If you practice medicine, you need the latest knowledge, tools and instruments specific to your specialty….and ready access to as much relevant information as possible about each patient. The latter is the driving force behind the current push for you to adopt and use an electronic health record (EHR) as part of your basic set of tools. Like your other major technical investments, your EHR must meet your needs for functionality. It must also possess state of the art security and be “interoperable” to the extent possible. At present, however, true interoperability – the ability to work with and communicate with other sources of information that give you the full picture of your patients’ health and history—remains the holy grail of medical informatics.
Why is interoperability such a challenge? And when can you expect to “plug and play”, meaning easily get information to and from any lab that is convenient for your patient, get a feed from a patient’s Holter monitor while he is wearing it, or see a current problem list to which all of your patient’s doctors have contributed? The challenges to achieving this type of data access are both technical and cultural.
The key to understanding interoperability on the technical side is to understand the various categories of standards necessary for disparate electronic information sources to communicate reliably and usefully – vocabulary or terminology standards, messaging standards, and a standard approach to implementation guidance. Using the transmission of lab orders and results as an example, we need a consistent vocabulary that goes far beyond the name of the test. We need standard terminology for everything related to the patient, for information identifying you as the ordering clinician, for presentation of results, for how the normal ranges are presented, for qualifying information about the test, for example, was the sample hemolyzed), and for qualifying information about the result such as recommendations for a follow up test. At present, we have standard terminologies for many of the actual test names, but little else.
Messaging standards determine how the information or data elements are packaged for secure travel over the internet. The good news is that there are a limited but sufficient number of messaging standards at present and a lot of work has been done to date to select the one that is most appropriate for a given situation. Continuing with our example with respect to lab data, the HIT community has agreed that HL7 (Health Level 7) is the most appropriate approach for messaging laboratory related information.
The most difficult step in the technical process is standards for implementation guidance. Simple translation: when the data are delivered to a disparate EHR system, implementation guides allow the second system to accept and integrate them in a way that makes them as presentable to the clinician as if it were entered locally. Implementation guides are specific for different types of data and need to work for all types of EHRs. While initial work on implementation guides for several types of lab data has commenced, a lot more work is necessary in this area before the industry can achieve true interoperability for lab data and information. Meanwhile, implementation guidance still needs to be written for many other types of data.
One frequently hears the terms “syntactic interoperability” and “semantic interoperability.” The former simply refers to the basic capability to communicate and exchange information and is the first step. Semantic interoperability is the ability to automatically interpret the data in the information exchanged meaningfully and accurately in order to produce useful results as defined by the end users of both systems. Much of the interoperability currently available clinically is in the first category: summary documents can be exchanged, opened, read, and stored. The data elements in these documents, however, may need to be extracted and manually keyed into the new system if they are to be used independent of the initial document.
The cultural challenges to interoperability may be even more daunting than the technical challenges. There needs to be both demand and a business case on the part of participants and the technology vendors to make the necessary investments in interoperability and put it to use. Laboratories with multiple different technological platforms will require a return on investment if they need to replace these platforms in order to be interoperable with EHRS. Providing data from a home based system that monitors anticoagulant effect to a clinician who is responsible for dosing will require that the clinician be compensated in some way for the time and expertise necessary to appropriately monitor the patient virtually. Lastly, and especially relevant to laboratory data, we need to assure that our laws and regulations allow for and support the exchange of electronic data. CLIA, the Clinical Laboratory Information Act, has been a barrier to health information exchange between clinical labs and others who need access to laboratory information. This Federal legislation has been under review for several years with the intent to issue guidance or modify its restrictions so as to allow information to flow where it is needed, not just to the ordering clinician.
Efforts in all these areas have intensified with the passage of ARRA (the American Recovery and Reinvestment Act of 2009). We still, however, have a long way to go to achieve true semantic interoperability in the healthcare industry. This should not stop us, however, from taking advantage of what information can be exchanged now, which includes patient summary data and documents. In order to facilitate this exchange, the Office of the National Coordinator for Health Information Technology (ONC), an agency of HHS, has developed a set of standards, services, and policies which allows participating providers to send but not query, find, and access, patient summary information and documents to known and trusted recipients. Known as the Direct Project, this set can be used by clinicians or institutions, public health departments, and laboratories to “push” information to receiving entities. A number of Health Information Exchange (HIE) organizations at local, regional, and statewide levels are also exchanging summary documents and public health information. Check with your local medical society, Regional Extension Center (REC), or HIE program to learn more about how you may participate in information exchange, using your certified EHR.
Karen M. Bell, MD, MMS
Chair, Certification Commission