Interoperability enables integrated health records, facilitating patient-centred care while leveraging legacy IT systems
Healthcare organisations today have at their disposal a wealth of information about the patients for whom they provide care. Yet they struggle with the challenge of ensuring these data are available to the appropriate caregiver at the most advantageous time. Too often, vital clinical information is segregated in silos within a provider organisation or health system. Radiology systems contain interpretations from imaging studies. Laboratory systems store results from tests and blood work. Electronic medical records (EMRs) archive medical history, documentation of past and present conditions, and care plans.
To be truly valuable, however, these datasets must be shared among all caregivers at the point of care. And therein lies the rub. Disparate health information systems are typically incapable of exchanging data in a useful, meaningful way.
The University of Pittsburgh Medical Center (UPMC) identified this challenge a number of years ago and initiated a variety of strategies to overcome the barriers between technology systems. None was successful, however, until the organisation began to deploy an interoperability platform that allows a secure flow of information among the various technologies utilised throughout the UPMC enterprise.
Unlocking the potential of patient data
A leading healthcare provider in the United States, UPMC has been an enthusiastic and judicious adopter of technology to support the delivery of superior care. Yet its leadership likewise recognised that the true key to unlocking the potential of patient data is to bring it all together in the physician's office, in the surgery centre, in the emergency department and at the bedside.
To this end, UPMC decided 12 years ago that it would utilise only one technology vendor to create a monolithic system throughout the organisation. It selected a partner that offered a wide variety of products – PACS, laboratory, radiology, pathology, ICU, EMR, and so on. The fully monolithic approach was not feasible, however, because no single solution met the diverse clinical needs throughout the organisation.
Subsequently, UPMC attempted to roll out an advanced ambulatory record system across the enterprise but encountered significant resistance because it, too, was incapable of providing the "best-of-breed" functionality required by each and every department.
Ultimately, neither approach accomplished the goal of ensuring information could be transferred from point A to point B, and all the way to point Z, as needed. Even with only a handful of systems (or applications within a single vendor's product line), sharing medical records proved virtually impossible because technology systems, for the most part, are ill-equipped to do so.
After conferring with consultants from the Carnegie Mellon University Software Engineering Institute, the leadership at UPMC decided to explore interoperability platforms that would serve as a bridge between existing data silos. This tactic would allow it to leverage the existing best-of-breed applications and software suites that were meeting the varying needs of individual departments and units. Advanced technology would allow these systems to come together to create a unified clinical framework that would be pervasive and patient-centred. In the end, it would produce a complete, longitudinal medical record that could be accessed securely by authorised providers at the point of care.
In February 2008, UPMC went live with its interoperability project. Based on serviceoriented architecture (SOA), the platform creates a collective medical record based on information from source systems that typically do not share architecture, technology or communication standards. This solution goes one step beyond basic interoperability and the provision of an integrated patient record by also providing "semantic interoperability".
This approach allows health information to be presented within a clinical context that is relevant to each caregiver. In other words, the technology not only allows two systems to share information, but also enables the receiving system to understand and make use of the incoming data while maintaining the original "meaning" of that data. Laboratories may report results for the same tests using different nomenclatures, for instance. Semantic interoperability enables the coalescence of these values, and delivers "intelligent" and highly usable information to data consumers, whether they are caregivers and/or analytic applications, tools or services.
Realising clinical and administrative benefits
As its use of the interoperability platform has expanded and matured, UPMC has realised benefits on both the clinical and administrative sides of the organisation.
Clinical care
Most significant have been improvements in patient care. For the first time, caregivers such as physicians, mid-level providers, nurses, ancillary staff and medical assistants are able to review an integrated medical record from across the continuum of care. Physicians in the hospital environment can view and use information gathered in other settings – for instance, perhaps discovering a co-morbidity that may affect the current course of treatment, or incorporating previous laboratory values to identify a trend leading to a definitive diagnosis. Access to this information undoubtedly enables better medical decision-making and the development of more effective care plans.
Consider this example. A patient found delirious by neighbours was brought to the emergency department in an unconscious state. No history could be located in the acute EMR system. The interoperability platform allowed UPMC staff to view the comprehensive patient record that included information documented in other clinical systems from remote sites. This access revealed the patient's chronic liver failure, as well as secondary issues that included hepatitis C. The emergency department physician quickly diagnosed a hepatic coma and prescribed medication to lower the patient's life-threatening ammonia level. In addition, the care team was made aware of the patient's bloodborne pathogen status.
Patient safety and risk
Availability of a current and complete medical record allows providers to identify safety issues and situations that might put the patient (and organisation) at risk. In the past, for instance, emergency physicians would need to rely on the patient's word regarding any medications they were taking. The UPMC interoperability platform delivers a complete list of the patient's medications and allergies to the physician's computer screen, thus virtually eliminating the possibility of drug interactions or adverse effects.
Less common insights might be revealed as well. While reviewing an interoperable patient record, a healthcare professional might see that a patient has certain risk factors for falls and can take the appropriate safety steps – protecting the patient from injury and the organisation from liability.
Not long ago, for example, an elderly gentleman visited his primary care physician with prostate issues. No latex allergy was noted in his primary care record. However, by reviewing the longitudinal record, the primary care physician discovered that an allergy to latex had been noted in an acute care environment in the past. If this had not been found, the routine examination of the prostate using standard latex gloves would have been uncomfortable at the very least – and may have even prompted a more severe reaction.
Workflow and efficiency
It has long been recognised that "efficiency" is a watchword rarely attached to healthcare delivery. A disproportionate amount of staff time is spent hunting for and gathering missing or misplaced information. In a pre-interoperability study at UPMC, for instance, the leadership discovered that 30% of its patients arrived in the preoperative area without the data necessary to move forward with the procedure. Through interoperability, however, all tests, reports and consent documents are available with the click of a mouse.
Several months ago, a patient was scheduled for a Monday morning cardiac catheterisation. Clinical and demographic information was needed from the patient's primary care physician by the end of business on the preceding Friday for the procedure to take place as scheduled. A cardiology nurse had sent out a request for information to be faxed to her. Late on Friday she had not yet received the necessary material and normally would have cancelled the case. However, she was able to access the system for the relevant data and, because she was able to find the required information, the case could proceed as planned.
Cost control
With comprehensive data at the provider's fingertips, UPMC has found that it has been able to better manage costs – an increasingly important issue with private and public reimbursements on the decline. Because a complete medical record is available, fewer duplicate tests are ordered. Likewise, a smaller number of procedures are delayed or need to be rescheduled because information is missing from the patient record, as noted above.
Patient information
In addition to these advantages, UPMC has discovered another invaluable benefit. Besides the support interoperability and data sharing offered to providers, patients also gain a better understanding of their overall wellness and care plan when a complete picture of their health is available.
In the not so distant future, interoperability will be capable of serving as a platform for a personal health record that can be made available to patients through secure portals or via USB drives. Access to this information is anticipated to encourage patients to become more engaged in, and to take greater responsibility for, their care.
Conclusion
There can be no doubt that interoperability platforms hold great promise for the advancement of healthcare worldwide. This emerging technology has the potential to save lives, time and money. By placing the right information in the right hands at the right time, healthcare organisations can ensure patients receive better care and, in many cases, experience better outcomes.
This article is also available on-line at Hospital IT Europe.