Proposed LOI and LRI IG Implications of Cancel scenarios below 1) Until specimen is received in laboratory , a. provider may cancel test [LOI cancel transaction] b. Laboratory may cancel test if unable to obtain acceptable specimen (e.g. patient did not show , unable to draw) [what is the correct transaction? LOI status, LRI or LRI cancel] 2) Once laboratory has received requisition and specimen a. Provider may request cancel [LOI cancel transaction?] b. Laboratory may cancel if unable to perform test (e.g. unacceptable specimen) [LOI status or LRI cancel] 3) Once any result has been reported to provider a. Provider man not request cancel b. Laboratory may not cancel once any report has been issued to the provider (preliminary, partial, final, …). If there is a problem with completing the testing (e.g. reflex, final, …) the appropriate comment is sent and provider is called [LRI only] Cancellation Scenarios and Actions for both Provider and Laboratory Our role is to support the development of HL7 LOI and LRI Implementation Guides that support the IT functionality laboratories will need for their practices. We should not prescribe workflow or business practice as these are determined by each individual laboratory. There are always exceptions and if we really want to determine practice on the cancellation process, then we should have that discussion. If we are saying that a laboratory would never cancel the order of a resulted test and that any reported result must always remain in the record, then we can make that recommendation. See proposed edits in red below to stimulate discussion. In summary, this table suggests: For provider collected specimens, providers can cancel a test request in the EHR from the time of order until the LIS indicates a receipt date and time For laboratory collected specimens, providers can a cancel test request in the EHR from the time of order until the LIS indicates a collect date and time Providers can send a “cancel request” for a pending test after the option to cancel a test request in the EHR is no longer available. Providers cannot send a “cancel request” once a preliminary or final test report has been received in the EHR Laboratories can cancel a test request received by the LIS (or queue for this purpose) any time before the test report (preliminary or final) is transmitted to the provider(s) Laboratories cannot cancel a test (and accompanying test results report) once a preliminary or final test report has been transmitted to the provider’s EHR Information process step (timeline) Status/Scenario Cancelled by Provider Cancelled by Laboratory Given the scenario, how should the cancellation be handled by the EHR? Given the scenario, how should the cancellation be handled by the EHR? Provider staff cancels the order in the EHR or can convert the order to “Laboratory collect”. (No specimens; no order in lab) Scenario continued: The patient’s mother refuses to take the patient to the laboratory for specimen collection. Scenario continued: The patient does not appear at the laboratory for collection (within a certain timeframe?) or the laboratory is unable to collect the blood specimen. 1 Tests ordered in EHR Provider collect Tests have been ordered in the provider EHR Specimens have not been collected Test request has not been sent to lab Scenario: Pediatrician orders a CBC on a 3 year old boy. The office staff is unable to collect the blood specimen. Laboratory collect Tests have been ordered in the provider EHR Specimens have not been collected Test request has been sent to lab Scenario: Pediatrician orders a CBC on a 3 year old boy. The patient is referred to a local laboratory for specimen collection. 2 Provider staff can cancel the order in the EHR. N/A Laboratory staff can cancel the order in the LIS, which in turn cancels the order in the EHR. The physician is notified of the cancellation, the reason, and of any guidance the laboratory may provide. Specimen collect time updated Provider collect Collect time entered in EHR May occur simultaneous with step 1 - ordering Laboratory collect Collect time entered in LIS May occur simultaneous with step 3 - receipt of specimen in in LIS Tests have been ordered in the provider EHR Specimens have been collected by the provider The specimen collect time has been recorded in the EHR Test request has been sent to lab Scenario: Pediatrician orders a CBC on a 3 year old boy. The office staff collects the blood specimen. Tests have been ordered in the provider EHR Test request has been received by lab Specimens have been collected by the laboratory The specimen collect time has been Scenario continued: The physician recognizes a CBC was done earlier that day when the patient was in the local emergency room and chooses to not send the specimen collected in the office to the laboratory for testing. Provider staff can cancel the order in the EHR. Scenario continued: Before the specimen is received by the testing location, the physician recognizes a CBC was done earlier that day when the patient was in the local emergency room and does not want to duplicate the testing. Scenario continued: Specimen processing staff in the laboratory recognize the specimen was collected in the wrong tube and reject it before the sample status is updated to “received” in the LIS. Laboratory staff can cancel the order in the LIS, which in turn cancels the order in the EHR. The physician is notified of the cancellation, the reason, and of any guidance the laboratory may provide. Scenario continued: Before the specimen is sent to the testing location, phlebotomy staff at the draw station recognize the specimen is clotted. recorded in the LIS Scenario: Pediatrician orders a CBC on a 3 year old boy. The patient is referred to a local draw station, the specimen is collected, and the time is updated in the LIS. 3 Specimen received in LIS 4 Specimen analyzed 5 Test results reported in LIS Scenario: Pediatrician orders a CBC on a 3 year old boy. The blood specimen was collected (by either the provider or the laboratory). Scenario: Pediatrician orders a CBC on a 3 year old boy. The blood specimen was collected (by either the provider or the laboratory), received at the laboratory, and testing initiated. Scenario: Pediatrician orders a CBC with diff on a 3 year old boy. The blood specimen was collected (by either the provider or the laboratory), received at the laboratory, and testing initiated. Provider staff can send a cancel request to the laboratory, but cannot cancel the order in the EHR after the draw station or laboratory has recorded a collect and/or receipt time. Laboratory staff can cancel the order in the LIS, which in turn cancels the order in the EHR. The physician is notified of the cancellation, the reason, and of any guidance the laboratory may provide. (NOTE – how is a reorder/recollect handled?) Scenario continued: After the specimen has been sent to the laboratory, the physician recognizes a CBC was done earlier that day when the patient was in the local emergency room and does not want to duplicate the testing Provider staff can send a cancel request to the laboratory, but cannot cancel the order in the EHR. Laboratory staff will determine per the laboratory’s policy on whether the test and associated charges can be cancelled at this point. Scenario continued: After the specimen has been sent to the laboratory, the physician recognizes a CBC was done earlier that day when the patient was in the local emergency room and does not want to duplicate the testing Provider staff can send a cancel request to the laboratory, but cannot cancel the order in the EHR. Laboratory staff will determine per the laboratory’s policy on whether the test and associated charges can be cancelled at this point. Scenario continued: After the specimen has been sent to the laboratory, the physician recognizes a CBC with diff was done earlier that day when the patient was in the local emergency room and does not want to duplicate the testing Provider staff can send a cancel request to the laboratory, but cannot cancel the order in the EHR. Laboratory staff will determine per the laboratory’s policy on whether the test and associated charges can be cancelled at this point. Scenario continued: Testing personnel in the laboratory recognize the specimen was collected in the wrong tube and reject it after the sample status is updated to receive in the LIS. Laboratory staff can cancel the order in the LIS, which in turn cancels the order in the EHR. The physician is notified of the cancellation, the reason, and of any guidance the laboratory may provide. Scenario continued: During testing, testing personnel in the laboratory recognize the specimen is clotted. Laboratory staff can cancel the order in the LIS, which in turn cancels the order in the EHR. The physician is notified of the cancellation, the reason, and of any guidance the laboratory may provide. Scenario continued: After the hemogram portion of the CBC is reported in the LIS and testing personnel reads the manual differential, testing personnel recognize the specimen is clotted. Laboratory staff can cancel the order in the LIS, which in turn cancels the order in the EHR. The physician is notified of the cancellation, the reason, and of any guidance the laboratory may provide. 6 Test report transmitted to provider EHR Scenario: Pediatrician orders a CBC on a 3 year old boy. The blood specimen was collected (by either the provider or the laboratory), received at the laboratory, and testing initiated. Scenario continued: After the specimen has been sent to the laboratory, the physician recognizes the CBC was sent to a laboratory not covered by the patient’s insurance. The physician asks if the lab can cancel the test and send the blood specimen to the correct laboratory. Provider staff can send a cancel request to the laboratory, but cannot cancel the order in the EHR. Laboratory staff will determine per the laboratory’s policy on whether the test and associated charges can be cancelled at this point. Scenario continued: Testing personnel in the laboratory recognize the results of testing were not correct due to a processing identification error. Laboratory staff can cancel the order in the LIS, which in turn cancels the order in the EHR. The physician is notified of the cancellation, the reason, and of any guidance the laboratory may provide.