Interoperability and EHRs: What Physicians Need to Know

For physicians who are part of Atrius Health, obtaining information about patients is often as easy as pushing a button - literally.

The Massachusetts-based nonprofit alliance, which oversees six community-based medical groups and a home health and hospice agency, implemented a "Web portal button" a few years ago. Physicians who use it have nearly instant access to another participating practice's EHR, says Michael Lee, Atrius Health's director of clinical informatics and a practicing pediatrician at Dedham Medical Associates, an Atrius Health affiliate.

"That was so popular with clinicians and patients that we have now enabled that with nine hospitals in the greater Boston area, so Atrius physicians can click a button and see our patients' records," says Lee, whose organization, which includes 1,138 physicians within 58 practices, is one of CMS' 32 Pioneer accountable care organizations (ACOs). "Having this interoperable network in place helps physicians intervene more quickly, with better information, so you can make changes to change the outcome." Now physicians in three affiliated hospitals can use the same technology in the opposite direction to view Atrius' information when Atrius patients are hospitalized, he adds.

Atrius Health's push-button EHR access is one example of interoperability - a term that denotes the ability of two differing sets of technology to communicate the same language over a health information exchange (HIE). But achieving even this small level of interoperability, which is part of a bigger strategy to connect health organizations and exchange data more easily, is an ongoing and laborious effort. Here's a look at the state of interoperability and EHRs across the country, and what this means to your practice.

State of EHR interoperability

As practices seek to rein in costs and improve patient care, sharing standardized data is critical. But while proprietary networks such as Atrius Health's allow for interoperability, there is still no national, universal standard by which all certified EHRs can easily communicate.

Last year, CMS placed more stringent technology specification requirements for certified EHRs when it unveiled the requirements for the second stage of meaningful use. Now, vendors must include a Continuity of Care Document (CCD), a specification based on the HL7 language, in their upgraded EHRs. However, there is still enough room for variation in EHRs to make data within one EHR unreadable to another EHR.

"A CCD … is a standard for the 'fields' within an EHR, such as the data, such as lab requirements," says Dave Caldwell, executive vice president of Certify, a subsidiary of Humana that makes technology to connect two systems that are not natively interoperable, so that they may work in an interoperable manner. "The CCD itself has little to do with how data is communicated across two different systems. Let's say a physician goes into his EHR, and close[s] out a patient encounter. His EHR then generates a CCD and puts it into a standard data structure. But getting that CCD from his EHR system to an emergency room doctor who sees the patient the next week, is a different story."

Interoperability progress

Caldwell notes, however, that progress is being made as the healthcare industry adopts new standards for clinical data exchange known as the Integrating the Healthcare Enterprise (IHE) actors and profiles. These standards allow EHRs to understand the proper messaging protocols when serving up clinical information to a health information exchange.

The requirements for the second stage of meaningful use could also spur further progress toward interoperability. Eligible providers, for instance, will need to transmit a summary of care record for more than 10 percent of all patient care transitions and referrals using a certified EHR. Or, they will need to transmit records via an exchange facilitated by a participant in the Nationwide Health Information Exchange Network, or in a manner that is consistent with the governance mechanism The Office of the National Coordinator for Health Information Technology (ONC) establishes for the nationwide health information network.

As part of the requirement, eligible providers will need to satisfy one of the two following criteria: 1. Conduct one or more successful electronic exchanges of a summary of care document with a recipient who has EHR technology that was designed by a different EHR technology developer than the sender's EHR; or 2. Conduct one or more successful tests with the CMS-designated test EHR during the EHR reporting period.

While these requirements present challenges for physicians and vendors alike, they could initiate more universal EHR standards, says Jeff Loughlin, project director with the Massachusetts eHealth Collaborative, which oversees the regional extension center (REC) for New Hampshire.

"At the practice level, there's strides to make sure that the data elements that providers are entering into the system, such as blood pressure, problem lists, medication lists, etcetera, are entered into their systems in a structured format using standard formats," says Loughlin.

Interoperability's benefits

Meanwhile, the growth of Patient-Centered Medical Homes and accountable care organizations (ACOs) have made coordinating care and cost savings top priorities at many practices and large health systems. Improved interoperability could help physicians succeed on both fronts. By exchanging data seamlessly, providers can more easily coordinate care and keep track of patients' conditions and medical histories. Having this information helps physicians provide more tailored, better-suited care to individual patients.

"The value in [information exchange] becomes that the data being received can more readily be consumed into a provider's EHR - activating alerts and reminders and support tools - and at a community level can easily be aggregated for analytics purposes to improve the quality of care," says Loughlin. "We can now take that data and start to build a community-based data set so we can look at population measures, not just individual practice measures."

Atrius Health exemplifies the benefits of interoperability on population health firsthand. Proprietary networks connect multiple offices to area hospitals so that physicians get notified immediately when any patients go into a hospital. While Lee says he hopes the proprietary networks can be replaced by a statewide HIE soon, the current solution helps physicians prevent rehospitalizations, among other benefits.

Ray Lavoie, executive director at Pawtucket, R.I.-based Blackstone Valley Community Health Care, a Patient-Centered Medical Home, hopes that exchanging standardized data will help the organization achieve its long-term goal of becoming an ACO. But because Rhode Island's HIE isn't completely built out, the practice relies on a commercial product, NextGen HIE, to connect to its referral network by making Blackstone's patient data available over the Internet via a secure portal. Resulting diagnoses, medications, etc., can be returned to Blackstone via the same portal.

"It's a big part of our Patient-Centered Medical Home going forward," says Lavoie. "We know which lab orders and radiology orders haven't been filled much more easily … we get notified when our patient gets discharged from the hospital, or admitted and transferred. We certainly have much more complete quality reporting. We're able to take much better care of our patients. We're able to help individuals, and information comes right to the physicians' inboxes."

Moving forward

What can you do to have interoperability with other providers? One possible first step is intermediary technology. Lavoie's medical group uses NextGen Ambulatory EHRs, for instance, so connecting all physicians on an interoperable network via NextGen HIE technology wasn't too cumbersome or steep an investment.

Physicians may choose to join an existing HIE from a list of certified participants at www.healthewayinc.org. Per the meaningful use rule, physicians may also opt to receive a summary of care record in a manner that is consistent with the governance mechanism ONC establishes for the nationwide health information network (but as of Nov. 6, 2012, there were no "ONC-established governance mechanisms"). While joining a state HIE would allow healthcare providers to exchange data with multiple healthcare providers to satisfy the meaningful use requirements for Stage 2, not all state HIEs are up to par.

Another option is to establish connections with top referral sources to send and receive standardized data. While building a propriety network is too expensive an undertaking for small practices, participating in a message exchange system such as the Direct Project (http://directproject.org) allows partner providers to establish secure e-mail addresses to communicate using the same standardized language. Direct messages can be accessed from an EHR, an e-mail client, or even a Web browser.

"Although by itself not a solution for full interoperability, Direct has the potential to allow them to reach a much wider variety of [providers] in the community, particularly those who do not have an EHR," says Jason Fortin, senior adviser for Naperville, Ill.-based Impact Advisors, a consultancy that works with physicians. "It's ideal for simple push transactions between known entities."

Marisa Torrieri is an associate editor at Physicians Practice. She can be reached at marisa.torrieri@ubm.com.

This article originally appeared in the September 2013 issue of Physicians Practice.