Electronic Test Orders and Results (ETOR)

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1 Electronic Test Orders and Results (ETOR) Portal for Antibiotic Resistance (AR) Lab Network Problem Statement Antibiotic-resistant (AR) bacteria germs that don t respond to the drugs developed to kill them threaten to return us to the time when simple infections were often fatal. Today, antibiotic-resistant bacteria annually cause at least 2 million illnesses and 23,000 deaths in the United States. 1 Combating AR bacteria requires early detection of new resistance and robust prevention efforts, including early outbreak detection and response. Creating regional capacity to detect AR bacteria and Candida will improve the ability to implement timely local prevention efforts and to develop national strategies that limit transmission of resistant pathogens and preventing infections. Some AR threats, like carbapenemresistant Enterobacteriaceae (CRE), are resistant to nearly all possible therapeutic agents and require enhanced detection and infection control measures to prevent the spread of infections. For other pathogens, like resistant Neisseria gonorrhoeae and Candida species, detection of resistance is challenging because antimicrobial susceptibility testing is not routinely performed in hospital or other laboratories. In these cases, resistance data are needed to identify outbreaks, prevention measures, and to develop treatment guidelines. 2 Public health laboratories (PHLs) face an increasing challenge to provide timely access to results on emergent diseases, particularly during an outbreak. Data are needed Figure 1 How Antibiotic Resistance Spreads by multiple decision-makers, including public health agency and lab staff, epidemiologists, and healthcare providers. PHLs must accommodate multiple

2 modes of test order transmissions, including paper, faxes, and orders through web portals, or direct HL7 messaging with EMRs. Clinical providers and public health staff need an efficient way to submit test orders, receive status updates, and view results. Current tools frequently lack the flexibility to dynamically capture epidemiologically-significant questions when a specimen is submitted for testing (known as Ask at Order Entry questions), or the information collected is often after-the-fact and cannot help with testing prioritization. Lastly, state epidemiologists need an efficient way to coordinate public health responses and capture needed data to provide testing prioritization based on submitter information and national disease case definitions. About the AR Lab Network Detecting, preventing and controlling antibiotic resistance requires coordinated efforts. Laboratory tests can help guide patient treatment, detect emerging threats, and prevent the spread of antibiotic resistance. Established in 2016, CDC s AR Lab Network (ARLN) supports nationwide lab capacity to rapidly detect antibiotic resistance in healthcare, food, and the community, and inform local responses to prevent spread and protect people. The AR Lab Network includes labs in 50 states, five cities, and Puerto Rico, including seven regional labs and the National Tuberculosis Molecular Surveillance Center (National TB Center). As a whole, the network tracks changes in resistance and helps identify and respond to outbreaks faster. More specifically, CDC s AR Lab Network closes the gap between local capabilities and the data needed to combat AR by providing comprehensive lab capacity and infrastructure for AR pathogens, cutting-edge technology, like DNA sequencing, in every state, and data to drive AR response and prevent infections. This infrastructure allows the public health community to rapidly detect emerging AR threats, sound the alarm for a comprehensive local response, and better understand these deadly threats so we can contain them quickly. 3 2

3 Figure 2 AR Lab Network 4 AR Lab Network Partnership with APHL In 2016, as part of CDC Epidemiology and Laboratory Capacity for Infectious Diseases (ELC) grant regional labs were tasked with (among other things) developing reporting process and IT infrastructure for timely reporting to facilities, state or local public health laboratories, epidemiologists, regional AR prevention partners, and CDC. Given the grave public health threat posed by the spread of AR bacteria like Carbapenem-Resistant Enterobacteriaceae (CRE), the testing had to be timely with results reporting back to submitting facility, HAI coordinator, and the state public health lab within 48 hours or less. The Association of Public Health Laboratories (APHL) was funded by CDC to offer technical assistance to the ARLN regional laboratories to help meet the demanding grant guidelines and expectations for timely data reporting. One of the key elements was the development of infrastructure needed to support standardized data transmission from the ARLN to CDC programs via the ARLN reporting portal and the deployment of an electronic test order and result (ETOR) portal to support the daily testing and reporting needs at the regional labs. 3

4 ETOR Portal Solution Figure 3 IT Infrastructure and ETOR Portal Solution After careful examination, the APHL Informatics committee selected iconnect Lab Web Portal (LWP) as the ETOR solution to support CRE colonization test orders to ARLN regional labs and results back to referring public health laboratory, originating public health jurisdiction and the originating healthcare provider. iconnect LWP is a secure web-based platform offering laboratory customers an intuitive, efficient and paperless interface to order tests, track progress and review results. LWP is hosted on APHL Informatics Messaging Service Platform (AIMS), a secure cloud-based computing environment used by 142 private and public trading partners with over 1 million messages transacted per month. Five of seven regional ARLN labs have chosen to implement LWP as their ETOR solution. APHL technical assistance team has worked with iconnect Consulting and AIMS specialists to: develop an HL Laboratory Orders Interface (LOI) and Laboratory Results Interface (LRI) message specification for regional ARLN labs to exchange data with the LWP. support negotiation of data elements for each regional ARLN lab with input from iconnect, CDC Program epidemiologists for CRE Colonization, and each lab itself. provide Technical Assistance for ETOR efforts to assist Regional PHLs with mapping, ingesting LOI message, and creating LRI message. collect and implement ETOR portal requirements for each regional lab. help onboard each regional ARLN lab and its region onto the ETOR LWP solution. As of August 1 st, 2018 three regional ARLN laboratories are live with LWP: Wisconsin, Maryland and Texas, and two more (Tennessee and Washington) will be in production soon. In addition to supporting the daily CRE testing and reporting needs at the regional ARLN labs, LWP also provides the following valuable features: Configuration via admin tools: Dashboards, Test Requisition Forms (TRFs), data grids and events, announcements, tiles, notifications, LIMS & 3 rd party interfaces, charting, user management 4

5 Intuitive User Experience: o Modern clean interface with mobile support o Integrated dashboard with key metrics and dynamic alerts o Configurable Test Requisition Form (TRF) with smart error handling o Asked-At-Order (AOE) questions o Robust querying engine to retrieve lab results/reports o Business intelligence tools Prebuilt Interfaces (DocuSign, Ellkay Bridge, CRM) Single Sign On (SSO) and LDAP support to integrate with state-wide security network High performance and responsiveness Figure 4 iconnect Lab Web Portal for Texas AR Laboratory On July 1 st, 2018 Phase II of APHL ARLN project was approved to expand existing functionality and onboard additional AR pathogens. Specific enhancements include: 1. LIMSConnect a. Smart synchronization platform that provides near-real time interface with lab s LIMS b. Replaces labor-intensive HL7 LOI and LRI interfaces c. Access to ALL LIMS data, not just what's been submitted through the portal 2. Expand epidemiologists capabilities by adding an HAI role to: a. Review and prioritize testing with lab staff b. Authorize test orders c. Coordinate communication across stakeholders 3. Enhancing LWP features to meet changing AR needs a. Batch upload of orders to accommodate high-volume submissions 5

6 b. Collect ongoing input from users to identify new needs and beneficial enhancements 4. Scaling to new AR threats beyond CRE Colonization like Neisseria gonorrhoeae and Candida species In addition, Lab Web Portal has also been approved for the following public health initiatives creating additional synergies with ongoing ARLN implementation: a. TB Drug Susceptibility National Reference Center (California Department of Public Health) o PHL to PHL coordination b. HHS Office of the National Coordinator ETOR initiative o Expand use of LWP to support Lab/Epi Coordination o Expand use of LWP to support emerging infectious disease use case Conclusion To be impactful, laboratory data needs to get into the right hands quickly to improve outcomes. Informatics tools must be adopted to support both disease and environmental surveillance and to streamline laboratory reporting needs. By facilitating electronic and timely test ordering and resulting of AR pathogens between submitters, local public health laboratories, epidemiologists, and ARLN regional labs - iconnect Lab Web Portal strengthens public health capacity to rapidly detect emerging AR threats and trigger comprehensive local and national response. References 1 About Antimicrobial Resistance. (n.d.). Retrieved from 2 Epidemiology and Laboratory Capacity for Infectious Diseases (ELC). (n.d.). Retrieved from 3 Antibiotic Resistance (AR) Lab Network. (n.d.). Retrieved from 4 About CDC s Antibiotic Resistance Lab Network. (n.d.). Retrieved from 6

7 About iconnect Consulting iconnect leverages over 40 years of combined laboratory, systems development, and customer service experience to provide software business solutions and services to laboratories in the public and private sectors. For more information on Lab Web Portal please reach us at or About Association of Public Health Laboratories (APHL) APHL is a national non-profit dedicate to working with members to strengthen laboratories with a public health mandate. By promoting effective programs and public policy, APHL strives to provide public health laboratories with the resources and infrastructure needed to protect the health of US residents and to prevent and control disease globally. For more information on ETOR please reach Michelle Meigs at or michelle.meigs@aphl.org iconnect Consulting

8 For more information, please call or visit iconnectconsulting.com iconnect Consulting. All rights reserved.

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