As Electronic Medical Records (EMRs) are increasingly adopted across the health chain, are we really reaping their benefits? Without interoperability and health information exchange, the data held in EMRs and in the many propriety systems across the health chain remains fragmented. Anne English reports.
EMR adoption is undoubtedly a major leap ahead for the health care sector in reaping the benefits of the knowledge economy. But the real value from EMRs only becomes a reality when you can interconnect and exchange that information. That’s why CIOs, CMIOs and senior IT executives are now tackling the issue of interoperability.
Without interoperability, EMRs cannot be the purveyor of the knowledge that still needs to travel between those silos of data that exist across the numerous players in the health chain. From physician to hospital, laboratory to pharmacist, emergency caregiver to public health nurse, each has their own system – albeit evermore electronic - of storing medical files.
In the absence of an interoperability platform that enables an integrated patient record based on data from all the various disparate sources across the health chain, the improved care, greater choice, safety, increased efficiency that can be afforded by the digitisation of this information cannot be harnessed. In fact, the continued fragmentation of patient health information on monolithic systems could serve to foster the level of error, duplication, and lack of coordination and transparency.
Not a Technical Problem
Interoperability is however, not a technical problem. Far more, it is a patient care issue. How can the knowledge required about a given patient be where that patient is, when he or she most needs it?
Yuval Ofek, CEO of dbMotion, describes how HIT (Health Information Technology) now needs to transition the data in the disparate systems into knowledge at the patient’s point of care. “Healthcare organisations have invested heavily over the past ten to twenty years in automating and computerising clinical/operational procedures. This process has led to a reality in which clinical environments are becoming IT and data rich, but knowledge poor.”
So what we need to do now is enable caregivers to easily extrapolate the knowledge rendered from interlinking this data, Ofek says, “It is interoperability that holds the key to unleashing the power of integrated data, heretofore trapped in disparate information silos, and this will transform healthcare by enabling better informed decisions, safety and outcomes by providing clinicians and applications with rich patient-centric information within current workflows.”
Right Information, Right Time, Right Clinical Decision
Far removed from the world of theory in HIT, a young man arrives to emergency with abdominal pain and is scheduled for a CAT scan of his abdomen requiring IV contrast dye. He has received past treatment in other hospitals where an allergy to IV contrast dye was entered into their systems and it was also noted in his outpatient chart in an ambulatory EMR. In short, this allergy was recorded in three disparate sources. In the absence of interoperability between the various systems, caregivers in emergency would have had no way of knowing about this information’s existence. Consequently, he could have received this dye had he not been able to relay this information e.g. consciousness, state of illness, etc.
Luckily, this emergency unit at the University of Pittsburgh Medical Center (UPMC) was using an interoperability solution that enabled the doctor to immediately prescribe the appropriate care thus avoiding serious, if not fatal, consequences.
Divergent Vocabulary and Semantic Meaning
There are three main steps to interoperability: accessing the data, bringing it to where it’s needed, and third - the most tricky - combining this information to display the most meaningful knowledge at the point of care. So how is the hurdle of divergent clinical vocabularies - the different set of terms (or language) that describe clinical findings and actions - overcome? According to Ofek, it is by adding semantic intelligence to interoperability tools and platforms that provides HIT real value. Of all the patient treatment errors in hospitals, it's been estimated that as many as 75% involve either a breakdown, or complete lack, of information exchange.
dbMotion uses Service Oriented Architecture (SOA), which facilitates interoperability among existing clinical systems, workflows and processes. Ofek explains that with interoperability you can create, for example, a comprehensive list of a patient’s biochemistry labs so you can view, integrate and exchange the data. However, with semantic interoperability, you can make use of the actual ‘meaning’ of the data exchanged. Some of the more straightforward applications of this capability revolve around using it to improve the understanding of information by, for example, grouping similar drugs such as antibiotics together or by grouping drugs that are known by different names. But the holy grail of semantic interoperability is in using the integrated data to facilitate care and decision support, regardless of the way the different data represents the information.
Safety versus Security
So will this increased health information exchange compromise patient privacy? According to Ofek, there is a fundamental choice to be made, “Are we better off when the information afforded by interoperability is not available or better off with caregivers having access to integrated data? You need to evaluate the theoretical risks to privacy versus the very real risk of patients being treated by staff who lack key information required for treatment.” If you choose interoperability, in practice safety is actually increased since patient information is available to the doctor who can then prescribe the appropriate course of care, thus avoiding potentially adverse life threatening consequences. Nevertheless, concerns about privacy cannot be dismissed and therefore caregiver access to information must be defined according to rigorous sets of rules-based privacy policies and the caregivers role and authentication. In some cases, it’s prudent to give patients the option of opting in or out of having their health information shared or accessible.
Adoption
According to Dr Daniel Martich, CMIO and Associate CMO of UPMC, “While we had transactional systems before, what we have now is transformational systems”. Martich has worked with many monolithic clinical information systems and knows first-hand how fragmented information can be, “large scale ‘rip and replace’ of legacy systems is not an option and prohibitive – the answer to better care lies in interoperability, its seamless integration within the caregiver’s existing workflow, and provision of meaningful information at the point of care.”
Interoperability and especially semantic interoperability incorporates medically oriented business-logic to the maze of complex monolithic systems in the background. But what the clinician sees is an easy-to-use interface where at the click of an icon, they get to see immediately that a patient requires a specific sort of care that they would heretofore not have been aware of.
And this is the key to adoption in Dr Joel Diamond’s view. Diamond, a practicing physician and CMO North America at dbMotion said, “The adoption of such systems lies in the hands of physicians and they must fit in without disrupting our normal work flow for us to adopt them”. So, powerful and pervasive as it needs to be, interoperability must be unobtrusive. Physicians need comprehensive user interfaces that apply easy navigation and enable them to drill-down into all aspects of the medical information. For every physician the primary focus is on optimizing patient care as opposed to honing their IT skills.
The Future of Interoperability
Without interoperability, EMR adoption can hardly avoid amassing the information silos that exist in today’s disparate systems and paper-based medical files, resulting in even greater proprietary control over health information. It would seem that efforts to support adoption of EMRs alone would be ill-advised, as stand-alone EMRs are limited in their ability to truly transform patient care. With interoperable information, there is little doubt that EMR adoption can improve patient care and caregiver efficiency.
And if interoperability is the key to realising the benefits promised by EMRs, semantic interoperability as is being borne out at UPMC is undoubtedly the next step to maximising the value of that health information exchange.
Side Bar: UPMC
The University of Pittsburgh Medical Center (UPMC) is a leading integrated health care enterprise, with 20 hospitals (4,000+ beds), 400+ outpatient locations, and 4,700+ affiliated physicians, with 2,475 employed. UPMC serves over 4 million people providing 4.5 million outpatient visits annually.
Challenge
UPMC has implemented a number of clinical systems and dozens of ancillary systems. However, caregivers did not have access to an integrated and unified view of the patient’s medical record. There was an urgent need to provide clinicians, within their current workflows, with more comprehensive, integrated medical data including Demographics, Problems, Allergies, Medications, Laboratory Test Results, Documents, etc, in the form of a coherent patient record.
Solution
UPMC’s interoperability platform is centered on the dbMotion Solution. It creates an integrated patient record composed of a patient’s medical data maintained at multiple different facilities. This is accomplished without the replacement of existing information systems. At UPMC, the dbMotion Solution aggregates and integrates data from all major clinical systems and performs semantic mapping of medication and allergy terminologies to optimize the integration with applications currently used by clinicians. The Solution ensures that the true meaning of the information is presented to clinicians in an intuitive manner and within their existing workflows.
Given the size and scope of UPMC, this project provides a model which might be applied on a regional, state, or even, national scale to address a critical problem in health care — how to quickly and accurately share data across disparate systems to more efficiently care for patients. Interoperability has become a key part in UPMC’s vision of providing “the right care to the right patient at the right time, every time”.
Side Bar: Patient & Caregiver – Quality & Safety
A woman is found delirious by her neighbors and brought unconscious to emergency where no patient history was found in the EMR. Using an interoperability solution a record of chronic liver failure secondary to Hepatitis C was found – noted in her records from an ambulatory EMR. This enabled the doctor to rapidly diagnose hepatic coma and prescribe the appropriate medication to lower the patient’s life-threatening ammonia level. In addition, despite a policy of ‘universal precautions’ the care team is made aware of the patient’s blood-borne pathogen status (Hepatitis C).
This article is also available on-line at e-health.