Monday, December 22, 2008

Next Steps for Interoperability

There are some folks in Washington who have made statements that we should delay investments in EHRs because current vendor products lack the functionality needed to support a coordinated healthcare system. Others have said that we lack the standards or security framework to implement interoperability. Here are my thoughts.

Take a look at the successes in Massachusetts and New York with commercial EHR products. We've implemented eClinicalWorks, which includes decision support, e-prescribing, administrative transactions with payers, clinical summary sharing across the community, and quality measurement (all the National Quality Forum high priority measures). It's web-based, using a service oriented architecture in a cloud computing environment. By implementing this product at BIDMC, we're meeting all the payer guidelines for delivering appropriate, coordinated, high value care. Vendor products from Epic, Allscripts, NextGen, GE, Meditech, eMDs, MedSphere, and other CCHIT certified vendors have similar features.

Should we wait for something better that has more interoperability?

Do you drive a car? Why? It pollutes, costs a lot, and generally is not very efficient in traffic. You'd be much better off asking Scotty to beam you up via the transporter. Should we eliminate all cars, planes and trains until the transporter is invented? The same can be said of EHRs and health information exchange. My definition of good enough includes:

*Support for medication interoperability such as e-prescribing linking providers, payers, and pharmacies
*Support for laboratory and radiology interoperability such as orders and results integration among providers, hospitals and commercial labs
*Support for seamless electronic interchange between providers and payers for administrative data flows.

In 2009, several EHR vendors will support clinical summary exchange.

We can achieve a substantial improvement in care quality and coordination by implementing the systems available now and not waiting. If anyone thinks writing a next generation interoperable EHR from scratch is a good idea, have them look at the UK implementation of the NPFit/Connecting for Health project. They hired numerous companies to implement an new scheduling/booking system, a nationwide PACS system and a coordinated health record. After spending billions, they have limited success and low provider satisfaction.

On December 18, HITSP completed all the national standards harmonization work for 2008. This included:

*Biosurveillance Interoperability Specification (IS02)
*Consumer Empowerment and Access to Clinical Information via Networks Interoperability Specification (IS03)
*Emergency Responder Electronic Health Record Interoperability Specification (IS04)
*Consumer Empowerment and Access to Clinical Information via Media Interoperability Specification (IS05)
*Personalized Healthcare Interoperability Specification (IS08)
*Consultations and Transfers of Care Interoperability Specification (IS09)
*Immunizations and Response Management Interoperability Specification (IS10)
*Public Health Case Reporting Interoperability Specification (IS11)
*Patient-Provider Secure Messaging Interoperability Specification (IS12)
*Remote Monitoring Interoperability Specification (IS77)

The documents are accessible through

This latest round of work means that we've completed the three year AHIC roadmap for standards. There are no unapproved standards at this point!

Of course standards will evolve and we'll keep enhancing this work, including lessons learned from implementation in vendor products. In 2009, we'll be given a new body of work including Newborn screening, and filling several small gaps required to support clinical workflows.

Thus, if we have products that are good enough and interoperability standards, what are we lacking? Some say security.

HITSP completed security standards harmonization in 2007.

The 2008 CCHIT criteria for security are rigorous. Vendors have described them to me as one of the most challenging aspects of certification.

Although there is still local/state variation in policies, we do have a national framework for EHR and PHR data exchange.

Some say that they have personal experiences with lack of coordinated care among multiple providers. Is that an issue with EHRs and standards? My view is that this is a process and policy issue. In the US we do not have a healthcare system, we have numerous providers, labs, pharmacies, and hospitals which do not constituent a single medical home for the patient.

Let's implement EHRs now and realize their benefits. Let's implement the interoperability for administrative transactions, labs/rads, and e-Prescribing that is robust today. Then let's implement the clinical summary exchange that's coming soon. It's a journey and we should start immediately. There is no reason to wait.


Unknown said...

love your enthusiasm! you have made some great points and I wholeheartedly agree with embracing technology now. If only physician practices would see the same benefits that you outline here.

health IT girl

Deborah said...

Excellent Points! If we wait for everything to be "perfect" we will never arrive at our destination.

The only way to "get it right" is to experiment and iterate until the bugs are out and the features implemented appropriately...(opinion based on my knowledge and experience in technology innovation).

It is the essence of issues related to "Wicked Problems" and decision-making. The "DIPs", decisions-in-progress will always prevent progress.

Billy said...

The premise of the first sentence, that a coordinated healthcare system is the reason to invest in EHR, is enough to debunk the logic of not investing in EHR. You do a good job of making the case that there are many existing reasons to invest regardless. I'm curious if the evolution of these standards and tools might facilitate another solution to the problem that hasn't been considered yet?

EMR investment like any technology should be built on a solid business case/foundation regardless of how well it complies with standards.

What will be interesting to watch is how those standards help support, in measurable terms, the business cases for investment, both for vendors and providers.

Phil Rosen said...

Right on, John, as usual! All ambulatory care providers need to implement EHRs now!! The main issue is funding and know-how. To address this, the Federal Government, the payers, and the private sector need to collaborate to make this happen for the small physician practices by providing the funding and know-how. This is fundamental and the foundation which needs to be built to achieve interoperability. Have a most outstanding 2009!
Best regards, Phil

Alex said...

With respect to all involved, PARTICULARLY to our host.

The commercial products referenced are all CCHIT certified EMRs and I work with CCHIT certified products all the time ONLY to realize they are nearly IMPOSSIBLE to integrate. CCHIT is a marketing joke and let's not mince words about it.

EMRs were NEVER designed to provide the population-based metrics and guideline-driven point-of-care decision support our physicians need in an ever more transparent environment, yet the only acronym CIOs/analysts/reporters know is "EMR" and expect the vendors to morph themselves into the latest desired incarnation.

It is one thing for a hospital with tens of MILLIONS of dollars and legions of nurses/residents/Attendings to put information into the system, but for normal/regular doctors in the community receiving less and less money for the quality they provide, your idea of a digital environment is ridiculous. They LITERALLY can't afford it, and merely trying to extend your EMRs into the community is silly as well because why should ANY doctor want to make themselves beholden to a hospital's (or plan's) IT systems?

We need to keep this discussion of interoperability real. Physicians at ALL levels need HIT tools that are SIMPLE, EFFECTIVE, AFFORDABLE and enable them to share appropriate clinical data about their patients with other selected providers in a secure way. Those systems should also SERVE THE DOCTOR in providing new means of revenue generation without significant administrative overhead.

Anything else is just noise. My fiancée is a cardio at a MAJOR health system with SIGNIFICANT money to put towards HIT and they do. She still has to log-on to four different systems JUST to find the clinical data she needs to address ONE patient's concerns. How is THAT lowering costs, making better care easier and less costly?

Let's keep this conversation real and focus less on the technology and more on the desired result.