The debate over the future of meaningful use seems to have found its bellwether issue: interoperability. For the uninitiated, this is the concept of sharing patient information across systems with the promise of improving the ease and quality of care. As you might expect, it is full of challenges, not the least of which is standardization. Competing vendors of electronic health record (EHR) software and technological hurdles have made the goal of true interoperability quite elusive, and there is no clear path to victory. Meaningful use and other incentive programs have set requirements for widespread rapid adoption of data sharing. Unfortunately, instead of encouraging innovation, they seem only to have created more stumbling blocks for physicians. Now providers are facing penalties for noncompliance, and national physician advocacy groups are taking notice.
On Oct. 15 of this year, a letter from key stakeholders including the American Medical Association (AMA), American Academy of Family Physicians (AAFP), and Medical Group Management Association (MGMA) to the Department of Health and Human Services laid out a “blueprint” for revamping the meaningful use program. The center point of this communication was a call for more emphasis on interoperability, as well as flexibility for both vendors and physicians. We tend to agree with these ideas, but wonder on a global scale what this interoperability should look like. In this column, we’ll address the essential pieces to making this a reality, and how physicians and patients can benefit from enhanced information exchange.
Information should be standardized
One of the fundamental challenges standing in the way of true interoperability is standardization: allowing data to be shared and viewed anywhere, independent of hardware or software. This is an idea that has allowed the World Wide Web to flourish; websites are readable by any computer or mobile device, using any operating system or browser. As of now, very little standardization exists in the world of medical data, in part because EHRs have been developed and promoted by private corporations, all competing for market share.
This evolution is quite unlike the history of the Internet, which was developed by government and educational institutions, with the express intent of connecting disparate computer systems. EHRs have essentially been developed in isolation, with much more emphasis placed on keeping information private than on making it shareable. Now meaningful use is forcing vendors to share data across systems, and – not surprisingly – each vendor is attempting to create their own method of doing so.
Some argue that EHR companies would prefer not to share, as this might threaten their hold on the market. In fact, Epic Health Systems, the world’s largest EHR vendor, has recently faced accusations of limiting interoperability to encourage physicians to use its software exclusively. Epic has fired back with statistics pointing to its accomplishments in data exchange. Both sides clearly disagree on what true interoperability should look like. This underscores a critical point: The concept of interoperability and what the standards should look like may mean different things to different parties.
One attempt at standardization that is commonly referenced is the continuity of care document (CCD), a key requirement for data exchange outlined in Stage 2 of meaningful use. This document, endorsed by the U.S. Healthcare Information Technology Standards Panel, has gained popularity as it can contain large amounts of data in one file. Unfortunately, it too is still limited and often isn’t user friendly at the point of care. It is in many ways merely a jumping-off point that will hopefully facilitate improved data accessibility and ease of sharing.
To improve usability and confidence in data exchange, many practices and health systems have joined together to create Regional Health Information Organizations and provide some governance structure to the process of data exchange. We strongly recommend getting involved in such an organization and engaging in the process of standardization. Regardless of your position on the usefulness or practicality of sharing patient records, a few notions are indisputable: Interoperability is coming, and point-of-care data availability – if accurate, secure, and useful – can ultimately usher in the promise of better patient care.
Information should be secure
In the process of seeking easier data exchange, we cannot lose sight of the importance of data security. Health care entities need to feel confident the information they are sending electronically will stay private until it reaches its ultimate destination. An attempt to address this issue led to the development of the “direct” encryption standard in 2010. Also known as Direct Exchange and Direct Secure Messaging, it specifies a secure method for the exchange of Protected Health Information. Providers can take advantage of the security offered through Direct by developing their own infrastructure or engaging the services of a Health Information Service Provider. These are private, HIPAA-compliant data exchange services that serve a health care community and facilitate direct messaging between health care settings. Ultimately, the goal is to create a robust Nationwide Health Information Network and achieve true widespread health information exchange. But before we actually achieve this, there is one more element essential to interoperability and improving patient care.
The information should be useful
In the preliminary stages of EHR interoperability, attempts at meaningful information exchange have led to only modest success. Outside of private health systems that have developed their own proprietary interfaces, data extraction and sharing between disparate electronic platforms have yet to have a meaningful impact on patient care. In part, this is because the information is not provided to clinicians in a useful format. Even the CCD described above is often confusing and replete with extraneous information – filtering through it during a patient encounter can be tedious and frustrating. Also, ensuring data integrity can be a real challenge, not only technically, but also practically. Questions occur regularly, such as “Did the data come through in the correct fields?” or “Did the medical resident remember to include all of the medications or allergies associated with the patient?” Ultimately, physicians need to decide whether or not to trust the information they receive before making it a permanent part of a patient’s health record.
Dr. Notte is a family physician and clinical informaticist for Abington (Pa.) Memorial Hospital. He is a partner in EHR Practice Consultants, a firm that aids physicians in adopting electronic health records. Dr. Skolnik is associate director of the family medicine residency program at Abington Memorial Hospital and professor of family and community medicine at Temple University in Philadelphia.
