How far away are we from having electronic medical records that can truly talk to each other, across health systems and across regions? We decided to find out.
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:
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.”)
A number of barriers block the way to widespread EMR interoperability. One echoes the “too many cooks in the kitchen” clichÃ©. Each EMR vendor has developed its own solution that includes proprietary programs and data conventions, and each vendor naturally touts its solution as the best one for you.
And as in any sector, EMR vendors generally don’t like to share. And who can blame them, really? Opening the export floodgates has a definite down side: While doing so is certainly helpful to you, your patients, and U.S. healthcare quality, it unlocks the exit door for clients.
Well, that’s just vendor greed or paranoia, right? Perhaps not. For the first time in our annual Technology Survey, the number of practices who said they use an EMR actually decreased. OK, maybe it’s just a blip - or not. It could be an indication we’ve reached a second wave of EMR purchasing, that many physicians are unhappy with their first EMR purchase. “People try out vendors,” says Bertman. “Then they find out it’s overpriced. They want to transfer their data.”
Why should vendors risk losing their paycheck-funders by allowing clients to grab their data off one EMR and load it onto another? What’s in it for them? That’s normal business, American-style, and so these are valid questions.
Another impediment to EMR interoperability is the way many EMRs are designed. Not to get too geek-speaky here, but the programming languages used to write all but the most recent EMRs are problematic to widespread use. Have you ever struggled to install some software on your computer that works great on your friend’s setup but it keeps crashing on yours? Same goes for first-generation EMRs. Many were created in such old-school languages as Visual Basic and C++, which are highly system-dependent. Making them work across all systems without hiccupping is a real challenge.
The same goes for the EMR’s data. Passing data between two EMRs requires flexibility on both sides. Many EMRs are incapable of bending and stretching their data architecture to fit another. Imagine trying to yank on a bathing suit that is two sizes too small.
Still another issue hampering true interoperability is that it does not mean just EMR-to-EMR. It also means provider/patient communication, claims submission, insurance verification, test results sharing, computerized physician order entry, electronic prescribing, and probably other functions. This requires a national platform that payers, physicians, vendors, pharmacies, hospitals, and you name who else, must agree to. See the problem?
What can you do?
Yes, you’re a physician - certainly more than a full-time job. And you’re in a career that’s fraught with regulations. But hammering out EMR interoperability standards - that’s an opportunity to participate in something where the rules are not yet etched in stone. Hmm, you could get involved. But how?
Even if you already have a system in place, ask your vendor where it stands on interoperability. Make it very clear that this is of supreme interest to you. “Demand that vendors go down the CCHIT path,” he says. After all, McDonald Happy Meals were only a special, temporary promotion when they first came out in the late 70s. It was customer support that got them onto the permanent menu, much to our kids’ delight.
Basically, the louder you proclaim you want full EMR interoperability, the more quickly a viable solution will gel. And it is happening. “Clients are really starting to push it,” says Decker. “And it’s the right thing to do.”
But we’ll only get there if we work together, says Julie Klapstein, CEO of Availity, a health information exchange organization based in Jacksonville, Fla., in a podcast of her talk at the Third Annual World Congress Leader Summit, titled “The Road to Interoperability.” She succinctly summed up the issue of successful EMR interoperability: It requires that many disparate bodies work together - and that’s hard.
“Collaboration isn’t for sissies,” noted Klapstein. “It takes real innovation. [Participants] have to agree to collaborate on a common portal and a common solution. … It’s really about leadership over self-interest in proprietary solutions.”
Shirley Grace, MA, is a former associate editor for Physicians Practice. She can be reached at firstname.lastname@example.org.
This article originally appeared in the October 2008 issue of Physicians Practice.