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A Case for Manual Entry of Structured, Coded Laboratory Data from Multiple Sources into an Ambulatory Electronic Health Record

Affiliations of the authors: Department of Medical Informatics, University of Utah, Salt Lake City (CJS, RSE, SPN, SMH); Departments of Medical Informatics (CJS, RSE, SPN, SMH) and Laboratory Services (STB), Intermountain Health Care, Salt Lake City; Department of Surgery, LDS Hospital (JBS), Salt Lake City, UT.

Correspondence and reprints: Catherine J. Staes, MPH, BSN, 257 East 200 South, Salt Lake City, UT 84111; e-mail: <catherine.staes{at}theradoc.com>.

Received for publication: 02/16/05; accepted for publication: 09/13/05.

Laboratory results provide necessary information for the management of ambulatory patients. To realize the benefits of an electronic health record (EHR) and coded laboratory data (e.g., decision support and improved data access and display), results from laboratories that are external to the health care enterprise need to be integrated with internal results. We describe the development and clinical impact of integrating external results into the EHR at Intermountain Health Care (IHC). During 2004, over 14,000 external laboratory results for 128 liver transplant patients were added to the EHR. The results were used to generate computerized alerts that assisted clinicians with managing laboratory tests in the ambulatory setting. The external results were sent from 85 different facilities and can now be viewed in the EHR integrated with IHC results. We encountered regulatory, logistic, economic, and data quality issues that should be of interest to others developing similar applications.

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