There is an unmistakable “great divide” within the community of medical group practices across the country when it comes to health information technology (HIT) adoption.
The vast majority, for instance, has yet to implement electronic medical records (EMR). The Medical Group Management Association (MGMA) reports that slightly less than 25 percent of physician practices utilize these systems, while the New England Journal of Medicine reported in June 2008 that only 17 percent of medical groups have implemented an EMR. (See references below).
On the opposite rim of the chasm are forward-thinking physicians who have eagerly embraced HIT. They have come to appreciate the benefits of capturing clinical information that is transformed into a user-friendly format enabling improved care management and patient outcomes, increased staff efficiency and productivity, reduced overhead and supply costs, and enhanced reporting capabilities for participation in pay-for-performance (P4P) initiatives.
In short order, these innovators have embedded EMRs and other HIT systems within their practices to improve care and optimize internal workflow processes. But it wasn’t long before they recognized the additional value they could attain by gaining access to data gathered by other providers, and likewise sharing information residing in their own systems. Soon, they were looking beyond their own walls for yet-to-be-developed solutions that would facilitate genuine data exchange among colleagues throughout the local healthcare community.
Into this vacuum swarmed a horde of untested solutions that pledged connectivity – such as portals and interface engines. While all held promise, each displayed significant shortcomings. Portals allowed data to be viewed, but not used. Interfaces permitted information to be transported between systems, but not integrated in a meaningful way.
Interoperability enables unified record
Alternatively, more and more providers and facilities are exploring the potential of interoperability platforms, which create a unified record from the various sources generating patient data, no matter what format they are stored in or where they are located.
This model overcomes many of the obstacles associated with those preliminary health information exchange solutions because it enables providers to access a comprehensive, current medical record. “In short, interoperability represents a data-sharing strategy that allows any information system to access the patient data it needs and to present it to caregivers in the format they prefer – without regard to the care setting in which they practice,” explains Anthony Fiorillo, MD, Medical Director of the Ambulatory eRecord at the University of Pittsburgh Medical Center (UPMC), which began implementation of an interoperability platform in early 2008. “There is no need to create a uniform format for patient medical records. Instead, this innovative technology allows caregivers to access and drill down to the data they need, on whatever information system they choose to use.”
An advanced version of this platform provides semantic interoperability. This approach allows two systems not only to share information, but enables the systems to truly understand and make use of the incoming data. At the same time, semantic interoperability maintains the original “meaning” of the information even if the data has been created and stored in varying systems and formats.
Semantic interoperability can be used for medication reconciliation by consolidating long lists of medications under a limited number of categorical headings, for instance – e.g., the medication list for a cardiac patient might be arranged by several therapeutic categories. Examples would include statins and beta-blockers, or lipid-lowering drugs and anti-hypertensives. Treating physicians are then able to drill deeper into categories of interest for greater detail – like dosage history. This functionality can greatly reduce the risk of error because physicians are no longer forced to hunt through this volume of information.
Likewise, these platforms assist caregivers in avoiding drug interactions. As any physician or clinician can tell you, medications are described by many different monikers. When recording an allergy to penicillin, for instance, physicians may represent the medication as “penicillin,” “pen.,” “PCN,” or ampicillin, to name a few. This makes reconciling a list of drug allergies extremely difficult. Semantic interoperability overcomes this barrier, however, by translating the disparate representations into a universal language. It consolidates all references to the medication under a single heading, “allergy to penicillin.” If the physician wants specific detail, he or she can then view more details to see what various notations other caregivers have recorded.
The benefits interoperability offers to community providers are extensive. To begin with, the availability of an interoperability platform means providers are able to use whatever HIT system they like within their own practices. A local urologist may prefer one vendor’s EMR, for instance, while the multispecialty practice down the road is committed to another. There is no need for various community providers to agree to adopt – or reinvest in – a common brand of technology. They can use best-of-breed systems that meet their individual clinical needs and workflow processes.
A second significant benefit is the opportunity interoperability provides for health systems and unaffiliated community physicians to work more closely. “These platforms facilitate communication between acute and ambulatory providers, and support a commitment to a fully realized continuum of care – in the truest sense of the word,” says Kevin O’Toole, MD, Assistant Chief of Emergency Services for UPMC.
Interoperability creates a genuine “communication bridge” among all care providers, whether they are affiliated with the same health system or not, O’Toole adds. “Each entity can leverage their own system and maintain their autonomy. Yet, they can all work together for the better good of the patient.”
SOA framework increased value of interoperability platforms
When physician communities begin to look at building an interoperability platform, they would be wise to consider approaches that are built within a service-oriented architecture (SOA) framework.
Although providers may not recognize it as such, they are undoubtedly familiar with the attributes of SOA. This framework is what allows them to access an independent rental car or hotel reservation system from the airline’s flight reservation system. Likewise, they may be familiar with retail operations that use SOA to manage inventory updating activities, consuming data across point-of-sale systems, handheld applications, customer service systems and e-commerce portals.
From a technical standpoint, SOA is defined as an approach to building applications with distinct units – also known as services – that can be distributed over a network, reused and combined to create new applications. This means a SOA-based platform facilitates interoperability among existing clinical or administrative systems, workflows and processes. Varying applications can consume data from each other, because functionality is agnostic to originating system architecture, format and structure. This is vital, since each of the many applications a healthcare provider typically deploys has been developed by a different vendor and has its own structure, developmental tools and underlying logic.
The benefits of operating within a SOA framework are wide-ranging. Services are written only once and reused by any and all applications. Maintenance and changes are automatically updated in all applications using the service. Ultimately, different applications can make use of a common set of services for potentially very different purposes.
‘Information gaps’ jeopardize patient safety
Once in place, interoperability platforms help providers overcome “information gaps” within patient records. In this day and age, patients see a variety of specialists, physicians and caregivers in clinics, group practices, long-term care facilities and hospitals. As a patient moves from one to another, it is an almost insurmountable challenge for a caregiver in one care setting to easily access and understand what providers in other settings have done. Information about hospitalizations, prior office visits, medications, allergies and other insights that enables caregivers to make well-informed decisions and provide the best quality care, is often elusive – or, in some cases, completely unavailable.
“These platforms facilitate communication between acute and ambulatory providers, and support a commitment to a fully realized continuum of care – in the truest sense of the word.”
Kevin O’Toole, MD
Assistant Chief of Emergency Services
University of Pittsburgh Medical Center
Breakdowns in the flow of information can be particularly problematic in community care settings, where a variety of group practices and clinics are typically engaged in treating the same patients. This is not only frustrating to both provider and patient, but can compromise care.
“I encountered a situation a couple of years ago where a patient suffering from chest pains went to the local hospital,” says a family physician who has since had the opportunity to utilize an interoperability platform. “After evaluating the patient, the emergency physician prescribed a medication containing nitrates — not knowing that I had prescribed Viagra to the patient six months previously, which could have resulted in harmful side effects.” If the ED physician had access to the patient’s complete medical history, this potentially hazardous situation could have been avoided, she points out.
More, better information improves care
Few – if any – community providers would argue that having more and better information at their fingertips could only improve the quality of care delivered to patients. They want to be confident that they have a complete picture – with full knowledge about what diagnoses, treatments and care plans other providers have provided. “At the same time,” adds Fiorillo, “these community providers want to ensure all other caregivers – whether practicing in an ambulatory or acute setting – know precisely what care has been provided in the office.”
Consider the advantages, for instance, when:
- A patient suffering from chest pains visits a cardiologist who, with a minimal number of mouse clicks, calls up the comprehensive medical record. He is able to see that another specialist had ordered a thyroid test a year earlier, diagnosed a problem and prescribed lipid medication for the patient. The knowledge of this patient’s history would be invaluable as the cardiologist determines treatment.
- A community physician is conducting rounds at a local hospital and, while on the unit, is able to access a patient’s outpatient record – which also integrates the up-to-date inpatient record. The physician has a comprehensive look at the patient’s current condition and can proceed with the exam accordingly.
- After a bowel resection and brief inpatient stay, a patient returns to her internist for follow-up care. The internist is able to view the patient’s discharge summary within his workflow, which outlines a care plan and documents newly prescribed medications. With complete knowledge of the treatment the patient received at the hospital, the internist is able to manage subsequent care more effectively.
Besides the undeniable quality of care and patient safety advantages, an interoperability platform also advances providers’ efforts to increase efficiency and reduce unnecessary expenses. Staff members no longer need to hunt for lab or radiology reports – nor are tests and studies duplicated unnecessarily – because data is unavailable, for instance. Consultants likewise are not forced to delay appointments while the treating physician’s request is located – which optimizes the doctor’s time and enhances patient satisfaction.
But does interoperability produce real value?
UPMC began the process of implementing an interoperability platform in 2008 to facilitate data sharing among its 20 hospitals, countless outpatient providers and more than 200 HIT systems. The clinical impact of the solution has been remarkable. Consider these brief case studies representing actual patient encounters:
Case #1 – An elderly gentleman arrived at his primary care physician’s office (PCP) with prostate issues. The PCP reviewed the patient’s medical record, which contained no documentation of a latex allergy. Lack of this notation was not unusual since allergies documented in a primary care record typically relate to drug allergies. However, this PCP was able to view the patient’s longitudinal care record within his normal workflow and saw that an allergy to latex had been noted during a remote hospital encounter in the past. If this had not been discovered, the results of a routine examination for prostate issues using standard latex gloves would have had at the very least uncomfortable consequences, if not a more severe reaction.
Case #2 – A patient came to his local hospital, complaining of back pain and stating that he had not seen his PCP in months. The treating physician proceeded to assess the patient and contemplate potential treatment. During the process, the physician attempted to contact the PCP’s office, but was unsuccessful because the latter’s phone system was not functioning. Via the interoperability platform, the treating physician was able to access a history of encounters and medications prescribed. This revealed that the patient had indeed been seen recently by his PCP and had been prescribed 60 Percocet tablets. The treating physician was able to confront the patient about dealing with his narcotic abuse. Subsequently, the PCP was also able to stay abreast of the patient’s care plan and rehabilitation progress, and integrate this information with future care delivery.
Case #3 – A patient that was admitted to the ED complaining of abdominal pain was referred for a standard workup. A nurse consulted dbMotion and discovered that the patient had a history of an aortic aneurysm. The patient was immediately sent for a CT scan, which revealed an acute dissection with the likelihood of rupture. The operating team was mobilized. Prior to transfer to a tertiary care center the nurse also noted, via dbMotion, that the patient was taking a blood thinner and appropriate therapy was initiated during transfer thus preventing further delay of surgery and most certainly saving the patient’s life.
Preparing physicians for data-sharing requirements
There is no doubt that market forces are driving healthcare providers towards greater data sharing. P4P initiatives, for instance, depend upon comprehensive performance and outcomes measures – and individual components of this “data picture” may reside multiple providers’ databases. For any single provider to successfully participate, he or she must be able to integrate information from disparate systems. While this is an important consideration today, when P4P payments are disbursed as bonuses, it will become even more crucial when providers will be penalized if they cannot share key clinical information.
The federal government is likewise exerting pressure for advances in data-sharing technology. In mid-2004, for example, President George W. Bush announced an initiative to computerize all patient records within the following 10 years, providing the commitment necessary to develop a Nationwide Health Information Network (NIHN). These efforts were designed to create a set of standards and secure infrastructure to give all clinicians access to vital patient information via a computer network. Shortly after he was elected, Barack Obama reaffirmed his campaign promise to advance efforts in lowering health care costs, and increasing patient care and safety by investing in electronic information technology systems.
To prepare for this eventuality, health care providers – hospitals, health systems, group medical practices – must develop their technological resources more aggressively. They must implement the necessary HIT for their own internal requirements and together begin to explore opportunities for adoption of interoperability platforms that advance data-sharing to improve quality, safety and efficiency.
References
Review the MGMA HIT adoption findings at http://www.mgma.com/about/default.aspx?id=750, and read the NEJM article at (http://content.nejm.org/cgi/content/abstract/NEJMsa0802005v1 ).
Elizabeth F. Willett is a Healthcare IT writer, based in Atlanta, following developments in Healthcare Interoperability and Intelligence.
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