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Policies,Clinical,UW Health Clinical,General Care and Procedures,Labs/Specimens

Sending Test Results into UW Health Link via LabDE (2.5.5)

Sending Test Results into UW Health Link via LabDE (2.5.5) - Policies, Clinical, UW Health Clinical, General Care and Procedures, Labs/Specimens

2.5.5


UW HEALTH CLINICAL POLICY 1
Policy Title: Sending Test Results into UW Health Link via LabDE
Policy Number: 2.5.5
Category: UW Health
Type: Ambulatory and Inpatient
Effective Date: August 28, 2017

I. PURPOSE

The purpose of this policy is to ensure consistency and quality practices in the use of LabDE for laboratory
test results that file to the UW Health Link (EPIC) electronic health record (EHR).

II. POLICY ELEMENTS

A. LabDE is an application that uses OCR (optical character recognition) technology in order to take lab results
from a scanned document and place in the appropriate fields in order to send to UW Health Link (Epic) via
an HL7 results interface. This application allows users with designated security to review the results that
have been interpreted by LabDE and approve prior to sending as discrete data elements to the EHR. It is
important for continuity of clinical care to have test results available in the EHR as discrete data elements.
Only diagnostic procedure/test orders written by a UW Health physician or authorized prescriber will be
accepted and executed. Authorized staff can perform and result diagnostic procedures/tests within a defined
scope of practice. The use of LabDE should be within that scope of practice. All diagnostic test/procedure
reports in the EHR must meet the requirements of all regulatory agencies, (e.g., CLIA) and accreditation
agencies (e.g. CAP, AABB, The Joint Commission). Each clinical site using LabDE to send test results
directly into UW Health Link (Epic) will identify, train, and monitor staff performing this function. Each clinical
site manager/supervisor must comply with auditing requirements defined in this policy.
B. LabDE is used to enter test results for patient care orders from or requested by a UW Health physician or
authorized prescriber but performed at healthcare facilities outside of UW Health ("External Results"). All
external laboratory results sent from LabDE are to be sent verbatim. Interpretations of results are to be
entered into the EHR via other methods available in the EHR.
C. Definitions
i. External Result - clinical test results collected and performed at healthcare facilities outside of UW
Health.
ii. LLB – Health Link/Epic term for performing laboratory.
iii. LRR - Health Link/Epic term for laboratory reportable result.
iv. Collection Date – date the specimen is collected.
v. Result date – date the testing was completed.
vi. Report date – date the testing was reported to the ordering provider via a paper report, fax or
electronic transmission into the EHR.
D. Laboratory Test Results
i. It is acceptable to use LabDE functionality in the following defined cases:
a. Diagnostic test result entry for any laboratory test ordered by a UW Health provider and
performed at a laboratory external to UW Health, if the result meets the following criteria:
1. Type of result has been approved by UW Health Lab Medical Director and the
UW Health Laboratory Testing Oversight Committee.
2. Appropriate system build and testing has been completed by Information
Services to support the type of result once approval has been given.
ii. It is not acceptable to use LabDE functionality for the following defined cases:
a. Historical reported results on new patients that predate the first appointment within UW
Health. These results can be scanned into the record on the Outside Documents tab
(exception to this can include Transplant, Gynecology and Obstetrics, Oncology,
Hematology and Gynecology/Oncology if lab results are required to trend or treat the
patient).
b. Any reported result in which the user alters or paraphrases the actual reported result of
the performing laboratory. For example, a Pap smear reported as Atypical Squamous
Cells of Undetermined Significance, cannot be interpreted as “negative” by the user.
“Negative” is not acceptable for entry into LabDE.
c. Patient self-performed over the counter test such as pregnancy test or glucose monitoring
or patient performed prescribed device testing such as home INR testing.
d. Any lab results that have not been approved for the UW Health Lab Medical Director and
the UW Health Laboratory Testing Oversight Committee.



UW HEALTH CLINICAL POLICY 2
Policy Title: Sending Test Results into UW Health Link via LabDE
Policy Number: 2.5.5


III. PROCEDURE

A. Requesting LabDE Functionality
i. CSAR (Computer System Authorization Request) submission
a. Clinics requesting use of LabDE for external results will make this request to the
respective Ambulatory Operational or HOD Director. The LabDE application is complex
and is only recommended for those who use on a regular basis. With each unique site that
requests there is also additional cost and analysis in order to implement. Discussion
needs to occur directly with Information Services before approval will be granted unless
the specific site is already using and a new employee just needs to be granted access.
b. Clinic or service manager will include director approval with submission in the CSAR
request.
ii. Each staff member must complete training for LabDE and be judged to be competent.
Documentation of such training is maintained by the operational manager.
B. LabDE procedure
i. Launch Lab DE application using appropriate shortcut.
ii. Reference the LabDE training handbook for specific documentation regarding the LabDE
procedure both within the LabDE system and within Health Link.
iii. While referencing the specific procedures keep the below information in mind:
a. The following elements are required as appropriate for all test results sent into UW Health
Link via LabDE:
1. Two patient identifiers (patient name and date of birth. MRN typically cannot be
used as the MRN on the paper document most likely will be different than the
MRN in Health Link)
2. Lab test/Component name
3. Specimen type if appropriate
4. Lab performing the test - select from Drop Down List:
 Outside facility results, lab needs to be suffixed with (EXTERNAL) when
it displays in Health Link
 If one is not listed, OTHER LAB: SEE SCANNED REPORT
(EXTERNAL) should be used. Submit a request for new performing lab
record if appropriate in order for LabDE and Health Link build to be
done
b. Collection Date–(Required).
c. Collection Time (Required).
d. Result/Value (Required).
e. Reference Range (enter low and high values) (Required if given).
f. Units of measure (Required if given).
g. Result Date (Required if given and system allows entry).
h. Result Time (Required if given and system allows entry).
i. Status is Final (Required).
j. Abnormal flag is set correctly, if used.
iv. Ensure that all available fields that are relevant to this test result accompany the result such as
comments.
v. The original laboratory report should always to be scanned into the record with the result and
should be viewable in a timely fashion (less than 14 days from result entry).
a. Based on workflow, the paper/fax report record should include:
1. Patient EHR Medical Record Number
2. Order number from Health Link
b. If the lab result flows directly through the fax server and stores to a folder rather than
printing to paper, then applying the patient EHR MRN and Order number from Health Link
is not applicable.
vi. If a result value is entered in error and result did NOT qualify for the QA queue within LabDE, the
user must correct this report in Health Link enter/edit by:
a. Entering the result record, correcting the result value and applying the "c" icon (which
indicates a correction) in the abnormal flag field.
b. Entering a comment on the Narrative tab in the result using the smart phrase



UW HEALTH CLINICAL POLICY 3
Policy Title: Sending Test Results into UW Health Link via LabDE
Policy Number: 2.5.5

EDITLABRESULT which states "The [name of the item] was corrected at date/time.
Disregard previous result of ***." (Staff will put the erroneous result in place of the ***s).
c. If other fields are corrected, add the "c" icon in the abnormal flag field and enter a
comment in the Narrative tab in the result using the smart phrase EDITLABRESULT which
states "The [name of the item(s)] was corrected at date/time. Disregard previous ***."
(Staff will enter the erroneous information [e.g. lab name, collection date, low/high
number, units, etc.] that was corrected in place of the ***s).
vii. If a result value is entered in error and was caught in the QA queue within LabDE, the error must
be corrected in LabDE.
a. If the error is a value, reference range or units of measure:
1. Click in the comment field below the results and place your comment before any
other comments
2. Type .edit (The *** was corrected at 07/1/2013 11:45:45 am. Disregard previous
entry of ***. Name) and hit enter
3. Complete the ***
4. Change the Result Status for each component that has been corrected to “C” for
corrected
b. If the error is the resulting lab:
1. Add an order level comment above the “Verified by ***” by using the .edit phrase.
In the first *** just enter the words “performing lab”.
c. Apply the “ErrorFoundandFixedInQA”.
d. Click save and send the result to Health Link.
viii. In accordance with laboratory policy, a PSN should be submitted for any test results that are
changed in the EHR.

IV. QUALITY ASSESSMENT

A. The desired quality standard for LabDE is 100% accuracy of all components outlined below.
i. Verify with two patient identifiers.
ii. Specimen Type (Required). If provided on lab result document
iii. Resulting Lab Info (i.e., Lab performing the test, with city and state) (Required).
iv. Collection Date (Required).
v. Collection Time (Required).
vi. Test (Required).
vii. Result (Required).
viii. Reference Range (Required if given).
ix. Units of measure (Required).
x. Result Date (Required if given and system allows entry).
xi. Result Time (Required if given and system allows entry).
xii. Status is Final (Required).
xiii. Abnormal flag is set correctly, if used.
B. The process of entering paper or faxed results on a single patient with a scan viewable in the EHR within 14
days is considered a correct entry.
C. Auditing
i. Initial training period or if retaining is required.
a. Step One: first ten entries (patient results) will be reviewed by manager/supervisor or
designee for accuracy in real time prior to sending the result to Health Link and if 100%
accuracy achieved move to step 2.
b. Step two: In the first month, the manager/supervisor or designee will audit a minimum of
20 entries (patients) with a required accuracy of 100%. These 20 entries should appear as
part of the 10% of results appearing in the QA queue.
c. If 100% accuracy is not achieved then retraining and repeat of step one and two until
100% accuracy is achieved.
ii. Ongoing random audits should be performed to verify 100% accuracy.
a. Currently, 10% of results verified will automatically be placed in the QA queue for review
by a coordinator/manager. These results will need to be reviewed for accuracy.
b. If no errors are found, the NoErrorFoundInQA icon is clicked and then the save button is
clicked.



UW HEALTH CLINICAL POLICY 4
Policy Title: Sending Test Results into UW Health Link via LabDE
Policy Number: 2.5.5

c. If an error is found, the supervisor/coordinator is to follow the steps found under III B 7 of
this procedure to correct. Additionally, supervisor/coordinator is to notify staff of error.
d. If a result files to Health Link and the error is found after the fact, correction of result will
need to occur via the enter/edit procedure. Please refer to Hospital Administrative policy
7.98 for correction process.
iii. Documentation of audits performed
a. Use of external entry reports or screen prints of above data will be accepted.
b. Summarized data of quarterly audits of outside lab results are to be sent to the UW Health
Laboratory Testing Oversight Committee for review. Use Health Link Enter/Edit Audit
Summary Sheet.
iv. Failure to complete required audit or poor performance using LabDE determined by the UW Health
Laboratory Testing Oversight Committee may result in loss of this functionality.

V. COORDINATION

Author: Director, Transplant Operations
Senior Management Sponsor: VP, Professional and Support Services
Reviewers: Clinical Systems Director, IS-Clinical Systems; Director, Clinical Labs
Approval committees: UW Health Laboratory Testing Oversight Committee, UW Health Clinical Policy
Committee
UW Health Clinical Policy Committee Approval: August 21, 2017

UW Health is a cohesive, united and integrated academic medical enterprise comprised of several entities.
This policy applies to facilities and programs operated by the University of Wisconsin Hospitals and Clinics
and the University of Wisconsin Medical Foundation, Inc., and to clinical facilities and programs
administered by the University of Wisconsin School of Medicine and Public Health. Each entity is
responsible for enforcement of this policy in relation to the facilities and programs that it operates.

VI. APPROVAL

Peter Newcomer, MD
Chief Clinical Officer

J.Scott McMurray, MD
Chair, UW Health Clinical Policy Committee

VII. REFERENCES

None

VIII. REVIEW DETAILS

Version: Revision
Last Full Review: August 28, 2017
Next Revision Due: August 2020
Formerly Known as: UWHC policy #7.11