The Road to EMR Interoperability

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:

• The federal government is certainly in the mix of developing a nationwide standard. In 2004, President Bush created an agency specifically to address healthcare interoperability issues, called the Office of the National Coordinator for Health Information Technology.

• One offshoot of this is the RHIO, or Regional Health Information Organization, to promote the exchange of health information. Think of RHIOs as data way stations, each harboring a portion of the citizenry’s health information - at least in theory. Although there are about 100 RHIOs across the U.S., very few are actually fully functional, due to lack of public trust, unclear leadership and financing, and, paradoxically, hazy standards.

• CCHIT - The Certification Commission for Healthcare Information Technology is an independent, voluntary, private-sector nonprofit whose main point is to promote EMR adoption through credentialing. EMR vendors can apply for such certification of their systems. Currently, there are 50 CCHIT-certified ambulatory EMRs, although Decker notes that because CCHIT tweaks its criteria every year, it’s getting harder for EMR vendors to make the grade. Decker says that for 2009, CCHIT is all about interoperability, a new focus for the credentialing group. “It’s not the end-all, but it’s a start,” he says.

• AAFP/ASTM International - The American Association of Family Practitioners and the American Society for Testing and Materials, along with many other physician organizations (including AAP, AMA, ACOG, AOA, ACOFP, MGMA, MMS, and AAN), have joined forces to develop the Continuity of Care Record, or CCR. This standard protocol delineates how to pass pertinent patient data between two disparate EMRs using XML technology, which is the exact same technology that allows banks, retail stores, and other industries to conduct business on the Internet.

• HL7 - Health Level 7 is another standards protocol; this one is backed by the auspices of the standards development organization ANSI (American National Standards Institute). HL7 uses templates, standard vocabulary, and much more recently, it’s been investigating XML technology, among other defined protocols.

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” cliché. 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?

• Get on board. EMR vendors aren’t the only ones guilty of foot dragging. The phlegmatic adoption of EMR technology by physicians in the U.S. hasn’t helped the cause either. If you’re still paper chart-based, you’ve got two hurdles to clear: the technology itself, and then the subsequent interoperable data sharing. This is a concern for many doctors, says Decker. “It’s a cultural challenge; there’s still a lot of nervousness. Do I really want to send out my patient data?”

• Guard your patients’ privacy. Certainly no technology meets every healthcare need - even EMR. But take a look at “Physicians’ Use of Electronic Medical Records” below. Overlay these results onto “Test Results or Medical Records Not Available at Time of Appointment, Among Sicker Adults.” The two charts dovetail pretty neatly, don’t they? When building a cabinet, such dovetailing is great. With patient care, not so much.

• Voice your support. If you don’t already have an EMR, choose a vendor who puts interoperability way high on its priority list. For those who claim they do, push them to define what interoperability means to them. Communicating with other products they’ve created? Uh-uh, not good enough.

• Keep your data door open to the outside world. “It’s one thing to say you’re interoperable,” says Bertman. “It’s another to let you truly take the data out.” Decker recommends putting CCHIT certification in your EMR RFP (Request for Proposal), which hopefully you’ll choose to write before you invest in this technology.

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.

• Join health IT advocacy organizations, such as eHealth Initiative, an independent, not-for-profit organization whose stated goal is to “drive improvement in the quality, safety, and efficiency of healthcare through information and information technology.” Also consider CCHIT, which also is largely volunteer-driven, or maybe just CHIT, the Center for Health Information Technology, which is part of the AAFP (the co-sponsor of the CCR).

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 sgrace@physicianspractice.com.

This article originally appeared in the October 2008 issue of Physicians Practice.