A More Important Kind of EHR Interoperability

June 13, 2011

Itinerant practitioners, of any sort, pose a challenge to the organizations that use them and present a challenge. They may work at several different facilities during a single week. Each facility has its own policies, procedures and data systems, all of which are notorious for being arcane and highly detailed.

One of the big complaints voiced by laymen about today's EHRs is that they are not interoperable. It is not possible, at the drop of a hat, to select some information from System A and send it to System B in such a way that it can be quickly assimilated, much less mean the same thing in System B that it meant at its point of origin.

There are numerous reasons why this is harder to accomplish. It may even be impossible, except for very simplified subsets of data that resemble the banking transactions that I have mentioned previously. Healthcare organizations vary widely in how they do business, what types of conditions they treat and whether they conduct clinical research. The interests and personalities of the staff and the local culture vary and may have a long history. Add to this the complexity introduced by a data system, whether purchased or bespoke and you have a very complex situation indeed.

The challenge is made tougher because establishing a data transfer channel requires the participation, cooperation, and coordination of many parties. This turns out to be, to put it bluntly, tough to do. This challenge is long-standing and widely appreciated but nevertheless, obvious. There is another interoperability challenge about which you never hear.

The practice of medicine is changing from one in which dedicated individuals take responsibility for a group of patients over a prolonged period of time, perhaps with little or no backup from other physicians beyond shared night call. The young physicians that are being trained today have different expectations and goals. They appear to be less interested in the stability of an office practice; they rather seem to dislike the idea. They seem more inclined to shift work where there are no long-term commitments to either an organization or a patient. This is reflected by the numbers opting for work in emergency rooms, as hospitalists, or as locums tenens. The situation is very similar to nurses who work out of registries rather than directly for a single hospital.

Itinerant practitioners, of any sort, pose a challenge to the organizations that use them. They may work at several different facilities during a single week. Each facility has its own policies, procedures and data systems, all of which are notorious for being arcane and highly detailed. A new practitioner cannot simply arrive on the doorstep and begin treating patients. There are required HIPAA orientations, safety training, in-service sessions on the various types of equipment, and training on the computer systems (most of which are impossible to use without extensive training.)

An individual practitioner may have to learn the details several times over and, like that old movie If It's Tuesday, This Must Be Belgium, they must unerringly follow the policies and procedures that are appropriate for where they are at the moment. It simply won't do to apply Hospital A's policy or procedure at Hospital B. These practitioners will start out being less than fully productive. They may never accumulate adequate training and experience with any of systems with which they work to be functionally equivalent to a full-time, experienced employee. This means that itinerant practitioners also pose a greater risk to patients and, indirectly, to the institutions that employ them. Being unfamiliar with equipment, policies and procedures increases the likelihood of both errors of omission and commission.

One approach that could mitigate these problems is to standardize the controls of an EHR in very much the same way that the controls of automobiles are reasonably standardized. Another approach would be for physicians, like carpenters, to bring their own tools to the job, in this case, a computer loaded with charting software that they know inside-out that can send completed notes and orders to the main system of the facility where they are working at the moment. Whether it be EHRs or cars, accidents result when individuals are faced with an emergency or high-pressure situation and find themselves in unfamiliar surroundings working with equipment they understand only superficially; people misinterpret or misunderstand the proper use or simply guess wrong, with disastrous consequences.

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