Like many complex healthcare systems, BIDMC does not have a one size fits all solution for ambulatory records. Although we favor integrated systems, we need to achieve interoperability via interfaces between two EHRs - a home built web-based product called webOMR and a commercial hosted version of eClinicalWorks.
Prioritizing our interoperability efforts to improve clinician workflow, enhance the quality of care delivered, and adhere to multiple federal and state initiatives requires extensive planning with many stakeholders. Here is our vision:
In January of 2010, the Federal Notice of Proposed Rulemaking on Meaningful Use will outline the data exchanges we must perform and the timeline to perform them. The 2011 exchanges are anticipated to be
Lab results delivery (true integration)
Claims and eligibility checking
Quality & immunization reporting
Registry reporting and reporting to public health
Health summaries for continuity of care
Here's our plan.
webOMR is an integrated system which is perfect for clinicians who order all their laboratories and radiology tests from BIDMC. It is not ideal for community clinicians with limited BIDMC interactions. For BIDMC-centric practices, lab results are already truly integrated with BIDMC lab. e-Prescribing is already live. Claims/eligibility/administration transactions are already live. We have begun a $500,000 Quality Registry reporting project, and have committed to a Boston Public Health Commission Public Health Reporting project. We will implement immunization registry reporting once a public entity is able to receive such data. We have already integrated webOMR into our tethered PHR (Patientsite), Google Health, and Microsoft Healthvault. We have already built outbound BIDMC discharge worksheets into eCW. We have already made webOMR data viewable inside eCW via the Magic Button pop up viewer. What remains to be done is that currently webOMR has no way to view eCW patient summaries.
eCW is a commercial EHR which is perfect for community clinicians who need to interact with non-BIDMC hospitals. eCW has already been integrated with Quest and soon with Needham. It is capable of receiving other lab feeds such as Milton or Caritas, as soon as those organizations provide outbound interfaces. e-Prescribing is already live. Claims/eligibility/administration transactions are already live. We have begun a $500,000 Quality Registry reporting project. We will implement immunization registry reporting once a public entity is able to receive such data. eCW has a patient portal that will go live in Spring 2010. We have already enabled eCW to receive clinical summaries from outside EHRs. What remains to be done? There is not a current timeline to interface eCW to public health reporting, but this must be done by 2011 if the public health entity is able to receive such data. There is not a current timeline to send clinical summaries between eCW and webOMR, but this also must be done by 2011.
Our next planning priority is to work with stakeholders to define the workflow and process needed to exchange eCW clinical summaries with webOMR. We will then meet with eCW to determine how to achieve this technically.
Thus, as you can see, we achieved a degree of interoperability that meets meaningful use criteria. We commit to have a plan and timeline in place for eCW to webOMR clinician summary transmission to complete our interoperability efforts. Will it meet all clinician needs? Many of them. Will it meet all their expectations? Probably not. We are still years away from being able to exchange the entire medical record between systems in the same way we can transport our cell phone numbers between carriers. It will be a journey. We'll start with the meaningful use transactions. We'll move from unstructured to vocabulary controlled structured data elements. True "end to end" point of origin to point of use interoperability across different EHRs will take years. I will do my best to educate our clinicians and move us forward continuously toward the nirvana of complete interoperability they seek.
Is or will the home health care department be part of the systems integrated EHR? Pat K.
Recently, in the HIT Buzz blog, and now in yours, there have been "hints" that some of the expected December regulations may not come out in December. Why is that? For example, you said "In January of 2010, the Federal Notice of Proposed Rulemaking on Meaningful Use will outline the data exchanges we must perform and the timeline to perform them." I thought ONC and CMS were required by ARRA law to release the draft of these rules by 12/31? Is there a reason why you said January, not December? The later it is, the less time the industry has to ensure that products meet the requirements (unless the whole calendar for MU years slides back).
Why are the clinical summaries something that can be left for a year or more? I was under the assumption that this would be a key element to achieving interoperability. Am I wrong to believe that the ability/necessity to share clinical summaries across providers is the strongest method to eliminating much of the waste in our health care system?
I am of the belief that the exchange of this data, from provider to provider is key to reducing waste, both in terms of duplicate tests, but also in physician time recreating histories and records that already exist.
Is that too pie in the sky?
Thanks again for the wonderful blog and your insights into the industry and your personal experiences.
In the end, have you not just optimized each of the two disparate EHR systems, but have yet to interweave them in a meaningful manner that permits the transmission of information?
Also, John, why did you list "populate PHRs" as an expected 2011 MU exchange? That isn't listed in the HIT Policy Committee's matrix until 2013 ("Access for all
patients to PHR populated in real
time with health data") whereas 2011 only mentions patient "electronic access to their health information" and "provide patient with electronic copy" -- both of which can be done through a PHR but also by other methods (portal, media, e-mail, etc.).
But regardless, thank you for sharing your real-world experiences at BIDMC. Very helpful!
Your efforts to meet the proposed 2011 regulations on meaningful use for two EHRs are appropriate for the current definition. I am curious about your thoughts on the loss of real time, bidirectional communication between providers now separated by the two EHRs. Pushing "clinical summaries" from one EHR to the other does not replace the ability to review the actual notes and tests performed by the referring provider. As a PCP , I write my progress notes with the intention of conveying meaningful information to another doctor -designed to assist the emergency room doc, hospitalist, specialist, or covering doctor. Access to a clinical summary rarely gives enough information to do a proper "hand off".
Will your current plan promote true "clinical integration", not just what the government defines it to be but what is necessary for patient safety, better quality, and reduced duplication/waste?
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