2. Clinical Lab Test Results

This lesson will demonstrate the steps necessary to meet the Meaningful Use requirement for Structured Lab Results.

Version:

SOAPware 2011 or later must be used.

Note: To determine the version of SOAPware being used, Click on Help > About SOAPware. This will open a window which will show the version and build of SOAPware currently in use.

Dashboard:

This requirement will be tracked via the Meaningful Use Dashboard.

Measure Criteria

Objective: Incorporate clinical lab test results into EHR as structured data.

Measure: More than 40 percent of all clinical lab test results ordered by the EP during the EHR reporting period whose results are either in a positive/negative or numerical format are incorporated in certified EHR technology as structured data.

For more detailed information on this measure, please Click on the "Reference" link below. This CMS documentation includes information on exclusions, attestation requirements, a definition of terms and important additional information.

CLICK TO VIEW THE CMS DOCUMENTATION ON THIS MEASURE:

Reference: CMS: Clinical Lab Results

Measure Calculation

Denominator: The number of lab test results that are entered into the SOAPware Labs Chart Section whose results are expressed in a positive or negative affirmation or as a number.

Numerator: The number of lab test results in the denominator whose results are entered in structured format.

(IMPORTANT NOTE: Entering lab results that are positive/negative or numerical into a SOAPware Lab docuplate is structured; however the lab test value must be reported as either a numerical range test type or the Value field must say exactly "positive" or "negative" .  Scanning the lab results into the Lab section is not structured.)

Threshold: The resulting percentage must be more than 40%.

* Scoring is individual, provider-based and not practice-wide.

 

Labs Chart Section

Labs Chart Section

The Labs Chart Section is where this structured data will need to be recorded. In most cases, HL7  lab results are structured if the results are in a postive/negative or numerical format AND the value is a numerical value or states exactly "positive" or "negative" for the results.

For in-house labs: In order for the labs entered to be structured data, lab docuplates need to be created utilizing numerical and positive/negative formats. To learn more about the Labs Chart Section as well as creating docuplates for labs, see: Labs.

Using Structured Labs

Structured labs will need to be created in SOAPware so that they will correctly increase the numerator and denominator for this Meaningful Use objective.  

Some of the lab tests that users were previously using may need to be edited or updated so that they will correctly increase the numerator and denominator.

Numeric Lab Test Results

Any lab test that has a numeric result must be created using the Test Type of Numeric Range in order to calculate appropriately.  Please see the instructions below on how to create a Numeric Range lab test.

Positive/Negitive Lab Test Results

Any lab test that has a result expressed in positive or negative format must have the Value of that test entered as exactly "positive" or "negative".  Any other variation of positive (ie: pos) or negative (ie: neg) will not properly calculate for meaningful use.  Please see the instructions below on how to create a Positive/Negative lab test.

Structured Labs: Creating Lab Tests as Numeric Range

Structured Labs: Creating Lab Tests as Numeric Range

To create a structured lab test for a test whose results are expressed in numerical format:

1.  Click Tools > Lab Tests

2.  Click the Add Test button (button with the green plus)

3.  Select a Test Type of Numeric Range

4.  Complete the test name, description, units and reference ranges.

5.  Click OK to save the new test.  

Once the lab test has been created as described above, it can be used in a lab docuplate or with a patient's chart to record the results.  Lab tests that are created with the test type of numeric range will increase the numerator for the Clinical Lab Test Results meaningful use objective with appropriately entered in the patient's chart.  

At this time, if a lab test with numeric results is created using a Test Type other than Numeric Range, it will not properly increase the numerator when entered into a patient's chart.

Structured Labs: Creating Lab Tests with Positive/Negative Results

To create a structured lab test for a test whose results are expressed in a positive or negative format:

1.  Click Tools > Lab Tests

2.  Click the Add Test button (button with the green plus)

3.  Select a Test Type of either Pick List or Text Field

4.  Complete the Test Name and Test Description

5.  If a Test Type of pick list has been entered, enter "Positive" and "Negative" in the Pick-list values box as shown in the screenshot above.

5.  Click OK to save the new test.  

Once the lab test has been created as described above, it can be used in a lab docuplate or within a patient's chart to record the results.  Lab tests that have a value entered that says exactly "positive" or "negative"* will increase the numerator for the Clinical Lab Test Results meaningful use objective with appropriately entered in the patient's chart.  

*Note, the lab results cannot read anything other than "positive" or "negative" (not case sensitive).  If the lab result reads "pos" or "neg" or any other variation, it will not properly increase the numerator for this meaningful use measure.

Scanning Labs Into the Labs Chart Section

Scanning Labs Into the Labs Chart Section

Scanning a patient's lab result into the Labs chart section will not count as a structured lab to meet the meaningful use requirement.  When a document is scanned into the Labs chart section, users will be prompted with a Meaningful Use alert (see screenshot above).  

Users must select Yes or No to indicate if the lab test contains results that are in a positive/negative or numerical format on the scanned lab.  This will allow SOAPware to properly calculate the total number of labs during the EHR reporting period whose results are either in a positive/negative or numerical format and are incorporated as unstructured data.

Scanning labs into SOAPware will increase the provider's denominator for this measure (the numerator will not increase unless the lab is incorporated as structured data).

Meaningful Use Dashboard

Meaningful Use Dashboard

This measure is tracked in the Meaningful Use Dashboard under "Clincal Lab Test Results".  In SOAPware versions prior to 2012.0.313, this item will be listed in the Patient MU Dashboard as "Structured Labs".

The Meaningful Use Dashboard can be accessed by selecting SOAPware > Meaningful Use Dashboard.

The Meaningful Use Dashboard will display the Numerator, Denominator and percentage for this measure, as well as, graph the trend for the dates selected.  Please see the following link for instructions on using the Meaningful Use Dashboard: Meaningful Use Dashboard.

*Note: The dashboard icon will display a gray X if the threshold for this measure has not been met for the selected reporting period. The icon will change to a green check mark once the threshold for the meaningful use measure has been met.