By Morris W. Stemp, CPA, MBA, CPHIMS, June 01, 2012
Interoperability is widely considered the Holy Grail of electronic health records elusive but worth seeking. Why do we need it? According to the Commission on System Interoperability, part of the Department of Health and Human Services, “Americans need a connected system of electronic health care information available to all doctors and patients whenever and wherever necessary. The lack of immediate access to patient health care information is the source of one-fifth of preventable medical errors. And one out of every seven primary care visits is affected by missing medical information.”
Achieving nationwide participation and compliance with the full measure of interoperability will cost billions of dollars. There has to be some huge payback to warrant this expenditure. The New York State Department of Health summarizes the key benefits of interoperability in its justification for investing hundreds of millions to build a technical infrastructure to support statewide interoperability: “Interoperability enables patient health information to be exchanged in real time among disparate clinicians, other authorized entities, and patients, while ensuring security, privacy, and other protections. Interoperability is necessary for compiling the complete experience of a patient’s care and ensuring it is accessible to clinicians as the patient moves through various health care settings. This will support clinicians in making fact-based decisions that will reduce medical errors, reduce redundant tests, and improve care coordination. Interoperability is critical to cost-effective, timely, and standardized data aggregation and reporting for quality measurement, population health improvement, bio-surveillance, and clinical research. Interoperability is also needed to facilitate convenient access by patients to their own personal health information, enabling this information to be portable rather than tethered to a particular payer or provider.”[pagebreak]
A futuristic scenario
Imagine: A patient walks into the office of his primary care provider. The front desk receptionist greets the patient and scans his iris for instant identification which automatically loads the patient’s medical record within the doctor’s EHR system. During the medical exam, the doctor identifies an unusual, crusty patch of skin and refers the patient to the dermatology clinic associated with the community hospital with a recommendation that the patient proceed immediately to the clinic.
Upon arrival at the clinic, the clinic receptionist scans the patient’s iris. Since this is the first time the patient is being seen at this clinic, the clinic has no existing medical record within its EHR system. Using the patient’s last name, date of birth, and Social Security number, the receptionist downloads the patient’s full demographics and clinical history and within seconds, a full medical record chart is automatically created within the clinic’s EHR system. The dermatologist examines the patient and takes a culture of the crusty patch of skin. She places it in a culture tube with a bar-coded label, scans the label into her EHR system, and sends the culture to the hospital’s lab. The patient is told the results will be available by the next day.
At the lab, technicians scan the bar code and begin their analysis, which reveals a severe case of MRSA (methicillin-resistant staphylococcus aureus), a rare, potentially fatal, infectious skin condition. The Centers for Disease Control and Prevention (CDC) is alerted when the LIS (Lab Information System) used by the hospital automatically transmits the results of the laboratory analysis along with the patient information to the CDC’s national public health management and surveillance system. The patient’s medical records at both the clinic and the primary care doctor are also automatically updated with the results of the tests.
After work, the patient returns home to find an encrypted email message in his Gmail account from his primary care provider. He opens the Gmail message, which directs him to connect to a secure website to read a communication from his doctor. The patient loads the website; it connects to his secure patient portal, where he can view the exam notes written by his primary care doc and the dermatology specialist, as well as his lab results.[pagebreak]
Interoperability: a working definition
I think the scenario envisioned above, while a few years away from real-life implementation, is a realistic example encompassing all the elements and nuances behind the definition of interoperability outlined in 2005 by the Health Information Management Systems Society (HIMSS): “the ability of two or more systems or their components to exchange information and to use the information that has been exchanged,” and, “the ability of health information systems to work together within and across organizational boundaries in order to advance the effective delivery of health care for individuals and communities.”
It is important to note that interoperability goes beyond just sharing medical records back and forth between provider and provider or provider and hospital. Interoperability also encompasses the ability to integrate electronic diagnostic equipment with a patient’s medical record. For example, patient clinical values required to initiate a diagnostic procedure should be downloaded directly from the patient’s medical record into the diagnostic device and the results of the diagnosis automatically uploaded to the patient’s record.
Interoperability: the ultimate goal of meaningful use
At its core, the meaningful use initiative of the federal government is designed to improve patient care and safety while lowering the overall costs of providing health care. The full impact of meaningful use was intended to be achieved in three stages through increasing use of EHR systems and electronic health information exchange.
The key requirement of Stage 1 of meaningful use is the implementation of a certified electronic health record system. Without capturing a medical record in electronic format, there is no way to share data with other entities, enhance organizational efficiency, or improve patient safety and health outcomes through more complete and legible records and decision-support systems.
Stage 2, with its implementation date recently extended from 2013 to 2014, focuses on increasing the capture of even more clinical information in structured data fields and enhancing the scope of electronic sharing of clinical data as follows:
- Adds additional quality and reporting measures and widens the scope of existing measures.
- Requires use of a data transport system, The Direct Project, to transmit health information, providing “a simple, secure, scalable, standards-based way for participants to send authenticated, encrypted health information directly to known, trusted recipients over the Internet.”
- While Stage 1 required providers to “provide patients with an electronic copy of their health information,” Stage 2 requires a more robust form of patient access through technology to “view online, download, or transmit.”
- Requires specialists to electronically report cancer and other diseases to a state cancer or specialized registry.
- Requires that eligible providers and hospitals transmit their clinical quality measures electronically.
It is clear that Stage 3, as yet undefined, will require even greater electronic sharing of information between providers, hospitals, and public health registries.
Note that Stage 2 requirements are not final as of the date of this analysis, so all requirements listed above should be considered subject to final revision.[pagebreak]
How does it work?
In order to achieve any level of interoperability, there must be a defined set of standards by which the sender and receiver communicate. Luckily, we need not study or understand the technical details of any of these standards. The idea behind the use of a certified EHR is that the EHR system will deal with compliance and adherence to all the required standards. Thus, it is the EHR software vendors who must incorporate these interoperability standards into their software so that one EHR can talk to another or transmit data to a government registry or health information exchange.
If you do want to understand what is involved in sharing data between different computer systems, you need to know the three standards of communication that must be in place: transport, structure, and vocabulary. Dozens of standards have been introduced regarding the structure and format of health information data needed to achieve interoperability. But the following three standards seem to have the greatest momentum at this time, primarily due to their inclusion as requirements in Stage 2. 1. Transport how will data be sent and received? The Direct Project, discussed above, provides these standards. 2. Structure and format of the data. The Continuity of Care Document (CCD), a format published by the Health Level Seven organization (HL7), seems to be the standard which will prevail. 3. Agreement on the specific vocabulary being communicated. In this case, SNOMED-CT (Systematized Nomenclature of Medicine-Clinical Terms) has become the standard. According to the International Health Terminology Standards Development Organization (IHTSDO), SNOMED is a “comprehensive clinical terminology that provides clinical content and expressivity for clinical documentation and reporting” with the “objective of precisely representing clinical information across the scope of health care.”[pagebreak]
The future is coming
The futuristic scenario described earlier is not that far off. Biometric technology to identify patients is already in use. Some level of physician-to-specialist and physician-to-hospital sharing is in place. Discrete data from labs is uploaded into discrete fields in EHR systems regularly and some diagnostic equipment interfaces are configured to upload discrete data as well. In addition, many practices already provide patients access to their medical records via patient portals.
Interoperability is indeed happening now, and its widespread adoption is sure to grow as meaningful use Stage 2 and Stage 3 force the issue. (See online-only bonus sidebar at www.aad.org/dw for a description of the progress being made toward achieving interoperability in New York and a look at whether interoperability can reduce health care costs.) While data sharing is the goal, I question what will happen when a specialist says “I relied on clinical data I downloaded from the health information exchange in treating my patient” if this data proves to be inaccurate and the specialist treats the patient without verifying the data. With meaningful use stage 2 and stage 3 undefined and with questions unanswered, achieving full interoperability may still be five to 10 years away; implementing EHR systems and agreeing upon interoperability standards for data sharing are just the first steps toward realizing the full potential of interoperability.
Interoperability: Where are we in 2012?
The kind of data sharing and interoperability described in the main article is actually currently taking place every day in 2012 using both existing standards and proprietary methods. However, considering the huge patient population in this country — basically everyone living in the United States — the actual numbers of shared transactions is extremely small. The goal of stage 2 of meaningful use, and eventually of stage 3, is to force adoption of electronic exchange of health information as the only acceptable method for sharing data.
The vision for nationwide sharing and availability of health information promulgated by the Office of the National Coordinator (ONC) is for a tiered structure of federal, state, and local Regional Health Information Organizations (RHIOs) and Heath Information Exchanges (HIEs). In New York, for example, there are 11 active RHIOs covering most of the major metropolitan areas throughout the state. The RHIO covering New York City (NYCLIX) just merged with the RHIO covering Long Island (LIPIX) to form HealthIX, which currently links more than 100 facilities covering more than seven million individual patient records. Considering the technical investment required to create and maintain a RHIO, more consolidations are anticipated. According to NYCLIX, the medical records for almost 20 percent of emergency room visits during a period of time under study were available by a hospital securely connecting to NYCLIX’s database of shared medical information. This means immediate availability of patient medical history at the critical time of emergency admission.
The 11 New York state RHIOs will be linked together in a statewide network called the Statewide Health Information Network for New York (SHIN-NY) which, according to SHIN-NY, “will allow patients and health care providers to have immediate access to histories, prescriptions, test results, medical analysis and diagnoses, and much more, anywhere in the state at any time.” While the New York RHIOs are in full operation and constantly seeking new provider organizations to upload their patient data (with patient consent), statewide coordination is still a few years away. Eventually, all the statewide HIEs (along with other major health care delivery systems, federal agencies, and other entities) will be linked into a national clearinghouse called the Nationwide Health Information Network (NwHIN).
EHR vendors are also working toward interoperability by making their software connect with established HIEs. Several vendors have started to advertise the interoperability features of their products, including toolkits to help achieve it, the ability to connect to established HIEs, and the ability to share clinical information with online registries, health information exchanges, and hospitals.
While RHIOs are conceived as regional organizations designed to communicate within a statewide network, there is a group of several states and EHR and HIE software vendors currently working to eliminate barriers to sharing health information across states. The EHR/HIE Interoperability Workgroup, originally formed by the New York eHealth Collaborative (NYeC), brought together seven states (California, Colorado, Maryland, Massachusetts, New Jersey, New York, and Oregon), representing approximately 30 percent of the country’s population with representatives of eight major EHR software vendors and three HIE software vendors. The multi-state multi-vendor initiative has since grown to 10 states and 26 vendors.
The goal of the EHR/HIE Interoperability Workgroup is to create an integrated system of EHR capabilities in which the interfaces between EHRs and HIEs are consistent across multiple states, thus facilitating the sharing and easy accessibility of healthcare data across state boarders and EHR systems. As someone who lives in NYC and enjoys skiing out west, I think it would be wonderful if, in the event of a skiing accident, my medical records from New York could be immediately available in an emergency room in Colorado.
Will it reduce health care costs?
While much of the focus of interoperability is on sharing of data to achieve better patient care, a recent personal experience suggests to me that interoperability alone will not be enough to reduce health care costs without substantial litigation reform.
I am about to undergo a surgery to repair my deviated septum and, in preparation for this surgery, the ambulatory clinic associated with the major hospital system in my neighborhood required me to undergo pre-surgical testing including a full check-up and EKG. I was examined by a PA and given full clearance. Of course, the PA had none of my records so I answered the same pre-examination questions I’ve answered hundreds of times before in my adult life and the PA and I spent 15 minutes going through my full history. Would all the time spent filling out forms and answering questions have been necessary if the clinic had already adopted the hospital’s EHR system and my primary care physician used an EHR? With interoperability in place and all parties signed up, possibly not.
But this examination by the PA was not sufficient. The clinic, for whatever reason, apparently required my personal doctor, according to an official notice he showed me, to “provide his independent judgment” as to my fitness for the surgery. During my visit with my GP, he once again, repeated the full check-up exactly as performed by the PA except for the EKG. I am totally confused. If the PA’s exam was not sufficient since she was not an MD, or for some other reason, then I should have just been examined by my GP who could have performed all the tests. It is not clear to me that any level of interoperability could prevent what seems to me to be an obvious duplication of effort and costs.
My experience demonstrates that achieving a reduction in costs through the elimination of duplicate testing that can be achieved through the sharing of data will require a level of cooperation beyond that needed to agree upon interoperability standards.