Interoperability: The Hard Way or the Easy Way?

“O ye'll take the high road, and I'll take the low road, And I'll be in there afore ye”

There isn’t any data that’s so important that I would disrupt a practitioner’s life or spend $150 billion to collect it. The purpose of interoperability (interop) must be to help physicians take care of patients. HIMSS (Healthcare Information and Management Systems Society) agrees.

“Interoperability describes the extent to which systems and devices can exchange data, and interpret that shared data. For two systems to be interoperable, they must be able to exchange data and subsequently present that data such that it can be understood by a user."  

Unfortunately talk is cheap. If you listen to the regulators and pundits, they more concerned about collecting and exchanging structured (discrete) data between systems than they are exchanging information between practitioners. You remember (of course) that data is not information. Information is facts in context. Data are the result of transforming and simplifying information to satisfy specific needs, usually to support specific processes, such as ordering.

EHRs (I can't say this often enough) are not primarily medical records, they are elaborate data collection and process control devices. It's true that somewhere within their bowels one can find narrative notes and other materials that contain sufficient context to constitute information, but the systems have little ability to make any productive use of it. That’s why they insist that the staff duplicate their work on data entry screens.

My interest is to have access to a patient's prior notes, lab reports, and images. Once I have read the past history and understand its implications, I rarely need to look at those records again. I may summarize what I have learned or perhaps copy a few salient sections and include them in my notes, but the bulk of the prior records will have served their purpose. Hence there is no need to import them into my system and store them forever. Think about it. How often do you look at last night's I/O or vital signs? When following serial electrolytes how often do you look at the values from last week? If a patient has had an uncomplicated surgical procedure such as an appendectomy, how likely are you to read anything but the operative report and discharge summary?

So… how do we get there from here? "There" being "presenting the old records in a way that can be easily understood by a practitioner." Well, we can get there the hard way (high road) or the easy way (the low road). Imagine that I want to get from my house to the one directly east of me - the distance is approximately 100 yards. I have two choices: 1) I can walk out my front door and across the street. 2) I can walk out my back door and travel 20,609 miles (the circumference of the earth at my latitude) in a westerly direction until I reach the house across the street.

Interop is like this. I can either:

1) Display documents that the practitioner can read or

2) I can decompose the contents of those documents into thousands of fragments (called structure data) each of which has to be defined and agreed to in advance. Then transmit those fragments, one at a time, to a receiving system where a process examines each fragment and finds a suitable location in which it can be stored (if one exists). Then reassemble them into a human readable form.

- Does the source of the material have the patient’s permission to send it?

- Should the incoming data be trusted (considered equivalent in every to values your institution might have generated) or should be viewed skeptically?

- How long should imported data be retained?

- Should the material be “pushed” whether or not someone needs it or “pulled” on request? If pushed, how will the practitioner be notified that there is material available to view?

Since a picture is worth a thousand words, here are pictures of the two roads. Which one would you take?

The low road:

The high road:

Portion of 37,000 character CDA Document

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--><component><section><code code="10153-2" codeSystem="2.16.840.1.113883.6.1" codeSystemName="LOINC"/><title>Past Medical History</title><text><list><item><content ID="a1">Asthma</content></item><item><content ID="a2">Hypertension (see HTN.cda for details)</content></item><item><content ID="a3">Osteoarthritis, <content ID="a4">right knee</content></content></item></list></text><entry><Observation classCode="COND"><code code="39154008" codeSystem="2.16.840.1.113883.6.96" codeSystemName="SNOMED CT" displayName="clinical diagnosis"/><effectiveTime value="1950"/><value xsi:type="CD" code="195967001" codeSystem="2.16.840.1.113883.6.96" codeSystemName="SNOMED CT" displayName="Asthma"><originalText><reference value="#a1"/></originalText></value><reference typeCode="XCRPT"><!-- A reference of type "XCRPT" can be used to show that this problem list value is excerpted from the referenced external observation. --><ExternalObservation><id root="123.456.789.23.17"/></ExternalObservation></reference></Observation></entry>

Sample HL7 Lab Result

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MSH|^~\&|LCS|LCA|LIS|TEST9999|199807311532||ORU^R01|3630|P|2.2
PID|3|2161348473|20923085580|01572633|20923085580^TESTPAT||19730204|
M|||^^^^00000-0000|||||||86427531^^^03|SSN# HERE
PV1||I|^802^1||||8625^Physician^Michael|86-7468^||xxx|||||||||V1001
ORC|NW|8642753100013^LIS|20923085580^LCS||||||19980728000000|||PEED
OBR|1|8642753100013^LIS|20923085580^LCS|083824^PANEL 083824^L|||19980728083600|||||| CH13380|19980728000000||||||20923085580||19980730041800|||F
OBX|1|NM|150001^HIV-1 ABS-O.D. RATIO^L|||||||N|X
OBX|2|CE|001719^HIV-1 ABS, SEMI-QN^L||HTN|||||N|F|19910123|| 19980729155700|BN
NTE|1|L|Result: NEGATIVE by EIA screen.
NTE|2|L|No antibodies to HIV-1 detected.
OBX|3|CE|169999^.^L||SPRCS|||||N|F|||19980728130600|BN
NTE|1|L|NOTE: Submission of serum
NTE|2|L|separator tube recommended
NTE|3|L|for this test. Thank you
NTE|4|L|for your cooperation if you
NTE|5|L|are already doing so.
OBX|4|CE|169998^.^L||SPRCS|||||N|F|||19980728130600|BN
ZPS|1|BN|LABCORP HOLDINGS|1447 YORK COURT^^BURLINGTON^NC^272152230|8007624344