With the policy landscape emerging out of healthcare reform having been clarified by a Supreme Court ruling and the November federal elections, and with the meaningful use process under the federal American Reinvestment and Recovery Act/Health Information Technology for Economic and Clinical Health (ARRA/HITECH) Act proceeding apace, there has never been a more urgent need for clinicians and others to share information across the inpatient-outpatient divide.
But the basic reality of disparate, multiple electronic health record (EHR) systems involved in most hospital-physician communications remains a stumbling block to easily facilitated sharing of key clinical information at the point of care or use. That reality is proving to be thorny on multiple levels, as healthcare IT leaders try to help lead their organizations forward towards such important goals as accountable care, health information exchange (HIE), analytics for value-based purchasing, and other efforts.
A report published last year by IDC Digital Marketplace predicted that ambulatory EHR use will increase from less than 25 percent adoption in 2009 to over 80 percent by 2016. With adoption on the rise, hospitals and medical groups are making a concerted effort to achieve total interoperability between their systems.
Getting to that point means having to overcome some basic challenges, according to a survey conducted by the Washington, D.C.-based Bipartisan Policy Center and Doctors Helping Doctors. Results of the survey, published in October, showed that 71 percent of clinicians cite lack of EHR interoperability and information exchange infrastructure as major barriers to the exchange of health information. In addition, 69 percent say the cost of creating and maintaining interfaces is a major problem.
Also, more than half of the respondents say they want critical data pushed to them electronically, but prefer to selectively retrieve other, less critical information. The desire to cherry-pick data comes as no surprise to Jody Cervenak, a principal at the Pittsburgh-based consulting firm Aspen Advisors. “Each physician has a need for very specific data,” she says. “Each wants a different slice of the electronic health record.” The kind of data being accessed will largely depend upon that physician’s specialty, she adds.
Donald Cope, Jr., director of information systems and security officer at Newman Regional Health in Emporia, Kan., notes that mobile technology has streamlined data capture and complicated issues of interoperability as well. “Clinicians want data sent to their cell phones, but they don’t want all the results,” he says. “They want the system to think for them—to alert them.”
Among the reasons for the lack of integration between a hospital’s EHR and those of its affiliated practices are the historically slow adoption rate of EHRs by physicians, and the variety of available best-of-breed systems, says Cervenak. “Many decisions were made before vendors had a solution for both sides,” she says. “Hospitals also may have acquired physicians and gotten their systems.” Additionally, organizations may not be inclined, because of time or cost, to replace these older systems with a single, integrated system, she notes.
Traditionally, getting disparate systems to communicate with each other has only required an interface engine based on an industry standard such as HL7 (from the standards organization Health Level Seven International, Ann Arbor, Mich.). But that may not be enough when all kinds of data need to travel from multiple departments in a hospital to the hospital’s core EHR and then to numerous physician practices. Likewise, physicians need to send orders and data from their EHR back to the hospital, so a bidirectional solution is needed.
In order to achieve that kind of high-level interoperability, a separate integration system needs to be installed, Cervenak says. Essentially “middleware,” that system is able to collect and “harmonize” data—converting it into an understandable, cross-platform format while maintaining the original meaning of the data.
ESTABLISHING THE LINK
While the meaningful use program offers financial incentives for physicians to purchase and use EHRs—and will eventually penalize those who don’t—a number of large hospitals have found it advantageous for themselves and their physician practices to offer their own form of monetary assistance.
Jim Venturella, CIO for physician and hospital services at the University of Pittsburgh Medical Center (UPMC) in Pittsburgh, Pa., has been working with his colleagues to provide connectivity to the organization’s more than 3,200 employed physicians and 2,000 non-employed, affiliated physicians.
UPMC’s inpatient EHR is from the Kansas City, Mo.-based Cerner Corporation, and was implemented in the late 1990s. On the outpatient side, Venturella notes that affiliated practices are offered several options when it comes to outpatient EHR adoption. The health system’s choice for its employed physicians is the EHR solution from the Verona, Wis.-based Epic Systems Corporation; non-employed, affiliated physicians may choose either Epic or the Chicago-based Allscripts; high admitters, he notes, tend to pick Epic. For those practices that already have their own EHR, UPMC offers a connection back to the hospital’s core EHR via a customized platform provided by MedLink, a self-developed solution at UPMC.
Since all of UPMC’s employed physicians use Epic’s EHR, true interoperability between Epic and Cerner was achieved by installing a semantic interoperability solution provided by Pittsburgh-based dbMotion Inc., Venturella says. This allows all data captured and stored in each system to be harmonized and readily retrievable by any clinician, he notes. The interoperability solution also allows UPMC to participate in a nine-hospital HIE which started pushing data last summer, he says.
Karen Thomas, vice president and CIO of Main Line Health in Bryn Mawr, Pa., is working toward total interoperability as well, but is not quite there yet. With a medical staff of 2,200 and non-employed physicians numbering about 1,900, Main Line is currently working on a bidirectional interface so that physician practices can send orders electronically to any one of Main Line’s six hospitals.
To facilitate that process, Thomas says her organization also plans to begin using continuity of care documents (CCDs). CCD is a relatively new standard developed jointly by ASTM International, West Conshohocken, Pa. and Health Level Seven International. It allows for the exchange of reports and clinical data in the original format.
Main Line’s core inpatient EHR is Soarian Clinicals, supplied by Siemens Healthcare, Malvern, Pa. It was chosen because it is scalable and has an integrated database between EHR and practice management functions, she says. The ambulatory EHR for employed physicians is supplied by NextGen Healthcare, Horsham, Pa.
Donald Cope, Jr.
Community physicians who are not employed by Main Line use an EHR supplied by eClinicalWorks, Westborough, Mass. To increase the EHR adoption rate among community physician practices, Thomas says Main Line offers a loan program that covers eClinicalWorks. “We bought the licenses and if they get meaningful use dollars, they pay us back,” she says.
Main Line has partnered with Siemens to provide its MobileMD solution to establish an operational link between these varied EHRs, Thomas says, adding that this allows harmonized data to be sent to a physician practice’s EHR so that the physician can select the data he or she wants. Thomas also notes that Main Line is planning to become part of a regional HIE; and she says she’s confident that the MobileMD platform will be able to handle the interoperability demands of multiple links.
THE HIE CONNECTIVITY FACTOR
Hoag Memorial Hospital Presbyterian, located in Newport Beach, Calif., has been part of a private, three-hospital HIE for two years, according to Tim Moore, senior vice president and CIO. To achieve the necessary connectivity to the HIE, Hoag chose Salt Lake City, Utah-based Medicity. Although the hospital’s core EHR is Allscripts Sunrise Clinical Manager, the EHRs being used by physician practices run the gamut from Allscripts to NextGen to eClinicalWorks, he says.
Moore says that until three years ago, Hoag had in place a program through which it helped subsidize a practice’s purchase of an EHR from one of those three vendors. But when the health system began to seriously consider joining an HIE, that program was discontinued.
Kieran Murphy, Hoag’s director of health information exchange, notes that Hoag has approximately 1,500 affiliated physicians, not all of whom have an EHR. Some are still using paper charts and fax machines, he says. Still, the emphasis on an HIE, which was primarily physician-driven because the hospital’s CEO is a physician, has paved the way for increased EHR interoperability, resulting in the connection of 825 physicians. “Medicity is our HIE platform. Now it’s our intercommunity communication,” he notes.
Not yet part of an HIE, Newman Regional Health adhered to a best-of-breed strategy until a few years ago, says the health system’s director of information services, Donald Cope, Jr. In 2010, there were three separate systems and no interfaces, he recalls. “The old systems weren’t robust, but each system suited the specialists,” he says. Instead of updating the modules, Newman Regional decided to look for one system that offers seamless integration. A hosted Magic Health Care Information System, supplied by MEDITECH, Westwood, Mass., was chosen for the 53-bed hospital. Each of the five clinics owned by Newman Regional rolled out NextGen Healthcare’s EHR. An interface engine resides in the hospital, Cope notes, and acts as a translator so that harmonized data can be sent from one system to the other.
BREAKING DOWN BARRIERS
Cope says that achieving interoperability between systems is the biggest challenge he has encountered. Even though the interface engine uses HL7, “There is a big difference between interfacing and integration. The challenge was in the translation of data,” he says.
Venturella agrees that achieving true interoperability can be problematic, especially since vendors are slow in developing cross-platform standards that would make it easier to integrate disparate EHRs. As a result, systems need to be reconfigured and a middleware solution needs to be employed. The problem of harmonizing data is magnified when a healthcare delivery system becomes part of an HIE, he says.
There are now a number of integration platforms that essentially act as middleware, according to Aspen Advisors’ Cervenak. But getting all types of data into a form that meets the criteria for semantic interoperability is still a major hurdle. For example, there is no one code for allergies, she says, and lab values vary widely from test to test.
There are many governing bodies working on standards, she notes, but vendors need to do their part. “To be meaningful use certified, they must incorporate standards,” she says, adding that “big industry players could come together and break down competitive barriers.”
In advising others who are attempting to achieve interoperability between their hospital’s core EHR and those of affiliated practices, Venturella says, “Make sure people understand the difference between interfacing and interoperability.”
And even if you’re relying on a sophisticated interface engine, Cope says, “Find a good interface engine for traffic control and one that is easy to use.”
But even before choosing a software solution, the needs of all stakeholders must be considered, says Moore of Hoag Hospital. “Start very early with physicians and get them involved. Then pick one good business partner.”
Thomas of Main Line suggests looking at the impact such interoperability efforts will have on physicians’ practices. That hospital started with a small pilot program and invited input from its physicians. “Start with small wins,” she says.
Given the rapidly changing landscape of healthcare delivery, it is obvious that the old ways of exchanging patient information are no longer viable. Whether through federal mandates or decisions made by hospitals to streamline processes and stay competitive in the marketplace, physicians are now beginning to see the importance of EHRs and the sharing of data, not just with their hospital, but with other physicians as well.
While there are still those who rely on paper charts and fax machines for the transmission of data, that number is declining. As private or state-run HIEs take hold, the electronic transfer of patient information will become even more relevant. For those who have an integrated platform from a single vendor spanning their entire enterprise, there is no problem in achieving interoperability. For those who don’t—and there are many—a middleware solution residing between disparate EHRs is at least, for now, a way to bridge the EHR divide.