Interoperability: Getting Beyond Point-to-Point Connections
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And more facilities are exchanging more information: Preliminary results of CMIO’s Top Trends/CMIO Census survey show that about 46 percent of respondents currently share information via a HIE with related facilities and almost 23 percent say they belong to an HIE that shares information with unrelated facilities. (See the July edition of CMIO and cmio.net for more complete survey results.)
Exchanging health information among disparate systems quickly, in usable formats, might be the vision for improving healthcare, but getting information beyond point-to-point transactions is a challenge for even the most engaged, forward-thinking and harmonized organizations. “A struggle” is the term that comes to the lips of many CMIOs.
“A lot of advanced technology [is] used in healthcare, and it’s an endeavor which is extraordinarily information-intense, but the places and manners in which information is created are not connected. Despite the use of advanced technologies, the exchange of information about patients remains horribly paper-based,” says Jonathan B. Perlin, MD, PhD, MSHA, FACP, FACMI, chairman of ONC’s Health Information Technology Standards Committee and president, Clinical Services and Chief Medical Officer of Hospital Corporation of America (HCA), based in Nashville, Tenn.
“Healthcare is very sophisticated in the use of technologies—[but] the information technology that should tie all the data that those technologies produce together is in its infancy,” Perlin says. “So we have an Information Age set of activities in healthcare tied to an Industrial Age way of managing the data.” This means “point-to-point connections are reasonably frequent, but the health information that you provide in one setting doesn’t necessarily get across the street,” he says.
The HIT Standards Committee is working with other groups in the ONC and federal agencies as well as industry stakeholders to identify workable standards for inter-organizational information exchange, among other target areas for standardization.
“The challenge is to be specific enough that the information is truly interoperable, current enough that the standards that are promulgated are not obsolete, but evolutionary enough that it also allows adoption of new standards over time. That’s something the ONC is seeking to work out currently,” Perlin says.
What makes a standard a standard? “At the HIT Standards Committee, we try to adopt standards that are anointed by the prevalence of their use. That’s a pretty good endorsement by the business of healthcare,” says Perlin. In areas where standards may not previously have been needed—for example, systematic reporting of immunization data and syndromic surveillance outside of certain environments, or quality reporting—the ONC is working to foster collaboration to identify possible standards, he says.
The words we use
As the drive for information exchange standards continues, some healthcare systems are harnessing tools that use semantic extraction, indexing and harmonization to get data where they’re needed, in a useful format, regardless of the originating system.
“When it comes to the actual exchange of data and true interoperability, transferring data from one system to another, once you get beyond point-to-point interfaces, it’s still very difficult,” says William Fera, MD, vice president of Medical Technologies and Medical Director of Interoperability at the University of Pittsburgh Medical Center (UPMC). UPMC has partnered with dbMotion, a SOA-based, healthcare-specific infrastructure tool, to launch a health information exchange (HIE). The intent is to provide a flexible platform for UPMC’s clinicians to securely access integrated patient information across the system’s 20 hospitals and 400 outpatient sites and doctors’ offices, without replacing existing systems. The platform also has the potential to link to other healthcare organizations as well as state and federal agencies, says Fera.
“We’re endeavoring to get to true semantic interoperability without a point-to-point interface. Organizations can build interfaces in a point-to-point fashion, and that’s what we’ve done historically, but it’s just not a sustainable strategy when you have a multitude of applications,” says G. Daniel Martich, MD, CMIO of UPMC.
“The platform that we have is a service-oriented architecture (SOA) which allows querying, extraction, and transfer of data without an HL7 interface,” Martich says. “We’ve done the extraction and harmonization [semantic part], where we organize the data to be in one format. How we port that data to be received by other systems and applications is the challenge that we’re addressing on an ongoing basis.” UPMC is working with various vendors to leverage some of their service-oriented tools in order to do that, he says.
The UPMC system includes approximately 200 different clinical applications throughout 20 hospitals. The organization has a workforce of nearly 50,000 and includes 400 clinic sites across western Pennsylvania and the world. “Our foundational systems, from an inpatient and outpatient standpoint, are Cerner and Epic, respectively. Those are the ones we’re trying to bring together first and foremost for better care coordination,” Martich says. “We’re not there yet completely, but we’re part of the way there.”
The dbMotion application has a separate viewer and unites medication data, allergy data, problems and lab data from those two disparate systems and harmonizes some of the data. “We’ve harmonized some of the medications … [and] that’s part of the semantic interoperability we continue to work on,” Fera says. All 30,000 clinical users have access to the system, he says. “dbMotion allows us to have one door to the outside world. Once we aggregate data internally, then we can expose it through dbMotion.”
“One of the things we particularly like is both the ability to have a data repository of our own data and the capacity to link up with other systems potentially, or even entities like the state or federal government with a federated model,” Fera says. “Data do not necessarily persist on our [UPMC’s] end, but we still have access to patient-specific data.”
The planned exchange will include online connectors such as with Quest Labs. The information exchange platform will be rolled out first in the emergency room, because “privacy and consent in the ER represents a safe harbor, so [when patients declare an emergency], if a physician needs information to render care, we would be able interrogate the Quest database to see if there’s any lab information about that patient,” Fera says.
dbMotion has an open architecture, but is not open source. The framework is SOA-based, “so the idea would be to convert to a baseline standard to form a knowledge framework that’s unique to dbMotion—unique in the way the ontology and the hierarchy of information is set up, but not unique from the standards point of view,” Fera says. Even widely used standards such as LOINC have local variations that can disrupt or corrupt data, and must be re-standardized to some baseline level of code. “Once you are harmonized down to that baseline level or complete standard that hasn’t been changed, you can translate it back out to a receiving system.”
However, most standards today have these local variations that don’t allow a one-to-one translation of a multitude of data elements. “Until we really have [this] true, generic standard, this will be a very difficult undertaking,” he says.
‘A moving target’
At the other end of the healthcare spectrum sits Lawrence General Hospital (LGH), a community hospital in Lawrence, Mass., that handles 73,000 emergency patients a year and faces interoperability issues of its own. “This thing is very much a moving target: Do we start our own HIE, do we buy a vendor HIE, or do we wait for NEHEN [New England Health Exchange Network] to begin to pass clinical data back and forth, and …delay a solution for HIE?” says Neil Meehan, DO, FACEP and CMIO, at the 189-bed facility. “I think the problem with that is the longer you wait for the state HIE [to] get up to speed, [the greater the chances] you end up behind the curve.”LGH sponsors a local HIE built on RelayHealth technology. Participation started slowly, but has gone from 600 transactions per month initially to 16,000 transactions per month today, he says. “We started rolling out the HIE to our affiliated physicians as an interim solution until there is widespread adoption of the EMR platform they want to work with and connect to the hospital that way… Right now, HIE on their side of things means a web portal with a log-on.”
“Lawrence General has virtually no ‘owned physician groups’ and getting 200 physicians to buy into HIE is daunting, to say the least,” Meehan says. “Some of them just got internet access in the office. So not only are the ambulatory physicians a moving target, but the technology solutions for data sharing within a community are moving targets as well.”
LGH has been testing information exchange from its emergency department to the HIE and the ability to push data based on the continuity of care document (CCD), a standard for summarizing medical information, back and forth within its Picis ED EMR. “This is not done much in this region, and I think it will really be looked at closely by the stakeholders in the HIE and turn some heads in surrounding hospital regions,” Meehan says.
“Interoperability is the biggest push right now. The new version of [the ED EMR] has an HIE module that’s built right into the software, so there’s almost no interface necessary for this. It will receive very granular CCD documents, not just ... blobs of text. The module takes allergies [and] medications, parses them into code and puts them into the actual components of the EMR, so it’s very seamless,” he says.
“In the Picis structure, the patient comes in, gets registered in the ER, and as soon as that AO4 [HL7 patient registration] message hits our software, [it] goes out and looks at the XDS registry, and pings it back for information,” Meehan says. The CCD is gathered, parsed at the Picis site, then populates the patient’s chart in the external data field.
“When I go to the medications of this patient, when I’m doing the medication reconciliation, [current medications are] sitting in the queue of that patient. The allergies are, too. The allergies are either from the old record from previous ER visit, or from an HIE, and it doesn’t have to be RelayHealth, it can be any HIE,” Meehan says. “Medications, allergies and problem lists are probably the most vital data that we have to obtain from this type of effort, and Picis covers a lot of that critical data for us.”
A time of transition
Standardization is needed to move more data among systems in regional health information organizations (RHIOs), says Ted Kremer, MPH, executive director of the Rochester RHIO, which was founded in 2006 and now serves 10 counties in the Finger Lakes region of New York. The RHIO includes 15 hospitals, three regional reference labs and many radiology providers, serving 1.2 million patients. It connects with physician practices, home and long-term care, and emergency departments, in a host of settings.“Clearly, we’re in a transitional period, but I think you have to take a pragmatic approach to your interoperability requirements,” Kremer says. “It would be a very awkward discussion to have to tell a 15-physician practice they have to wait half a year to get their lab results into your EHR until you get your new standard interface established. On the other hand, there could be a rationale to saying ‘well, until you can query the CCD from the HIE, we need to get that standard in place.’”
The Rochester RHIO uses Axolotl for its HIE services, and “we do hang a couple of other HIE-like products on top of it to connect to radiology images and elder care communities,” he says. RHIO participants can exchange laboratory and pathology information, radiology reports and images, and can access transcribed reports and eldercare information through the HIE. “We’re just about ready to go live with adding EMS [emergency medical service] information and patient-supplied information through our PHR [personal heath record] gateway,” says Kremer.
Rochester RHIO is flanked by RHIOs on two sides, “so our next level of expansion, besides [building out] data sources, is RHIO-to-RHIO interoperability with our neighbors,” Kremer says. These exchanges use different HIE platforms, so we’ll be using NHIN, IHE-type profiles for PIX [patient identifier cross-referencing], PDQ [patient demographic query], and we’ll be exchanging CCD,” says Kremer.
The Rochester RHIO connects with six EHR platforms, and plans to connect to another five, Kremer says. “Our experience with a lot of EHR vendors [is that] all of the vendors want to move toward a place where there’s a common approach to connecting with an HIE or with a hospital. I think everyone realized it’s in their best interest to move forward that way,” he says.
“It’s true, though, that if there’s no impetus either from the market or their customers, and their connections are already established, maybe they move a little slower. But most EHR vendors we’re working with all have on their road maps now a fairly robust vision for exchanging CCD. I think you’ll see that become a pretty common landscape functional requirement.”
The open-source vs. open architecture discussion can miss the point, Kremer says. With open source tools, as with proprietary ones, “you still need someone using the tool, managing your interfaces and operationalizing your HIE services.” Rochester RHIO looked at open source solutions early on, “but for a startup with a staff of one or two, that was sort of a non-starter,” he says. “You really need some bandwidth to take on open source and own it. Where people have that kind of bandwidth, it could certainly be an interesting alternative.”
“[This] really is a transitional period, where people are moving out of the old 2-dot-whatever of HL7 into the IHE profiles and moving into web services and XML, but I don’t think those standards per se should get in the way of us providing value to customers today, and I think everyone is trying to move to them as quickly as we can,” says Kremer. “We’re already starting to [look at] some of the initiatives that are in draft. For example, dynamic XDS services for dynamic document rendering looks really interesting, and as soon as that gets out of draft and becomes operationalized or approved, we’d want to start moving toward that as well.” In addition, “the NHIN Consent Directive [for accessing patient information] is something we’re pushing everyone on,” he says.
“The biggest challenge is to keep abreast of all the technology and standards that are out there, because everyone’s got their day job, too,” says Kremer. The vast amount of healthcare information now being generated could be the greatest asset available in improving patient care. However, to do the most good, this information must be effectively exchanged—and delivered securely—among more stakeholders than ever before.