An enormous amount of attention is focused these days on the exchange of health information between hospitals, labs, physicians, and other providers of patient care. Health information exchange is a key element in every definition of “meaningful use” and is an absolute requirement if we’re going to improve healthcare delivery in the United States.
So how do we go about it? Conventional wisdom says we adopt common standards for exchanging information and provide financial incentives to advance the effort. And so we march along – defining standards and certification processes to ensure that data formats and vocabulary, document structure and security, and business functionality are the same in all products and networks. We will soon spend billions of dollars to adopt standards-based EHRs and build community, state, and national level networks to form the backbone of a nationwide exchange. Complete this and – voila – it all comes together and everyone is happily exchanging information … right?
Well, maybe not. From my perspective (i.e., someone who has been in the trenches for years, integrating systems and building electronic information exchange networks) the reality is that things aren’t that simple. This is not to say that the “standards and stimulus” approach isn’t a good thing – it’s just that the day-to-day problems we really deal with may not be adequately addressed by the current approach.
If you integrate hospital systems and EHRs, you soon find that the two most vexing challenges you encounter are the cost of the EHR interface and the need to validate the information that is displayed in the EHR (such as lab tests and reports).
The first challenge – EHR interface costs – is well understood by hospitals, physicians and anyone that works in this area. At an average price of $15,000 ($7,500 each for a lab and document interface per hospital), a physician working with three area hospitals and labs would spend more than her potential $44K in stimulus dollars on EHR interfaces alone – leaving the cost of the EHR, installation, and other costs to be picked up by the physician. Since meaningful use is predicated on these interfaces being in place, physicians are significantly under water from the start.
As far as the second challenge is concerned, as an integrator, I know that transforming data from one format to another is fairly easy. Mapping an element from a proprietary term to a standard like LOINC is more difficult but certainly doable using today’s technologies and standards. On the other hand, ensuring that the data is displayed the same way in all receiving EHRs and validating that fact to the satisfaction of organizations like CMS (through its Clinical Lab Improvements Amendments) is where we spend the majority of our time and effort when implementing EHR-to-hospital connectivity. Yet no one is embarking on developing standards that guarantee how information is actually displayed in the EHR.
Being a practical person, I know that there are no silver bullets to solve these challenges. EHR companies spend significant time and effort working with HIE vendors and with hospitals and physician practices to enable interoperability and should be compensated for that effort. But the cost of the interfaces should not be an optional add-on if meaningful use is a requirement; they should be factored into the total cost of the EHR so there are no surprises down the road. Creating universal standards for what a pathology report will look like when it is rendered in an EHR may be impossible to achieve today, but let’s not fool ourselves into thinking that simply adopting interoperability standards that represent clinical data formatted in XML incorporated into a CCD document will suffice. The reality is that it’s going to take a lot more than interoperable EHRs and common standards to achieve our goals.
Instead, we must focus on the real task of integrating systems. At this stage, adaptability, agility and experience remain the best tools to achieve our goals.
