among ARRA, HITECH, and these two regulations are depicted in Figure 1.

Relationships among ARRA, HITECH, and Final Rules from CMS and ONC. (CMS, Centers for Medicare and Medicaid Services; ONC, Office of the National Coordinator for Health It.)

ONC is the primary bureau in the federal authorities charged with developing and coordinating nationwide Hitting policy and promoting the evolution of a nationwide wellness It infrastructure for utilize and exchange of electronic wellness information. The ONC resides in the Department of Health and Human being Services. ONC was created past Executive Order in 2004, and the HITECH Act made ONC permanent in law.

The ii agencies in HHS, CMS and ONC, have worked together to coordinate the meaningful apply criteria and the EHR certification criteria where appropriate. In short, EHR certification criteria (ONC-defined) specified "what" an EHR arrangement must exist able to exercise, while meaningful apply criteria (CMS-defined) specified "how" a certified EHR arrangement must be used past an eligible provider or within an eligible hospital environment to authorize for incentive payment and to avoid hereafter penalties. Meeting criteria for meaningful apply of EHR requires use of certified EHR technology.

MEANINGFUL Utilize OF EHRs

Overview

The EHR incentive program establishes the criteria, reporting requirements, incentive payments, and (future) penalties for eligible professionals and hospitals related to achieving the meaningful use of EHRs. Eligible professionals and eligible hospitals are those that participate in the Medicare or Medicaid programs. There are separate only related incentive programs for both Medicare and Medicaid-eligible providers and hospitals. Although in that location are some differences in some provisions of the assistants of the Medicare and Medicaid programs, the meaningful use criteria and required quality measures are largely common to both. The Medicaid program volition be voluntarily offered past individual states.

"Meaningful use" has no simple definition, and is ultimately defined past the specific requirements laid out in the Last Rule. The rule embodies and implements the statutory requirements of the HITECH Act that specified 3 requirements for meaningful use:[1]

• Utilize of certified EHR technology in a meaningful manner (e.g., eastward-prescribing).

• Employ of certified EHR technology in a manner that provides for electronic exchange of wellness information to improve the quality of care.

• Use of certified EHR applied science to submit clinical quality measures (CQM) and other measures determined past the HHS Secretary.

CMS intends to implement meaningful use requirements in three stages. The current rule describes Phase 1 requirements that are applicable to 2011 and 2012. CMS expects to update meaningful use criteria biannually, with Phase 2 criteria expected past the finish of 2011 and Stage 3 criteria expected by the end of 2013. Stage 1 focuses substantially on capturing and sharing electronic wellness information at fundamental levels and establishing capabilities for data commutation and reporting information to diverse agencies. In Stage 2, CMS has indicated that it will build on the requirements of Phase 1 with more rigorous expectations for health information exchange and for additional EHR functionalities. In Stage iii, CMS expects to focus on promoting and making improvements that lead to improved health outcomes both at the individual and at the population levels, including greater use of decision support tools and patient access to self-management tools.

Definitions, Eligibility, and Incentives/Penalties

The EHR incentive programme Final Dominion contains several intertwined definitions for different categories of EHR users. These definitions are fundamental to interpreting eligibility for incentives/penalties and the applicability of certain meaningful utilise requirements. The most relevant definitions of EHR users are:

Eligible Professional (EP) (sections 495.iv, 495.100, 495.304):

For the Medicare EHR incentive program, EP generally includes the following types of professionals:

• Medico of medicine or osteopathy.

• Doctor of dental surgery or medicine.

• Dr. of podiatric medicine.

• Md of optometry.

• Chiropractor.

For the Medicaid EHR incentive program, EP generally includes:

• Physician.

• Dentist.

• Nurse/mid-wife.

• Practitioner.

• Physician assistant in a federally qualified health heart (QHC) or rural health center (RHC) that is and so led past a physician assistant.

Infirmary-based EP (495.4):

An EP (as divers under this section) who furnishes xc% or more of his or her covered professional services in a hospital setting in the year preceding the payment year.

Meaningful EHR user (495.4):

An EP (or) eligible hospital that, for an EHR reporting period for a payment year, demonstrates meaningful use of certified EHR technology.

Qualifying EP (Medicare-applicative) (495.100):

An EP who is a meaningful EHR user for the EHR reporting menstruum for a payment year and who is non a infirmary-based EP.

In the Medicare EHR incentive programme, EPs tin receive up to $44,000 in incentives over v years, although to get the maximum incentive payment the EPs must start participation by 2012. Note that only qualifying EPs will receive payments; in accordance with the definitions, qualifying EPs are those that meet al50 the requirements for demonstrating meaningful use of certified EHR engineering. Hospital-based EPs are non eligible to receive incentive payments. The stated rationale for excluding hospital-based EP from incentives is that paying incentives to hospital-based EPs and eligible hospitals would represent double payment, in that hospital-based EPs would be using the EHRs of the eligible hospitals. Under the Medicaid EHR incentive program, EPs tin can receive upwards to $63,750 over half dozen years. Incentive payments for eligible hospitals are based on a number of factors, which include the number of acute care inpatient discharges and the number of inpatient bed-days. For both programs, eligible hospital incentive payments begin with a $2,000,000 base of operations payment and may go upward from in that location.

Showtime in 2015 and continuing in subsequent years, in the Medicare EHR Incentive Program, EPs who have not demonstrated meaningful apply of certified EHR technology volition receive reduced payments for professional services (495.102(d)). For 2015, the penalty will be a i% reduction in the Medicare dr. fee schedule amount for professional person services, and this increases to ii% in 2016 and to 3% for 2017 and each subsequent year. Hospital-based EPs are not subject to the fee schedule reduction penalties that start in 2015. No payment reductions are included in the Medicaid EHR incentive program.

As described above, hospital-based EPs are not eligible for EHR meaningful use incentive payments and are not discipline to downwardly payment adjustment penalties for not being meaningful users of EHRs. The definition and means of determining a "Hospital-based EP" are antiseptic in the Provisions of the Proposed Rule and Analysis of and Responses to Public Annotate in pages 44439–44442 of the CMS Final Dominion. CMS defines a infirmary-based EP equally an EP who furnishes 90% or more of his/her covered professional services in a hospital setting in the year preceding the payment yr. A setting is considered a hospital setting if it is a site of service that would exist identified by the codes used in the HIPAA Standard Transaction every bit a hospital inpatient or emergency room setting. Specifically in the Final Rule, CMS indicates that it will apply but two place of service (POS) codes used on doc claims to determine whether an EP is a hospital-based EP: POS 21 (Inpatient Hospital) or POS 23 (Emergency Room, Infirmary). From the dominion:

"An EP volition be divers equally being infirmary-based and therefore ineligible to receive an EHR incentive payment under either Medicare or Medicaid, regardless of the type of service provided, if more than 90 pct of their services are identified as existence provided in places of service classified under ii place of service codes 21 (Inpatient Hospital) or 23 Emergency Room, Infirmary."

Are Pathologists Subject to Future Meaningful Use Penalties?

The definition of infirmary-based EP in the Final Rule raises questions and concerns as to whether pathologists are eligible for incentives and, more importantly, subject to penalties for not being meaningful users of EHR. The Core Measures and CQM that are required to become a Meaningful User of Certified EHR engineering science (run into later department) are largely either not applicative to or out of the scope of the exercise of pathology. Furthermore, pathologists (generally) practice non see and treat patients in an role setting and, therefore, the use of certified EHR engineering science in the comprehensive manner prescribed by CMS is not relevant to the pathologists.

Whatever eligible provider who is not either a qualifying EP (i.e., meaningful user of an EHR) or a hospital-based EP will be subject to Medicare payment reductions starting in 2015. Role of the event stems from the fact that the definition of "hospital-based" is rooted in the law and a subsequent amendment of the HITECH Human action. The CMS Final Rule explains (italics added):

"Sections 4101(a) and 4201(a) of the HITECH Deed originally defined the term 'infirmary-based eligible professional' to mean an EP, such equally a pathologist, anesthesiologist, or emergency doctor, who furnishes substantially all of his or her Medicare-covered professional services during the relevant EHR reporting menses in a hospital setting (whether inpatient or outpatient) through the use of the facilities and equipment of the hospital, including the hospital's qualified EHRs."

In April 2010, however, afterwards the publication of the incentive program Interim Final Rule that was available for public comment, an amendment to the HITECH Act was signed into law that inverse the statutory definition of a infirmary-based EP. This amendment inverse the key wording in the definition from "…in a hospital setting (whether inpatient or outpatient)…" to "in a hospital inpatient or emergency room setting".

The removal of "outpatient" is crucial to the relevance of the new definition of hospital-based EP to pathologists because, typically, greater than 10% of the services (doc claims) that pathologists provide, even pathologists in hospital settings, are for outpatients. Based on the new definition of infirmary-based EP, the method for determining whether an EP is hospital-based is based "solely" on the POS codes, on physician claims existence POS 21 (Inpatient Hospital) or POS 23 (Emergency Room, Hospital).

Pathologists' concerns about existence field of study to payment penalties because the requirements for Cadre Measures and CQM are exterior the scope of pathology practice were addressed straight in the Final Rule. In cursory, CMS indicated that the definition of infirmary-based EP is based in law and that the Secretary (of HHS) has no discretion to exempt pathologists from the definition in the police (p.44443):

"An organization representing pathologists expressed concern that the Medicare EP definition, as currently drafted would subject field certain pathologists to payment incentive penalties for non existence meaningful EHR users if the pathologists performed less than 90 percent of their professional services in any inpatient or outpatient setting in the prior year. All EPs have to study on all Core Measures and a subset of clinical measures that pathologists could not meet in their 24-hour interval-to-solar day practice given the nature of pathology's scope of practice. Accordingly, this organization recommended that CMS ensure that pathologists who are currently defined as Medicare EPs be considered as 'non-qualifying' EPs, that are exempt from future meaningful user penalties.

Response (from CMS; italics added): While nosotros appreciate the comments that we received on the Medicare EP definition, we are unable to expand or alter this statutory definition or consolidate it with the Medicaid program EP definition as suggested by the commenters. Under the EHR incentive payment program, the law provided a split Medicare EP definition rather than giving the Secretary authority or discretion to determine who is a Medicare EP or, who is an EP for both the Medicare and Medicaid programs."

The legal definition of hospital-based EP and the fashion in which information technology will exist determined appear to indicate that pathologists for whom less than 90% of professional services autumn under POS codes for hospital inpatient (POS 21) or emergency room (POS 23) volition not meet the definition of infirmary-based EP that would exempt them from future meaningful use penalties. While farther clarification would be welcome, pathology practices should be aware of these issues and should assess their situations in light of the combination of the eligibility considerations and definitions described above and the lack of applicability of EHR meaningful use requirements to general pathology exercise.

MEANINGFUL USE REQUIREMENTS

The CMS Final Rule on the EHR incentive plan lays out the requirements for eligible professionals and eligible hospitals to meet the definition of meaningful employ of certified EHR applied science. The requirements are a combination of required cadre objectives, objectives selected from a card set, and reporting of CQMs in a manner specified by the HHS Secretary.

Eligible professionals must meet:

• xv core objectives.

• Five objectives out of a menu ready of 10.

• Reporting requirements for half dozen CQMs.

• Three cadre or alternate core CQMs and three of 38 from an additional set of CQMs.

Hospitals must meet:

• 14 core objectives.

• Five objectives out of a menu ready of x.

• Reporting requirements for fifteen CQMs.

The core objectives for eligible providers are listed in Table 1 and for eligible hospitals in Tabular array 2. The menu gear up objectives for eligible providers are listed in Table 3 and for eligible hospitals in Tabular array 4. Many of the Stage 1 objectives will have compliance assessed past obtaining a sure per centum measure. For example, to run across certain objectives, 80% of patients must have records in certified EHR technology. Other objectives are related to the presence or absence of certain functions such as implementation of at least one clinical decision support dominion.

Table one

Core objectives for meaningful use of EHRs: Eligible professionals

1. Computerized provider order entry (CPOE)

2. E-prescribing (eRx)

3. Report ambulatory Clinical Quality Measures to CMS/States

4. Implement ane clinical determination back up rule

5. Provide patients with an electronic copy of their health data, upon request^**

6. Provide clinical summaries for patients for each office visit

7. Drug–drug and drug–allergy interaction checks

8. Record demographics

9. Maintain an up to date problem list of current and active diagnoses

10. Maintain active medication listing

11. Maintain active medication allergy list

12. Record and chart changes in vital signs

13. Record smoking status for patients 13 years or older

14. Adequacy to exchange key clinical information amidst providers of care and patient-authorized entities electronically^**

15. Protect electronic wellness information

Table 2

Core objectives for meaningful use of EHRs: Hospitals

1. Computerized provider order entry (CPOE)

2. Drug–drug and drug–allergy interaction checks

3. Record demographics

4. Implement one clinical determination support rule

5. Maintain upwards-to-engagement trouble list of current and active diagnoses

6. Maintain active medication list

7. Maintain active medication allergy list

8. Record and chart changes in vital signs

9. Tape smoking status for patients xiii years or older

10. Report infirmary Clinical Quality Measures to CMS or States

11. Provide patients with an electronic copy of their health information, upon request^**

12. Provide patients with an electronic copy of their discharge instructions at time of belch, upon asking

13. Capability to exchange primal clinical information among providers of care and patient-authorized entities electronically^**

14. Protect electronic wellness information

Table three

Carte du jour objectives for meaningful utilize of EHRs: Eligible professionals^***

• Drug-formulary checks

• Comprise clinical lab test results as structured information^**

• Generate lists of patients by specific weather condition

• Send reminders to patients per patient preference for preventive/follow-up intendance

• Provide patients with timely electronic access to their wellness data^**

• Use certified EHR engineering science to identify patient-specific teaching resources and provide to patient, if appropriate

• Medication reconciliation

• Summary of care record for each transition of care/referrals

• Adequacy to submit electronic data to immunization registries/systems^*

• Capability to provide electronic syndromic surveillance data to public health agencies^*

Table iv

Card objectives for meaningful use of EHRs: Hospitals^***

• Drug-formulary checks

• Record advanced directives for patients 65 years or older

• Incorporate clinical lab examination results as structured information^**

• Generate lists of patients by specific conditions

• Use certified EHR engineering to identify patient-specific instruction resource and provide to patient, if appropriate

• Medication reconciliation

• Summary of intendance record for each transition of care/ referrals

• Capability to submit electronic information to immunization registries/systems^*

• Adequacy to provide electronic submission of reportable lab results to public health agencies^*

• Capability to provide electronic syndromic surveillance data to public health agencies^*

CQMs are assessments and measures of healthcare quality that accept been developed and endorsed by CMS in collaboration with other healthcare quality agencies such every bit the National Quality Forum (NQF), the Bureau for Healthcare Research and Quality (AHRQ), and others. With respect to reporting CQMs to CMS (or to the State in the example of the Medicaid program), the Final Rule indicates that CQMs are to be reported in the fashion specified by CMS. CMS specifies the CQMs for eligible professionals in Table 6 of its final rule, and specifies core and alternate core measures in Table vii of its concluding rule. CQMs for hospitals are listed in Table ten of the final dominion. The CQMs are summarized here in Tables ​ v and ​ 6. Eligible professionals must report on a total of 6 CQM, of which three must exist from a defined core set of three CQMs or from a set of upwardly to three alternate cadre CQMs if one or more cadre fix CQM(due south) is not applicative to a given eligible professional's practice setting. In add-on, eligible providers must written report on three CQMs out of a carte of 38 options [Tabular array 5]. Overall, eligible professionals must written report on a total of six CQMs – three core or alternate core measures and iii additional measures. Hospitals must report on 15 quality measures [Table six].

Table 5

Core Gear up CQMs (must consummate iii core or alternating cadre)

Hypertension: blood pressure measurement Preventive intendance and screening measure pair: (a) tobacco use cess, (b) tobacco cessation intervention Adult weight screening and follow-up

Alternating core set CQMs

Weight cess and counseling for children and adolescents Preventive care and screening: Influenza immunization for patients 50 years old or older Babyhood immunization status

Additional set CQM (must consummate three of 38)

Diabetes: hemoglobin Alc poor control* Diabetes: low-density lipoprotein (LDL) management and control* Diabetes: blood pressure direction Heart failure (HF): angiotensin-converting enzyme (ACE) inhibitor or angiotensin receptor blocker (ARB) therapy for left ventricular systolic dysfunction (LVSD) Coronary avenue illness (CAD): beta-blocker therapy for CAD patients with prior myocardial infarction (MI) Pneumonia vaccination status for older adults Chest cancer screening Colorectal cancer screening* Coronary artery disease (CAD): oral antiplatelet therapy prescribed for patients with CAD Center failure (HF): beta-blocker therapy for left ventricular systolic dysfunction (LVSD) Anti-depressant medication management: (a) effective acute phase treatment, (b) effective continuation phase handling Primary open up angle glaucoma (POAG): optic nervus evaluation Diabetic retinopathy: documentation of presence or absence of macular edema and level of severity of retinopathy Diabetic retinopathy: advice with the doctor managing ongoing diabetes care Asthma pharmacologic therapy Asthma cess Appropriate testing for children with pharyngitis* Oncology breast cancer: hormonal therapy for Stage IC–IIIC estrogen receptor/progesterone receptor (ER/PR) positive chest cancer* Oncology colon cancer: chemotherapy for Stage III colon cancer patients Prostate cancer: avoidance of overuse of bone browse for staging low-take chances prostate cancer patients Smoking and tobacco use cessation, medical assistance: (a) advising smokers and tobacco users to quit, (b) discussing smoking and tobacco use cessation medications, (c) discussing smoking and tobacco apply cessation strategies Diabetes: eye test Diabetes: urine screening* Diabetes: human foot exam Coronary artery disease (CAD): drug therapy for lowering LDL-cholesterol Heart failure (HF):Warfarin therapy patients with atrial fibrillation Ischemic vascular affliction (IVD): claret pressure direction Ischemic vascular illness (IVD): utilise of aspirin or some other antithrombotic Initiation and engagement of alcohol and other drug dependence handling: (a) initiation, (b) engagement Prenatal care: screening for human immunodeficiency virus (HIV)* Prenatal intendance: anti-D immune globulin* Decision-making high-blood force per unit area Cervical cancer screening* Chlamydia screening for women* Use of appropriate medications for asthma Low-back pain: use of imaging studies Ischemic vascular illness (IVD): complete lipid panel and LDL control* Diabetes: hemoglobin Alc control (<8.0%)*

Table vi

CQMs for meaningful use of EHRs: Hospitals (must complete all xv)

• Emergency department throughput – admitted patients median time from ED inflow to ED departure for admitted patients

• Emergency section throughput – admitted patients –admission decision fourth dimension to ED departure time for admitted patients

• Ischemic stroke – discharge on antithrombotics

• Ischemic stroke – anticoagulation for A-fib/flutter

• Ischemic stroke – thrombolytic therapy for patients arriving within 2 h of symptom onset

• Ischemic or hemorrhagic stroke – antithrombotic therapy by day ii

• Ischemic stroke – discharge on statins^*

• Ischemic or hemorrhagic stroke – stroke education

• Ischemic or hemorrhagic stroke – rehabilitation assessment

• VTE prophylaxis within 24 h of arrival

• Intensive care unit VTE prophylaxis

• Anticoagulation overlap therapy^*

• Platelet monitoring on unfractionated heparin^*

• VTE belch instructions

• Incidence of potentially preventable VTE

Tabular array 7

EHR certification criteria that mention laboratory results as part of the functional requirement (42 CFR 170.302, 304, 306)

• Incorporate laboratory test results (general benchmark)

• Generate patient lists (laboratory results as criterion) (general criterion)

• Computerized provider society entry (CPOE) (ambulatory, inpatient)

• Patient reminders (convalescent)

• Clinical decision support – implement rules (ambulatory, inpatient)

• Electronic copy of health data^* (ambulatory, inpatient)

• Timely admission (for patients) (ambulatory)

• Clinical summaries^* (ambulatory)

• Commutation clinical information and patient summary record^* (convalescent, inpatient)

CMS finalized as reporting requirements only those CQMs for which there are available electronic specifications (as of the appointment of the Concluding Rule). CMS indicates in the Terminal Rule that additional CQM will exist included in proposed Phase 2 meaningful utilize requirements.

Meaningful Use Requirements Most Applicative to Laboratories

The meaningful apply requirement most directly relevant to laboratories is one from the menu set objectives:

"More than 40% of all clinical lab tests results ordered by the EP or by an authorized provider of the eligible hospital…whose results are either in a positive/negative or numerical format are incorporated in certified EHR technology as structured data."

Regarding the definition of "structured" data in this context, the Final Rule states that (p.44346):

"Structured data is not fully dependent on an established standard…Structured data within certified EHRs technology but requires the system to be able to place the data as providing specific information. This is normally achieved by creating fixed fields inside a record on file but not solely accomplished in this mode."

While CMS highly encourages electronic information exchange of laboratory results, the measure does not include a specific requirement for transmission or electronic receipt of lab results (although such a requirement is expected in time to come stages). Coming together the to a higher place requirement, however, in most settings volition be realistically possible merely with an electronic interface between the laboratory information system (LIS) and the EHR (rather than through manual entry).

Some of the core and menu gear up meaningful apply objectives include laboratory test results as function of the required data elements. The meaningful use core objectives and menu gear up objectives that specifically mention laboratory test results or diagnostic exam results in the rule are denoted in Tables ​ ane–4. In addition, several of the ONC EHR certification criteria (come across below) specify functional requirements that include treatment of laboratory and/or diagnostic exam results in EHRs. Some of these certification requirements that involve laboratory results underpin meaningful utilize objectives in the CMS Terminal Rule that may not mention the laboratory results specifically. Examples include EHR capabilities to implement decision support rules based on laboratory results and to provide patients with online access to clinical information that includes laboratory results.

Twelve of the CQMs in the Stage i meaningful employ requirements for eligible professionals include measures that include or depend upon laboratory testing. For example, the CQM entitled "Diabetes: Hemoglobin A1c Poor Control" requires reporting of the percentage of patients between eighteen and 75 years old with diabetes (type 1 or two) who had hemoglobin A1c greater than nine.0%. 3 of the reportable CQMs required of hospitals include or depend upon laboratory testing. The CQMs that involve laboratory testing are denoted in Tables ​ v and ​ 6.

Computerized Md Order Entry (CPOE) for laboratory exam orders was a requirement that was initially included in the CMS-proposed Interim Terminal Rule; notwithstanding, the CMS chose to remove the CPOE requirements for laboratory test requirements for Phase one in the Terminal Dominion. It is fabricated clear in the Final Dominion, nevertheless, that CMS expects to include CPOE requirements for laboratory tests in Phase ii. In add-on, a CPOE requirement for laboratory test orders are specifically included in the current ONC EHR certification criteria.

ONC CERTIFICATION CRITERIA FOR EHRs

In July 2010, the Department of Health and Man Services and the Office of the National Coordinator for Health Information Technology (ONC) published the Terminal Rule: Wellness It: Initial Ready of Standards, Implementation Specifications, and Certification Criteria for Electronic Health Tape Technology (45 CFR Part 170).[vi] This rule identifies the functional and technical capabilities that the EHR technology and systems must possess and demonstrate in order to ensure that uses tin use such technology to achieve Stage i meaningful utilise criteria:

"…certification criteria establish the required capabilities and specify the related standards and implementation specifications that serve as an electronic health tape (EHR) engineering will need to include to, at a minimum, back up the achievement of meaningful utilise Phase ane by eligible professionals, eligible hospitals, and/or critical admission hospitals…under the Medicare and Medicaid EHRs Incentive Programs."

The Final Rule sets forth the following definitions of certified EHRs technology (170.102):

"Certified EHR Engineering science means: (i) A Complete EHR that meets the requirements included in the definition of a Qualified EHR and has been tested and certified in accordance with the certification plan established by the National Coordinator as having met all applicative certification criteria adopted by the Secretary; or

(2) A combination of EHR Modules in which each constituent EHR Module of the combination has been tested and certified in accordance with the certification program established by the National Coordinator as having met all applicable certification criteria adopted by the Secretary, and the resultant combination also meets the requirements included in the definition of a Qualified EHR.

Complete EHR means EHR technology that has been adult to meet, at a minimum, all applicable certification criteria adopted by the Secretarial assistant."

Elsewhere in the Final Rule, ONC divers an EHR Module and added clarification as follows:

"…'any service, component, or combination thereof that can meet the requirements of at to the lowest degree one certification benchmark adopted past the Secretary.' Consequently, EHR Modules, by definition, must provide a capability that tin can exist tested and certified in accordance with at least i certification criterion adopted by the Secretary."

and,

"An EHR Module could provide a unmarried capability required by one certification criterion or it could provide all capabilities but i, required by the certification criteria for a Complete EHR."

The ONC rule includes certification criteria that are applicable mostly to EHRs and criteria that are applicable more specifically to EHRs designed for ambulatory and for inpatient settings. While the ONC certification criteria align with and complement the meaningful use requirement in the CMS EHR incentive programs, the stardom between the CMS and ONC rules is important to understanding and interpreting the regulations. The ONC rule describes the capabilities that certified EHR engineering science must be able to demonstrate to support the use of the EHR in a fashion that meets the meaningful use objectives of the CMS rule. Certification criteria also crave that EHR engineering tin generate reports for each meaningful use objective measure that is percentage based (including numerator, denominator, and percentage). The specified capabilities include compliance with data standards in certain circumstances or for particular functions. The ONC dominion makes a point that the dominion is not intended to specify when or how persons or organizations using EHR technology must implement detail capabilities in their environments. Rather, the "how" of using EHRs is the purview of electric current and futurity meaningful use requirements:

"…we anticipate that future meaningful employ objectives and measures volition specify, equally necessary and appropriate, the conditions which certain health care providers will demand to apply adopted standards and implementations specifications."

Certification Criteria and Standards Most Relevant to Laboratories

Several of the certification requirements for EHRs specifically mention laboratory and/or diagnostic test results, and some of these align with meaningful employ objectives that may not overtly specify laboratory results. EHR certification criteria that specifically mention laboratory results as part of the EHR functional requirements are listed in Table 7.

The certification benchmark that almost directly relates to laboratory testing is a requirement for EHR technology in general in 170.302:

(h) Contain laboratory examination results—(i) Receive results.

Electronically receive clinical laboratory exam results in a structured format and display such results in a human being readable format.

(2) Display exam report information.

Electronically display all the data for a test report specified at 42 CFR 493.1291(c)(1) through (vii).

(three) Incorporate results.

Electronically aspect, acquaintance, or link a laboratory test event to a laboratory club or patient record.

This certification benchmark only states that EHRs must exist able to receive laboratory results in a structured format. The dominion does not impose any further or specific requirements for what constitutes a "structured" format in this context, stating:

"…we do non believe that it is within the telescopic of this rule to dictate the standard by which laboratories transmit test results."

The ONC certification requirement correlates with the CMS meaningful apply requirement, which states basically that 40% of clinical lab test results whose results are either in a positive/negative or numerical format are incorporated into EHR technology as structured data. Every bit described earlier, the description of structured information in the CMS rule on meaningful utilize states that "structured data within certified EHR technology merely requires the system to be able to place the data every bit providing specific information."

The merely requirement relating to the content and style for laboratory results display in the certification criterion higher up is that EHRs display elements that are specified in the CLIA rule (42 CFR 493.1291 (c)(ane) through (7)), which states:

(c) The examination report must indicate the following:

1. For positive patient identification, either the patient's proper name and identification number or a unique patient identifier and identification number.

2. The name and address of the laboratory location where the test was performed.

3. The exam report date.

4. The test performed.

5. Specimen source, when appropriate.

6. The examination issue and, if applicative, the units of measurement or interpretation, or both.

7. Any information regarding the condition and disposition of specimens that do not meet the laboratory's criteria for acceptability.

No other requirements pertaining to how laboratory result data are displayed in EHRs are included in the certification criteria.

Another EHR certification benchmark that relates specifically to laboratory testing includes the capability for CPOE for laboratory orders, both in ambulatory and in inpatient EHRs. The difference between this requirement and the CPOE requirement in the meaningful utilize objectives may be easily dislocated. To analyze, this requirement for CPOE for laboratory orders is a adequacy that an EHR must possess to get certified. This is in distinction to the meaningful use criteria, in which the utilize of CPOE for laboratory orders is non required for Phase ane. This certification benchmark paves the way for the expected requirements of CPOE for laboratory orders in Stage ii of meaningful employ.

Data Standards for Electronic Health Information, Including LOINC

In add-on to the certification requirements for EHRs applied science to support meaningful utilise in Stage 1, the Last Rule sets along the Striking standards that have been deemed to take been adopted past the Secretary. Standards designated in the rule include:

• Content substitution standards, including HL7 version 2.5.one and/or version 2.3.1 for certain public health data reporting requirements (170.205).

• Vocabulary standards for representing electronic wellness information, including ICD-9-CM, SNOMED CT, and Logical Observation Identifiers Names and Codes (LOINC) (170.207).

• Standards for protecting the exchange of electronic health information, including encryption standards (170.210).

The accounted standards are in turn referenced equally part of specific certification requirements and implementation specifications. For example, ambulatory EHR systems must enable a user to create an electronic copy of a patient'due south clinical data that includes a problem list (170.304(f)) that uses either vocabulary standard ICD-nine-CM or SNOMED CT. Another instance is the requirement for inpatient EHR systems to submit reportable lab results to public wellness agencies (170.306(m)), which requires the utilise of HL7 v2.5.1 for that particular criterion.

LOINC is specified in the ONC dominion as a vocabulary standard for representing laboratory test results; however, it is important to realize that the requirement in the regulation regarding LOINC at this time is that certified EHR engineering must be able to re-employ a LOINC when it has been received from the laboratory and such code is attainable in the EHR. Specifically, the dominion states that the HHS Secretarial assistant adopts LOINC as a standard for laboratory test results (only) "when such codes were received within an electronic transaction from a laboratory." In other words, when received from a laboratory as LOINC codes, the EHRs must be able to utilize those LOINC codes for other certification criteria in which employ of laboratory data is required, such as electronic copies of wellness information for patients (170.304(f)), clinical summaries (170.304(h)), and others. The EHR certification criteria that specifically reference LOINC as a requirement are noted as role of Tabular array 7. It is worth reiterating here that neither the electric current ONC certification criteria and implementation specifications nor the Stage 1 CMS meaningful utilise requirements require laboratories to transmit results using LOINC codes.

ONC Temporary Certification Plan for EHR Technology

Elsewhere in the ONC's Final Rule (45 CFR Part 170 subpart D), in June 2010, the ONC established a Temporary Certification Program for EHR Technology. This plan authorizes ONC-Authorized Testing and Certification Bodies (ONC-ATCBs) to exam EHR technology and to certify that EHR systems run across the standards, implementation specifications, and certification criteria as specified in the Concluding Dominion. The rule also describes how organizations can go ONC-ATCBs. The temporary certification programme will be replaced eventually by a permanent certification program. Every bit of this writing, three organizations take qualified every bit ONC-ACTBs:

• Certification Committee for Health It (CCHIT).

• Drummond Group Inc. (DGI).

• InfoGard Laboratories Inc.

An up to date list of ONC-ATCBs may exist found on the ONC web site at http://healthIT.hhs.gov/ATCBs. ONC maintains an up to date Certified HIT Production List (CHPL) at http://onc-chpl.force.com/ehrcert. As of this writing, the CHPL web site lists 115 systems from 79 vendors that have been certified by ONC-ATCBs under the Temporary Certification Plan.

Other Related ONC Programs

There are 2 other ONC-sponsored programs (from HITECH) of which pathologists and laboratories should be aware, which take been created to foster EHRs adoption: Regional Extension Centers (RECs) and Health Information Exchanges (HIEs).

The HITECH Human action allocated $677 million to the establishment of Health Information technology Regional Extension Centers (RECs) that will offer health care providers with technical assistance, guidance, and data on best practices to back up and accelerate health care providers efforts to go meaningful users of EHRs.[7] RECs cover all geographic regions of the The states. As of this writing, 62 RECs for practitioners have had funding announced and an additional 46 RECs take been funding to help disquisitional admission and rural hospitals adopt certified EHR technology. The RECs volition focus mostly on clinicians providing primary care services, with an emphasis on individual and small group practices (fewer than 10 providers). The RECs aim to provide assistance in EHRs product option and implementation every bit well as guidance on improving clinical administrative workloads to utilize EHRs most effectively, and meeting legal, regulatory, and other requirements. The relevance of RECs to laboratories is that understanding RECs efforts in their area may provide an opportunity for laboratories to piece of work with the RECs, doctor offices, and EHR vendors to improve success in implementing laboratory interfaces.

The HITECH Act as well funds the State Health Information Commutation Cooperative Agreement Programme.[8] Under this program, the federal government has awarded $548 million to support exchange of health data across different health care organizations through the establishment of HIEs. HIEs are groups of organizations working together with a goal of improving the quality of health care delivery in a region, typically a state, by focusing on standards-based interoperability of healthcare information and healthcare information systems. The goals, capabilities, and participants in HIEs will vary across states, and participants in HIEs will vary across states. Reflecting a priority for the electronic exchange of laboratory results in HIEs. In July 2010, the ONC issued a Programme Information Discover (PIN)[9] that directed HIE efforts and award grantees to focus their efforts on receipt of structured laboratory results as one of three priorities for HIEs for 2011 (the others beingness eastward-prescribing and sharing patient care summaries across organizations). HIE efforts in a laboratory, land, or region, although varying in maturity, may have relevance to laboratories that either need to or wish to participate or that see value in leveraging an HIE's capabilities to facilitate laboratory information exchange.

OTHER IMPLICATIONS FOR LABORATORIES OF EHR MEANINGFUL Apply REQUIREMENTS

The HITECH Act and the CMS EHR incentive/penalty programs aim to increase the use of EHRs by health care providers. Greater implementation of EHRs has of import clinical, operational, and business implications for laboratories, peculiarly those that serve physician practices. Laboratories can expect to see a dramatic increase in the expectations for LIS-EHR electronic interfaces for test results and laboratory examination orders (eventually if not immediately), as physicians implement EHRs more widely. The increase in expectations for electronic interfaces will stalk from (1) the fact that laboratory result interfaces volition facilitate meeting meaningful utilise requirements (come across to a higher place) for incorporation of laboratory information in an EHR and (2) the fact that implementing an EHR generally volition atomic number 82 to the desire to have laboratory results delivered electronically. Further to the latter point, one time a dr. practice has an EHR in place, the expectation will understandably follow that laboratory results volition be electronically incorporated into the electronic record instead of being entered manually or instead of being viewed on separate laboratory web portal sites or the like.

Meaningful apply requirements and the expected increment in EHR implementation offer some opportunities for laboratories. Implementing an electronic interface from the laboratory data organisation to a provider'south EHR can facilitate coming together the requirement for the incorporation of clinical laboratory test results into the EHR, and for higher volume practices, meeting the requirement is realistically possible to achieve only with an electronic interface from the laboratory (although results interfaces are not specifically mandated in the Stage 1 meaningful use criterion). Because many of the CQMs that are options for clinicians to written report involve laboratory tests [Tables ​ 5 and ​ six], laboratories may find opportunities to facilitate their clients' power to meet these meaningful use reporting requirements. At minimum, eligible providers volition probable want to receive test result data in a way that will automatically populate information into their EHRs and in turn facilitate CQM reporting to meet meaningful use criteria.

Challenges for Laboratories

For laboratories, more than widespread and fourth dimension-sensitive expectations for LIS-EHR interfaces present substantial challenges and bring with them considerations that get beyond the specific requirements mentioned in the Last Rules. Implementing interfaces between LISs and EHRs is not "plug and play," and requires considerable attending to technical likewise as organizational/administrative factors. In addition, there may be considerable expenses involved in implementing interfaces and maintaining interfaces. At that place may be lack of command or involvement available to the laboratory for EHR management at physician sites. Poor process design resulting in problems with laboratory testing may exist blamed inappropriately on the laboratory.

Primary amidst the challenges is that the laboratory has the responsibleness for the accurateness of test result information that are transmitted from the laboratory to receiving systems. The CLIA (Clinical Laboratory Improvement Amendments) regulation states this responsibility specifically (42 CFR 493.1291(a)):[10]

"The laboratory must have adequate transmission or electronic organization(due south) in identify to ensure test results and other patient-specific data are accurately and reliably sent from the signal of data entry (whether interfaced or entered manually) to last report destination, in a timely manner. This includes the following:…(2) Results and patient-specific data electronically reported to network or interfaced systems."

Equally part of its stated goal to promote the electronic exchange of wellness information and in recognition of the fact that laboratory data is an integral part of EHRs, CMS recently issued a revised guidance related to estimation and compliance with CLIA requirements for laboratory result reporting and laboratory information exchange. This guidance was issued in March 2010 in the form of the document entitled "Issuance of Revised Survey Procedures and Interpretive Guidelines for Laboratories and Laboratory Services in Appendix C of the Country Operations Transmission." [11] Generally, such interpretive guidance in the Land Operations Manual is the guidance for surveyors for interpretation and application of CLIA requirements when surveying or inspecting laboratories. In the document, the CMS indicates that this is the showtime of a series of forthcoming memoranda from CMS on electronic commutation of laboratory information. The document provides important management to laboratories on meeting CLIA requirements and includes revisions in requirements related to the electronic exchange of laboratory data, data retention, and direction of corrected laboratory reports in EHRs. Guidance is besides offered related to the definition of individuals who are authorized to receive laboratory results and how others may be designated by the authorized individuals to receive laboratory information. An extensive section of frequently asked questions includes further clarification on the higher up topics likewise as clarification on HIEs and designating "agents" for the receipt of laboratory test results.

When meeting such requirements equally the above, every bit well every bit in pursuit of a stewardship function for the quality of laboratory data in medical practice, laboratories need to be aware that EHRs may vary in their effectiveness of result display. Laboratory report elements that may be field of study to variation in EHRs include:

• Reference range direction.

• Explanatory comments and footnotes.

• Abnormal consequence flags.

• Preliminary reporting and updates.

• Reporting and documentation of corrected results.

• Unsolicited results and reflex test lodge/results.

• Proper name and address of performing laboratory.

EHR certification requirements dictate only that the CLIA-mandated elements (see previous department) that found a examination report must exist displayed in the EHRs and take no further requirements every bit to format, readability, or display. The issues related to the higher up items every bit well as other aspects of more than complex laboratory event display commonly ascend during the class of interface implementation. Failure to address these issues might have negative consequences, which include misinterpretation of laboratory results and the perception (even so inappropriate information technology might be) that the laboratory is responsible for less than optimal display of laboratory results in EHRs and interpretive errors that might arise from such display.

Laboratories must consider other technical considerations necessary to come across the need for LIS-EHRs interfaces. Whether laboratories interface directly from their LIS to EHRs interfaces or interface through some type of integration services provider or interface engine, the capability will be necessary to interface with a wide diverseness of EHRs and vendors that are available. Every bit of this writing, according to the ONC CHPL web site (http://onc-chpl.force.com/ehrcert), 115 EHRs have been certified from 79 vendors. Laboratories volition need to establish a network connectivity model (e.k., virtual private network, VPN) for electronic advice with the EHR sites. Laboratories will need to secure the availability of technical support expertise for implementing and supporting the interfaces. Compatibility with ONC-mandated interoperability standards is of import, perhaps not as much in the current requirements, merely certainly with an middle toward the future.

Operational Considerations for Laboratories and LIS-EHR Interfaces

Attention to the operational aspects of LIS-EHR results reporting interfaces is necessary for successful implementation and ongoing back up. Some of the more than of import factors are summarized here:

• The importance of and methods for maintenance of the laboratory examination definitions in the EHR must be understood, particularly when information technology comes to change control. For instance, will clients be changing their laboratory test definitions settings in the EHR, which in turn will affect the right filing in the EHR of test results that are received in interface transmissions?

• Laboratory procedures should address change control and communication that should occur when the laboratory makes to the exam definition in its own LIS. Some of these changes, such as examination definition updates or reference range adjustments, may bear on interface transmission and/or the brandish of results in the receiving EHR and, therefore, procedures are necessary for communicating such changes to the interfaced sites.

• Ongoing troubleshooting of interfaces and interface-related client back up issues will grow as the number of interfaces abound, and must be accounted for in laboratory management planning.

• Overall client site contact and engagement volition be of import to be able to have successful communication of laboratory results electronically on an ongoing basis and to manage changes. Implementing EHRs interfaces requires some involvement by support personnel at the client site; however, getting admission to and attention of such people at client sites can be challenging and frustrating if such personnel resource at any item site fifty-fifty exist.

• There may be a need to train EHR interface clients as to how laboratory results are viewed.

• A procedure for handling and communicating corrected results must be implemented and validated.

• Depending on the exercise setting, the establishment of procedures may be necessary for the communication of laboratory test results in situations in downtime situations when the interface is not available.

• Providers with differing clinical needs, dissimilar examination mixes, and/or different EHR solutions may require dissimilar laboratory workflow or at least must be accommodated inside laboratory operations; however, this need must be balanced against reduced efficiency that may result from creating too many exceptions or variations in laboratory procedures.

• LIS upgrades or updates must likewise take into account any effects on interfaced systems and sites.

Anticipated Requirements in Future Stages of Meaningful Use

While current requirements for Phase one of meaningful use criteria and related information standards adopted past HHS/ONC are relatively express with regard to the laboratory, predictable requirements in the future stages of meaningful employ can be expected to accept a greater touch on on the laboratory. Equally mentioned, CPOE as a requirement for laboratory exam orders was removed from Stage 1, but is expected to exist nowadays in Stage 2. When implemented, electronic orders for laboratory tests will originate in the CPOE module of EHRs and will exist subject for the vagaries of how CPOE is implemented in different EHRs. Laboratories should look to have processes in identify to handle electronic transmission of orders from interfaced clients in advance and expectation of these requirements. Examination bill of fare/test itemize management volition exist of paramount importance, given the diverseness of the EHR environs (as evidenced past the number of EHRs already certified). CPOE systems must exist configured correctly for laboratory test ordering in terms of menus, guild tests, and the options for how examination social club choices are presented to the ordering md. Test requests in CPOE systems must include the capability to include all the items that CLIA mandates in exam requests and, furthermore, the CPOE systems should be set upwardly to accommodate other nuances of laboratory test ordering, including "enquire at society entry" questions and provision of clinical data when necessary. There are meaning negative consequences for the laboratory of improperly designed or implemented EHR CPOE processes (fifty-fifty if the laboratory has little influence or opportunity for involvement in the implementation procedure), such as incorrect, incomplete, and/or inappropriate exam orders also as inefficiencies attributable to CPOE problem resolution. Depending on the clinical setting, the CPOE process for laboratory tests may demand to account for hereafter orders, duplicate gild handling, and canceled order handling. Billing issues may arise every bit well if not factored into planning.

Stage two meaningful use criteria are expected to include requirements for electronic manual of diagnostic test results that extend beyond the current applicability to numeric results and yes/no results and also include pathology results and genetic tests (in addition to radiology, cardiac imaging, pulmonary function tests, etc.).

As HHS has adopted LOINC and HL7 v2.5.1 in certain EHR certification criteria, information technology might be expected that broader requirements regarding use of these data standards may be forthcoming in future stages. LOINC, and the capabilities of laboratory information systems to accommodate LOINC, is of particular interest for laboratory examination information management every bit laboratories examine the capabilities of their LISs. In line with the HHS-stated goals, broadly speaking, there will be greater expectations for exchange of healthcare data with unaffiliated entities and more conclusion support in full general, both of which tin can exist expected to involve laboratory tests.

CONCLUSIONS

As a outcome of the recent federal government efforts nether the HITECH Deed, well-nigh notably EHR meaningful utilize and EHR certification criteria, utilize of EHRs can be expected to increment dramatically in the coming months and years. Meaningful use criteria dictate how eligible providers and hospitals must use EHRs technology, while certification standards specify what capabilities that EHR must possess in order to support meaningful use. Some of these criteria and requirements are directly applicative to laboratory testing currently, and more than hope to be applicative to laboratory testing in the future.

As EHR uptake expands, in that location will exist greater expectations for electronic interchange of laboratory data, and laboratories must prepare now to meet the needs of the future environment. Implementation of LIS-EHR interfaces promises to exist a major priority in the future and a claiming for laboratories serving outreach clients. In addition, some of the new and futurity requirements and programs may provide other opportunities for ways that laboratories tin can improve serve their provider community.

Footnotes

REFERENCES

2. Hsiao C, Hing E, Woodwell DA, Socey TC, Cai B. Electronic medical record/electronic health tape apply by role-based physicians: United States, 2009 and Preliminary 2010. Hyattsville, Doc: National Center for Health Statistics. Available from: http://www.cdc.gov/nchs/data/hestat/emr_ehr_09/emr_ehr_09.htm [cited on 2011 Jan 18]

5. Centers for Medicare and Medicaid Services, Department of Health and Human Services. 42 CFR Parts 412, 413, 422 et al. Medicare and Medicaid Programs; Electronic Health Record Incentive Programme; Final Dominion; published July 28, 2010. Available from: http://edocket.access.gpo.gov/2010/pdf/2010-17207.pdf [cited on 2010 Dec eight]

6. Department of Health and Man Services. 45 CFR Part 170. Health Information technology: Initial Set of Standards, Implementation Specifications, and Certification Criteria for Electronic Health Record Technology; Terminal Rule; published July 28, 2010. Bachelor from: http://edocket.admission.gpo.gov/2010/pdf/2010-17210.pdf [cited on 2010 Dec 8] [PubMed]

11. Centers for Medicare and Medicaid Services, Section of Health and Man Services. Clinical Laboratory Comeback Amendments of 1988 (CLIA) – Issuance of Revised Survey Procedures and Interpretive Guidelines for Laboratories and Laboratory Services in Appendix C of the Country Operations Manual to Facilitate the Electronic Exchange of Laboratory Data; published March 1, 2010. Available from: http://www.cms.gov/SurveyCertificationGenInfo/downloads/SCLetter10-12.pdf [cited on 2010 Dec 8]

Source: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3049251/

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