Interoperability and Standards: The Effect on Patient Care

As the on-call hospitalist for the night, you are called down to the emergency room to see Mr. Smith for a CHF exacerbation and atrial fibrillation. After you begin reviewing his chart, you realize that Smith is normally seen at the university hospital across the street, but that hospital was on divert. Thus, as you scan your hospital's electronic medical record (EMR), there is a paucity of information on Smith’s medical history. You begin your interview with the patient and obtain a sketchy history of his previous medical problems. In addition, he only knows that he takes “some blood pressure pill” and a bunch of other pills that are, of course, still at home. You know very little about Smith’s complex medical history, yet now you have to take care of him tonight and hopefully obtain information from his primary care doctor, the other hospital, and his pharmacy over the next few days.Unfortunately, this scenario is all too familiar for the hospitalist. In this day of pervasive Internet access, we can view our utility bills, pay our credit cards, and even access our home PCs from anywhere. We can fly across the world, put our ATM card into the machine, and obtain money in the local currency 24/7. So why are we unable to see Smith’s records electronically from his other care centers?

Let’s explore the issues of interoperability and standards in healthcare information technology and discuss how and why solving these issues will improve Smith’s care.

What is interoperability? As clinicians, we are increasingly accustomed to using EMRs in the hospital, as well as practice management and billing systems in the office. However, the real meat of these applications is not what we see on the screen, but rather all the complex programming architecture (the “guts”) that sits underneath these applications and makes them work. Unfortunately, most healthcare IT programs today are unable to sync with other programs and share data because their architecture does not conform to interoperability standards.

Simply put, “interoperability” is the seamless and secure exchange of healthcare information among diverse systems. There are many dimensions to practical interoperability, including content or standards, format, transit, and security. We are able to use our ATM cards around the world because the fi nancial industry agreed to a common set of technical procedures to handle this kind of transaction. Standards include common terminologies or code sets; for healthcare, this includes ICD-9-CM, CPT, and other administrative classifi cations. But they also include new terminologies, such as SNOMED CT and LOINC, that more broadly cover the medical domains of problems, procedures, and labs. An example of the need to adopt standards can be found in a simple terminology discrepancy. Suppose one hospital uses the abbreviation “serum K,” while another uses “potassium.” Even though both of these terms mean the same thing, these facilities’ computer systems would be unable to communicate and exchange data. To return to our financial industry analogy, banks have agreed on a standard format so that ATM computer systems operated by diff erent banks can accept user PIN information, correctly retrieve the amount of money requested, reconcile the request with the amount of money the cardholder has in the bank, etc.

Ensuring that labs, procedures, diagnoses, medications, and more are encoded using the same terminologies is the fi rst step on the road to system interoperability. The healthcare industry also needs to agree on the format or structure of the data that will be sent between systems—a standard called “HL7” helps to address this issue—as well as agree on the actual transit mechanism (the networks over which patient information will be transmitted).

Problem-solving So, what is being done to achieve interoperability and defi ne healthcare information technology standards? Fortunately, over the last few years, the US government and governments around the world have recognized the need to improve the technology infrastructure of healthcare. In 2006, President Bush released an executive order to promote quality and efficient healthcare in federal government-administered or -sponsored healthcare programs. This order requires federal agencies and entities that work with federal agencies to utilize health information technology systems and products that meet recognized interoperability standards. This order also lays the groundwork for the pay-for-performance models now being put in place by some insurance carriers. A number of government and industry committees have been working to create and recommend specifi c standards and processes.

The National Committee on Vital and Health Statistics (NCVHS) has already recommended specifi c standards that electronic health systems should use. The Healthcare Information Technology Standards Panel (HITSP) is continuing the NCVHS work by facilitating partnerships between the public and private sectors to achieve widely accepted standards to support interoperability. Another important group is the American Health Information Community (AHIC), which makes recommendations to the Secretary of the Health and Human Services on how to accelerate the development and adoption of health information technology.

Recommending standards is only the first step. How do we ensure that the systems in our hospitals or that we are about to buy for our practices actually use these standards? The Certification Commission for Healthcare Information Technology (CCHIT) is an independent private sector initiative that created a comprehensive certifi cation program in order to accelerate the adoption of health information technology. For the most part, the industry has been receptive to CCHIT and many vendors have put their systems through the CCHIT certification process.

Finally, how will all of these disparate healthcare systems actually communicate with each other? One possible solution is the Nationwide Health Information Network (NHIN), which provides a “secure, nationwide, interoperable health information infrastructure that will connect providers, consumers, and others involved in supporting healthcare.” The NHIN is not actually going to be a central EMR that stores our patient data in one place, but rather a network of networks—built out of state and regional (so-called RHIO) systems. The NHIN will help to develop the architecture and framework for healthcare systems to interoperate. It will still be up to the vendors of information systems to build applications that coordinate with the NHIN.

There are similar initiatives occurring throughout the world. In the UK, for example, the National Health Service (NHS) has actually mandated the use of specific standards including terminologies such as SNOMED CT in the creation of a national electronic health record (EHR) project. In this case, certain patient information will actually be stored in a central location that can be accessed by clinicians throughout the country.

What does it mean for you? All these committees and governmentsponsored initiatives sound important, but how does it apply to your practice, and how will it improve your daily life? By achieving interoperability between systems, your daily clinical workfl ow will be positively affected in several ways. If your hospital is now part of a Regional Health Information Organization (RHIO), when Mr. Smith shows up in your emergency room, you may be able to access his pertinent medical history. For example, some RHIOs off er a Webbased patient portal where you could review Smith’s problem list, medications, allergies, lab test results, and more. By retrieving this information at the point of care, your ability to diagnose and treat Smith is obviously signifi cantly improved.

The use of standards by the EMR will also improve your access to decision support information at the point of care. Not too long ago, we turned to medical textbooks or even our local medical librarian to help answer questions about current treatment guidelines. Unfortunately, the information was rarely available in time to aff ect immediate care. Now, with ubiquitous access to information over the Internet, we can look up reference information on PDAs or on computer terminals around the hospital. But even with this approach, it is often diffi cult to find the most relevant information to our patients immediately at the point of care. With the use of standard terminologies used both by the EMRs and by the creators of decision support information, we will be able to interact with patient-specific information immediately at the point of care. For example, while reviewing Smith’s information in the EMR, his problem lists and medications can be automatically sent to an electronic decision support service, and specifi c care pathways, drug interaction checking, drug dosage recommendations, or the latest treatment guidelines could be presented immediately. A key to improving patient safety is consistent treatment and adherence to standard protocols.

Electronic prescribing (e-prescribing) also requires standards and interoperable systems. In order for the hospitalist to write a prescription on a computer system and have it sent to a pharmacy for fi lling, all the systems need to be speaking the same language and understand each other—just like the use of ATM machines.

Interoperability and standards will improve the ability to report patient data to satisfy the rapidly increasing requirements by CMS, insurance carriers, and other government agencies. Three reporting requirements specifi cally will aff ect the daily hospitalist practice: CMS Present on Admission (POA) requirements, Patient Quality Reporting Initiative (PQRI), and JCAHO Core Measures. CMS now requires hospitals to indicate whether a specific diagnosis was present on the admission. For certain hospital-acquired conditions, such as catheter-associated urinary tract infections or vascular catheter-associated infections, the hospital will be reimbursed at a lower rate. Thus, in a sense, the hospital will not be reimbursed for the treatment associated with the preventable condition. The key to preventing these conditions will be to identify these at-risk patients during their hospital stay and follow treatment guidelines and other evidence based protocols. As discussed above, the use of standards in the EMR will improve the ability to follow patient specifi c guidelines and order sets. In addition, it will be easier for the hospital to identify at-risk patients if patient data is collected using standards encoded electronically instead of trying to sift through hand-written patient charts.

The CMS PQRI allows clinicians to receive fi nancial incentives for reporting and following the guidelines of 119 quality measures. For example, one of the measures evaluates the percentage of adult patients with a diagnosis of coronary artery disease and prior myocardial infarction who were prescribed beta-blocker therapy. As hospitalists, we are in the position to order this class of medicines for the appropriate groups of patients. But without standard EMRs, it will be diffi cult to identify all patients who fi t this category and even more diffi cult to actually report to CMS if we do not have access to the appropriate data. We certainly will not have time to comb through charts manually to try to fi nd the patients we need to report. Th at is what computer applications based on standards are good at doing!

JCAHO core measure reporting is done by the hospital. Th e hospitalist is aff ecting the care for the heart failure, pneumonia patients, and others who need to be reported to the government. As the hospital strives to improve treatment for these groups of patients, the hospitalist looks for systems and policies to facilitate this process. As described above for the POA and PQRI reporting, access to and use of standards and interoperable systems is essential.

The use of electronic systems and the Internet is beginning to improve our ability to manage patients appropriately and improve their safety. But just using electronic systems is not enough, we need applications that can communicate with each other and share information. Solving these technical challenges is not easy for governments and vendors, but the ball is now rolling full steam ahead for the use of standards to achieve interoperability. What can the hospitalist do? Become involved with your hospital’s application vendor and ask what they are doing behind the scenes to solve these issues. Ask for reports from your hospital on patient care and use the information to improve treatment you deliver.

Brian Levy, MD, is a practicing board-certifi ed internist in both inpatient and outpatient settings at a University of Colorado-affiliated hospital. He has years of medical informatics experience in the areas of terminology and clinical content development and the use of the Internet by patients and physicians to improve care delivery.