About two-thirds of the world agrees that driving on the right side of the road is the, er, right side. But in times past, people generally took to the left. Why? Because if you are on the left, you can easily use your right hand to draw your sword against an approaching enemy, and you can mount your horse from the road shoulder, rather than in oncoming traffic (and you won’t be impeded by your left-hanging sword either).
That’s how many standards come about — need and practicality. In a perfect world, a standard achieves global adoption — everyone on the same side of the road, writing in the same direction across a page, or omitting the “u” from “color.” In reality, though, don’t plug your made-for-America hairdryer into a Brazilian outlet without a converter, unless you like the smell of fried circuitry.
Healthcare IT is no exception; standards will help pave the way to interoperability. However, lovely as that would be, in reality the interoperable wires are crossed, especially with electronic medical records, or EMRs. “The optimal goal is you walk into a cardiology practice and you bring your data in, the cardiologist plugs it in and away you go,” says Jon Bertman, a Hope Valley, R.I.-based family care physician who is also the creator and founder of Amazing Charts EMR. “That’s not here yet.”
That’s for sure. A myriad of healthcare IT-standards development organizations are scurrying to put forward “the” last word on the subject. Any success? Some, in a fractured sense. The only real results so far are the acronyms — HL7, HIE, CCR, CCHIT, RHIO, among many, many others — that point toward the goal, but don’t quite get there.
Why is this all so hard? Are we anywhere close to settling on an industry-wide standard? And what can you do as a physician to help forward the cause?
Everywhere and nowhere
Remember the Five Ps — Prior Planning Prevents Poor Performance?
So true, but not heeded in terms of EMR interoperability. A few decades ago, some entrepreneurial soul thought, “Hey, I know! We can use a computer to organize patient data!” Thus, the putty that fills a market niche is created.
By and by, others joined in — with competing solutions. No single EMR emerged early on as the undisputed market leader, unfortunately. Compare this to the Apple iPod or Microsoft Windows. Whatever their failings, they dominate their markets and so define the standards, which makes things easier for everyone — manufacturers, vendors, and users.
Not that there’s no standardization at all with EMRs. With meds, for example, most vendors use the same nomenclature, developed by First Databank (a commercial company owned by Cerner). But for, say, managing referrals, there’s no such common protocol. “Everyone has their own little customs,” says Scott Decker, senior vice president for NextGen Healthcare.
And there are many organizations that dictate healthcare IT interoperability protocols to a certain degree, although no single organization can claim “King of the EMR.” Here’s a brief rundown of some of the major players:
- The federal government is certainly in the mix of developing a nationwide standard. In 2004, President Bush created an agency specifically to address healthcare interoperability issues, called the Office of the National Coordinator for Health Information Technology.
- One offshoot of this is the RHIO, or Regional Health Information Organization, to promote the exchange of health information. Think of RHIOs as data way stations, each harboring a portion of the citizenry’s health information — at least in theory. Although there are about 100 RHIOs across the U.S., very few are actually fully functional, due to lack of public trust, unclear leadership and financing, and, paradoxically, hazy standards.
- CCHIT — The Certification Commission for Healthcare Information Technology is an independent, voluntary, private-sector nonprofit whose main point is to promote EMR adoption through credentialing. EMR vendors can apply for such certification of their systems. Currently, there are 50 CCHIT-certified ambulatory EMRs, although Decker notes that because CCHIT tweaks its criteria every year, it’s getting harder for EMR vendors to make the grade. Decker says that for 2009, CCHIT is all about interoperability, a new focus for the credentialing group. “It’s not the end-all, but it’s a start,” he says.
- AAFP/ASTM International — The American Association of Family Practitioners and the American Society for Testing and Materials, along with many other physician organizations (including AAP, AMA, ACOG, AOA, ACOFP, MGMA, MMS, and AAN), have joined forces to develop the Continuity of Care Record, or CCR. This standard protocol delineates how to pass pertinent patient data between two disparate EMRs using XML technology, which is the exact same technology that allows banks, retail stores, and other industries to conduct business on the Internet.
- HL7 — Health Level 7 is another standards protocol; this one is backed by the auspices of the standards development organization ANSI (American National Standards Institute). HL7 uses templates, standard vocabulary, and much more recently, it’s been investigating XML technology, among other defined protocols.
What’s the deal-i-o?
It’s a challenge, getting an EMR to be interoperable. Or maybe you know it as EHR, or “electronic health record.” At one time, these two terms had disparate definitions, with “EMR” meaning a piece of medical data — such as a lab report — as opposed to “EHR,” a whole patient record. These days, the two terms have become fairly interchangeable.
But dissenting confusion lingers. Electronic medical records have also been called — brace yourself for more acronyms — Computerized Medical Record (CMR), Electronic Patient Record (EPR), or Digital Medical Record (DMR). Sheesh, three decades after this technology’s inception and we can’t even settle on what to call it, much less define nationwide standards to communicate practice-to-practice or practice-to-hospital. (Our standard, by the way, is to use “EMR.”)