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E-Patient Update:  Keeping Data From Patients Has Consequences

Posted on September 20, 2016 I Written By

Anne Zieger is veteran healthcare consultant and analyst with 20 years of industry experience. Zieger formerly served as editor-in-chief of and her commentaries have appeared in dozens of international business publications, including Forbes, Business Week and Information Week. She has also contributed content to hundreds of healthcare and health IT organizations, including several Fortune 500 companies. Contact her at @ziegerhealth on Twitter or visit her site at Zieger Healthcare.

Given who I am – an analyst and editor who’s waist-deep in the health IT world – I am primed to stay on top of my health data, including physician notes, lab reports, test results and imaging studies. Not only does it help me talk to my doctors, it gives me a feeling of control which I value.

The thing is, I’m not convinced that most physicians support me in this. Time and again, I run into situations where I can’t see my own health information via a portal until a physician “approves” the data. I’ve written about this phenomenon previously, mostly to wring my hands at the foolishness of it all, but I see the need to revisit the issue.

Having given the matter more thought, I’ve come to believe that withholding such data isn’t just unfortunate, it’s harmful. Not only does it hamper patients’ efforts to manage their own care effectively, it reveals attitudes which are likely to hold back the entire process of transforming the health system.

An Example of Delayed Health Data
Take the following example, from my own care. I was treated in the emergency department for swelling and pain which I feared might be related to a blood clot in my leg. The ED staff did a battery of tests, including an MRI, which concluded that I was actually suffering from lumbar spine issues.

Given that the spinal issue was painful and disabling, I made an appointment for follow up with a spine specialist for one week after the ED visit. But despite having signed up with the hospital’s portal, I was unable to retrieve the radiologist’s report until an hour before the spine specialist visit. And without that report the specialist would not have been able to act immediately to assist me.

I don’t know why I was unable to access the records for several days after my visit, but I can’t think of a reason why it would have made sense to deprive me of information I needed urgently for continued care. My previous experience, however, suggests that I probably had to wait until a physician reviewed the records and released them for my use.

Defeating the Purpose
To my way of looking at things, holding back records defeats the purpose of having portals in the first place. Ideally, patients don’t use portals as passive record repositories; instead, they visit them regularly and review key information generated by their clinical encounters, particularly if they suffer from chronic illnesses.

It’d be a real shame if conservative attitudes about sharing unvetted tests, imaging or procedure data undercut the benefits of portals. While it’s still not entirely clear how we’re going to engage patients further in managing their health – individually or across a population – portals are emerging as one of the more effective tools we’ve got. Bottom line, patients use them, and that’s a pretty big deal.

I’m not saying that patients have never overreacted to what looked like a scary result and called their doctor a million times in a panic. (That seems to be the scenario doctors fear, from conversations I’ve had over time.) But my guess is that it’s far less common than they think.

And in their attempts to head off a minor problem, they’re discouraging patients from getting involved with their care, which is what they need patients to do as value-based care models emerge. Seems like everyone loses.

Sure, patients may struggle to understand care data and notes at first, but what we need to do is educate them on what it means. We can’t afford to keep patients ignorant just to protect turf and salve egos.

An Improved Interface for Lab Tests

Posted on December 29, 2015 I Written By

Andy Oram is an editor at O'Reilly Media, a highly respected book publisher and technology information provider. An employee of the company since 1992, Andy currently specializes in open source, software engineering, and health IT, but his editorial output has ranged from a legal guide covering intellectual property to a graphic novel about teenage hackers. His articles have appeared often on EMR & EHR and other blogs in the health IT space. Andy also writes often for O'Reilly's Radar site ( and other publications on policy issues related to the Internet and on trends affecting technical innovation and its effects on society. Print publications where his work has appeared include The Economist, Communications of the ACM, Copyright World, the Journal of Information Technology & Politics, Vanguardia Dossier, and Internet Law and Business. Conferences where he has presented talks include O'Reilly's Open Source Convention, FISL (Brazil), FOSDEM, and DebConf.

Electronic health records have been the butt of complaints for years (and in fact, doctors are getting less satisfied with them over time), but we don’t really know how to make them better–if we did, we would have fixed them long ago. Two principles raise the hope of improving the usability of EHRs in the future:

  • Involve the clinicians themselves intensively in design.
  • Allow access by third parties who can experiment with new innovations.

One specific improvement in user interface design is now being proposed: a better organized display for lab tests. This deserves more news coverage in its own right, and additionally illustrates the two principles at work. I talked recently to Dr. Robert Coli, the chief proponent of the design.

A uniform display format

Current lab results tend to be presented as incomplete and badly fragmented data, instead of the complete, integrated, and actionable information that physicians and patients need. Fragmented data wastes a lot of space, doubles or triples the number of screens to scroll and pages to turn, and lacks the connections that could help physicians draw conclusions. Confusion over test results slows down physicians and increases the risk of errors, both of omission and comission. Doctors might reorder tests merely because they are time-constrained and have trouble finding what they need: the results of recent tests and historical trends.

The proposed user interface adheres to a uniform format developed by doctors, with input and feedback from doctors and nurses to ensure it is clinically intuitive. It will help physicians as well as patients view and share test results displayed by EHR, PHR, and HIE platforms. A group of Rhode Island physicians have supported its development and unsuccessful efforts to distribute it as a commercial product for more than 20 years. Various levels of display are illustrated on their web page.

Their key advance, based on principles of human-centered design, is to group tests by organ systems (a classification that already exists in medicine) and then to display them chronologically within clinically logical categories and subcategories. In one example, the first three subcategories of the first main test category, “MICROCHEM TESTS,” displays about 50 clinical lab tests that are most frequently ordered and repeated. The less commonly ordered and less frequently repeated lab tests are displayed in the fourth subcategory, with Microbiology results presented in subcategory five. Clicking on rows will display useful details, including reference ranges and units.

In the second main test category, “SUBSPECIALTY TESTS,” imaging, endoscopic and other testing modalities are indexed by organ system and clinical specialty in alignment with physicians’ common thought flow and workflow.

According to Coli, existing displays are packed with fragmented data. They use five times as much space, are more confusing, and make it difficult to find individual test results or to follow trends over time. The same flawed user interface design seems to have persisted for an astonishingly long time. Figure 1 shows a printed hospital report of lab results dating from the 1970s, while Figure 2 shows a modern EHR display using the same suboptimal design. Both reporting formats list tests in a rather haphazard order over short time periods, include an enormous amount of useless white space, and are laid out inconsistently to that doctors cannot find important information quickly even after considerable practice.


Figure 1. Old paper lab results report


Figure 2. Putatively modern electronic display of lab results

Often, user interface advocates call for customizable interfaces. But Coli argues that for lab and other test results, consistency is generally more important than customizability. A single, platform-neutral, uniform report display will allow doctors to quickly learn how to find the information they are seeking and apply these skills throughout their careers, at any point of care. The format could also be the basis for other enhancements, such as showing a chart with a normal range and the patient’s actual result, and using color to highlight anomalies. Specialty-specific customized views of cumulative results and Clinical Decision Support (CDS) applications for optimizing cost-effective test selection can also be developed as value-added enhancements to the standard reporting format.

History of the proposal

Coli rebelled at lab test displays back in the days of paper, and developed his current format when starting his own practice in 1979. Enthusiasm grew among his colleagues, but he could not drive adoption outside the circles of clinicians who knew and respected him. Amazingly, he has kept up his efforts over the years, and saw the passage of HITECH as the opening he needed.

Between 2011 and 2013, Coli accepted an invitation from Direct Project Coordinator, Arien Malec, to attend weekly virtual meetings of the Standards & Interoperability (S&I) Framework as it developed HL7-balloted implementation guides, pilot projects, and reference implementations for key lab-related standards. Although the Framework’s scope of work did not include standardizing the presentation of test results for physicians and patients, it was relevant to other Framework efforts, including EHR-LIS open source lab results reporting, lab test ordering, and an electronic directory of lab services standards. Coli’s proposal also drew approval from the judges of the eHealth Initiative’s 2015 Innovation Challenge.

Coli is currently investigating possible work with the Healthcare Services Platform Consortium (HSPC) to implement the standard reporting format over SMART on FHIR. And he’s in the process of connecting with all the right consortia actively seeking to advance interoperability, including the CommonWell Health Alliance and the Argonaut and Sequoia projects. Recognizing the spread of open source solutions in health care, Coli is offering these public/private sector consortia and leading standards organizations a royalty-free license to a patent that his company holds on the format.

Still, vendors have taken little notice of the lab results format. This is why a third-party market is so important. There is no reason for suffering clinicians to wait until one implementation detail rises high enough on some vendor’s checklist to have it done. Tools and standards have advanced to the point where innovations like this can be developed and disseminated quickly.

Docs Using EMR Data Order Fewer Lab Tests

Posted on December 2, 2013 I Written By

Anne Zieger is veteran healthcare consultant and analyst with 20 years of industry experience. Zieger formerly served as editor-in-chief of and her commentaries have appeared in dozens of international business publications, including Forbes, Business Week and Information Week. She has also contributed content to hundreds of healthcare and health IT organizations, including several Fortune 500 companies. Contact her at @ziegerhealth on Twitter or visit her site at Zieger Healthcare.

A new study has concluded that when doctors viewed lab test cost data in an EMR, they decreased their order rates for certain tests, cutting the overall cost of lab tests meaningfully, according a story in Healthcare IT News.

The Atrius health study, published in the Journal of General Internal Medicine, found that docs who reviewed lab test cost data decreased their ordering rates for certain tests and saved up to $107 per 1,000 per month. The study also found that lab test utilization decreased by up to 5.6 lab orders per 1,000 visits  per month, HIN reported.

The study, which was led by Daniel Horn of  Massachusetts General Hospital’s Division of General Medicine, surveyed 215 primary care docs at Atrius Health. Physicians in the intervention group got up-to-date information on lab costs for 27 individual tests when they placed e-orders. There was also a control group of physicians who didn’t get the information.

Researchers saw significant decreases in ordering rates for five out of 27 high and low cost lab tests, and a decrease in utilization for all 27 tests, though not all shifts were statistically significant. Meanwhile, 49 percent of doctors felt that they had enough information to make their ordering decisions.

Thomas Sequist, MD, Atrius Health director of research and co-author of the study, said these findings suggest that seeing lab data in EMRs could scale up in big ways. For example, he notes, in a large physician practice managing 20,000 visits per month, that’s $2,140 per month and more than $25,000 per year.

This isn’t the only evidence that access to lab test costs and info reduces ordering. A study published last year in the Archives of Internal Medicine concluded that during the period between January 1, 1999  and Dec. 31, 2004, during the test of a health information exchange, there was a 49 percent reduction in number of tests for patients with recent off-site tests.

That being said, other studies — such as this one appearing in Health Affairs — have found that doctors who see earlier tests and images actually tend to order more follow up tests.

It seems clear that this is an important area for further study, as needless tests are a big cost driver. In the mean time, we’ll have to make do with contradictory evidence.