For all the innovation in healthcare, it’s still common for patient information to be incomplete at the point of care. Frequently, multiple medical records exist and everything from disease information to full medication lists aren’t shared between providers. To understand how it could be that patient data is still largely siloed even when that information is available electronically—and especially given how data exchange is so fluid in our everyday lives—it helps to know a little about the legislation that sparked broader use of electronic health records in the first place.
Signed into law in 2009, the Health Information Technology for Economic and Clinical Health (HITECH) required health systems to implement the use of EHRs. The problem? There was no requirement to standardize EHRs to ensure data could be shared between different electronic health records before they were widely adopted.
“There’s always that regret of why didn’t we have standards before we started doing that?” said Dr. Douglas McKee, chief medical information officer and vice president of Health First in central Florida.
Today, health systems are prioritizing efforts to improve interoperability between EHRs and aggregate patient data for a more complete picture. By demand and necessity, EHRs and other vendors are following suit. The government is also helping the process by adopting new standards like the Fast Healthcare Interoperability Resources (FHIR) that lays out how healthcare information can be exchanged.
But full interoperability and data standardization remain the holy grail: mysterious and elusive. So hospitals are employing different strategies aimed at breaking down data silos to bring more complete patient data to clinicians’ fingertips and improve care.
McKee said one of the biggest things Health First is doing in this regard is working with the company Tendo, which creates software to pull patient data together from different sources. Even within Health First’s integrated care delivery network—which includes four hospitals, outpatient services, hospice and pharmacy—there are two major EHRs. Health First uses Allscripts for acute care, when a patient visits the hospital, and relies on athenahealth in the outpatient setting. As such, Health First’s initial efforts with Tendo involve connecting its two main EHR systems, so patient data shows up all in one place, McKee said.
“Unsurprisingly, there’s a lot of disparate and disconnected information about a person’s health,” said Jennifer Goldsmith, Tendo’s president and co-founder.
But turns it out, the problem for most health systems starts in house.
“Almost every healthcare system in existence today has multiple EMRs,” Goldsmith said. “This is a remnant really of the rapid acquisition of different healthcare systems”—each having their own medical records software from different EHR vendors.
That problem of myriad EHR systems can work itself out over time as the acquired entities migrate to one EHR system. But not all health systems feel the need to having one unified EHR across their hospitals and clinics. Take Health First, for instance.
McKee said he couldn’t speak to what led to Health First having two EHRs in the first place since that decision was made years ago. But Health First doesn’t have any plans to consolidate to a single, system-wide EHR.
“We plan on using Tendo to bridge the gap between the EHRs,” McKee said.
In addition to data sharing between its own EHRs, McKee said Health First is also focused on bringing in patient data from outside providers through health information exchanges and connectors like CommonWell and Carequality and even consumer apps like Apple Health. A major part of the purpose of working with Tendo is not only connecting the different pieces of information for providers, but bringing it all together in a very patient-friendly format. Patients will be able to access their information with a user interface that’s simple and easy to use in the Tendo app, McKee said, adding that this is currently still in development.
Other health systems, like Intermountain Healthcare in Utah, are busy trying to not only break down barriers to information exchange for themselves, but for all hospitals.
Searching for a solution for all hospitals
Stan Huff, Intermountain’s chief medical information officer, said this is primarily taking shape in two ways.
For one, “we’re working on a digital platform of the future … an overriding project to create an infrastructure that’s really based on interoperability,” Huff said.
The other involves Graphite Health, a nonprofit company that launched in October of last year with a stated goal of accelerating the digital transformation of healthcare. At present, the organization is being led by four members — Intermountain, Kaiser Permanente, SSM Health and Presbyterian Healthcare Services.
The aim of Graphite Health is to create a standardized, interoperable data platform that enables a secure and open marketplace to make it easier to distribute digital health solutions for health systems and entrepreneurs.
“Once you standardize the data, you can do more than just support that open marketplace,” Huff said. “It also creates data that can, with the proper approvals, be shared across organizations for patient care.”
Intermountain is able to do that now with external hospitals through the Utah Health Information Network (UHIN). But even where information is freely shared, it is still typical for reports to be faxed, he said. That can leave a clinician who has precious little time scrambling to try to quickly find the information they’re looking for in a long report. It’s time that could be better spent with patients, according to Huff.
“So you really want the information integrated into an application so that the data retrieval happens automatically electronically within a few seconds,” Huff said.
He notes that there are some areas where standardization of data is further along, like with lab results or medication data. In the case of the latter, standardization was needed as electronic prescribing has largely become the default. But the ideal would ultimately be for all patient data to be standardized as its entered into an EHR or immediately thereafter, he said. This would enable any health organizations providing care for a patient in the future to access it without encountering technological barriers.
The role of health information exchanges
For now, a patchwork of exchanges attempts to fill that gap. In addition to some public or nonprofit exchanges that serve this purpose, EHRs have also created private exchange networks to allow more data sharing between different health organizations with the same or different platforms. Epic, athenahealth and eClinicalWorks were among the early major EHR adopters of the Carequality Interoperability Framework. Allscripts, athenahealth, Cerner, McKesson helped created CommonWell.
But a new governmental framework is seeking to formalize, standardize and ramp up the development of health exchanges. In January, the Trusted Exchange Framework and the Common Agreement (TEFCA) was published, establishing requirements for how entities can be designated as a Qualified Health Information Networks.
That’s something Dr. Eric Alper, senior vice president, chief clinical informatics officer and chief quality officer at UMass Memorial Health, is keeping a close eye on. Currently, Worcester, Massachusetts-based UMass takes advantage of private health information exchanges, like Epic’s proprietary Care Everywhere platform.
Care Everywhere allows UMass to exchange very robustly with other hospitals and health systems that use Epic, Alper said. It also allows UMass to exchange with a number of non-Epic systems by connecting to entities like Carequality, the eHealth Exchange and now even CommonWell.
“The quality of the data isn’t as great, the volume isn’t as robust … but it allows us to get that initial glimpse into that patient’s history,” he said.
In the last five years, UMass has done about 15 million data-sharing transactions across all 50 states and 400 health organizations that use Epic, with almost 6.5 million of those transactions happening just last year, he said.
But he added that there are still blind spots, areas where UMass is looking to improve data sharing. That includes the painfully slow pace of prior authorizations, which ensure patients can move forward with treatment that’s covered by insurance. The health system is evaluating software programs that could make it easier to exchange patient data to drastically speed up this process.
Epic has prior authorization capability with certain payers, but Alper noted that the EHR vendor doesn’t work with many of the payers in the region where UMass operates. While he wasn’t involved in the UMass analysis into prior authorization tools and said he isn’t an expert on all the options available, Alper believes that other vendors have more experience with prior authorization software compared with Epic. However, he fully expects the Wisconsin EHR behemoth to expand its software solutions to target this dire need.
“Prior authorizations is one of probably the greatest sources of burnout and frustration for our physicians as well as our other clinical staff,” Alper said.
Another kind of patient data UMass has started receiving from outside its walls is imaging. The health system uses PowerShare from Microsoft’s Nuance, a tool that allows exchange of radiology studies. So if a patient had a CT scan at another hospital, radiologists, surgeons and oncologists at UMass can access those, Alper said.
The long road to interoperability
Taken together, the obstacles put in place by a lack of standardization in the past, the present-day patchwork of data-sharing initiatives, and future ambitions for universal interoperability are daunting propositions.
To fully realize the vision of standardization of patient data and interoperability is not going to happen overnight. For example, it will probably be a minimum of a year before Graphite, the nonprofit focused on overcoming healthcare interoperability challenges, will have a usable platform, Huff said.
“The thing people need to realize is how hard of a problem this is,” he said. “People don’t like to hear it, but it’s going to take five or 10 years to start realizing that vision.”
If and when full interoperability is realized, both health systems and patients stand to gain.
“In spite of the fact that it’s a long journey, it’s going to be incredibly worth it,” Huff said. “In the end, all of this has to do with taking better care of patients and doing it at the lowest possible cost.”
Photo: marchmeena29, Getty Images