Will EHRs Ever Work Together?

April 1, 2010
Bruce Kleaveland

Interoperability is the buzz word right now in health IT, but how close are we to exchanging information across wildly fragmented data systems? We investigate the progress and trends.


In a perfect healthcare IT world, everyone knows my name.

And my most recent labs, current meds, problem list, and the interpretation of the last imaging study on my trick knee. And they can access this information whether I am in Syracuse or Seattle. The information is fully secure, only accessible to qualified healthcare providers or ancillaries, with an option for me to opt out if I decide I don’t want to share.

We are not quite in a perfect world. But we are making progress.

The focus of efforts to achieve this healthcare IT nirvana all revolve around facilitating interoperability - which is just a fancy word that means that disparate computer systems can easily talk to each other and exchange information.

The objective is fairly simple: to move patient information to help facilitate care. In a fully interoperable world, the doctor’s EHR would be auto-populated with lab data, hospital discharge notes, pharmacy refill histories - in addition to the progress and nursing notes created at the office. Moreover, the data within the doctor’s EHR could be electronically accessed at the emergency department or other locations as needed to support patient care.

Facing a challenge

However, achieving this ideal state has been challenging for a number of reasons.

First, healthcare information is wildly fragmented, residing in a broad mix of paper charts, ancient legacy systems, new Web-based tools, and everything in between. To move information between disparate systems requires building an interface - a dedicated piece of software that allows information to be coherently sent and received between two software programs. Part of the reason for the government’s big push for EHRs is that information on paper is not easily moved. (You can digitize charts via scanning, but this is a cumbersome and inefficient way of sharing patient data.)

Secondly, patients are peripatetic when it comes to receiving care - moving from primary-care physician to hospital to specialist to urgent-care facility to imaging center and so on. Providing the links between all these different settings in a way that is both secure and reliable is a pretty tough problem.

Finally, the sheer number of software and/or devices that generate patient information is daunting. It would not be unusual for a doctor’s office to have an EHR, an electronic vital signs monitor, an ECG machine, a bone density scanner, various lab analysis tools - all made by different companies. The doctor is also likely to use a clinical reference lab which generates a tremendous volume of critical information. Primary-care docs will routinely interact with a broad spectrum of specialists, each with their own potpourri of digital systems.

The road to interoperability

What is being done to help make sense of this complex maze of information? There are two major efforts underway that will help:

Data communication standards. These represent detailed specifications about how computers communicate with each other. They function as a type of recipe for linking two systems. Because there so many types of systems, standards have to be built for each data or transaction type. For instance there are standards for communication for e-prescribing (NCPDP), for EHRs with lab systems (HL7 2.5.1), and for EHRs with other EHRs (CCD or CCR - more details below). As standards are finalized and agreed upon, it makes it easier for vendors to build and implement communication. The recent activity on meaningful use has been in shot in the arm for finalizing these standards, because the government will link incentive payments to systems that are standards compliant.

Health Information Exchanges (HIE). Just like politics, healthcare is largely local, with most people (snowbirds being a notable exception) receiving services within the same geography. A health information exchange (also referred to as a regional health information organization or RHIO) provides a common communication network for the sending and receiving of information within a particular region. The HIE functions as the central information highway that allows all the various players - i.e. doctor’s office, hospital, pharmacy, lab, imaging center - in a given region to talk to each other through a single hookup to the HIE. There is just one interface to the HIE, rather than multiple interfaces. After a rough start, HIEs are starting to gain momentum. According to eHealth Initiative, a healthcare IT public interest group, the number of HIE initiatives grew from 42 in 2008 to 57 in 2009 - a jump of about 35 percent. Considering that five years ago HIEs were largely nonexistent, it’s pretty good progress.

Bottom line: the full meal deal of complete nationwide interoperability is a good ten years off, but at least we have broken ground.

But what about simple EHR-to-EHR communication, that is, the ability for me to send an electronic file with a patient summary from my brand X EHR to my specialist colleague who has a brand Y EHR system?

As noted above, there are two standards that support this transaction: the CCD (continuity of care document) and the CCR (continuity of care record).

Here’s how it works: First, your EHR vendor has to have built CCR/CCD capability into the system. Second, you push a button within your EHR and create a CCR or CCD file. Third, you send the file to a colleague, who imports the file into his CCR or CCD compatible EHR and reads the patient information as if you just sent him a PDF. Voila!

Both the CCR and CCD are snapshots of the patient’s history, including information such as patient demographics, insurance information, diagnosis and problem lists, medications, and allergies.

The fact that there are two standards essentially means we have the equivalent of a VHS and betamax dilemma, which primarily puts the burden on the EHR vendors to support both. The hope is that over time the two standards will harmonize into one, but that has not happened yet.

From a practical perspective, for those with EHRs, you should ask when your latest upgrade will include CCR and CCD compatibility. For those of you shopping, make sure it is on your “must have” list.

Bruce Kleaveland is president of Kleaveland Consulting, a management consulting firm focused on healthcare IT. He can be reached via physicianspractice@cmpmedica.com.

This article originally appeared in the April 2010 issue of Physicians Practice.