October 2,
2006
Technology
Drives Success of Data Sharing
By Sarah T. Corley, MD, FACP
For The Record
Vol. 18 No. 20 P. 46
EHR systems serve as the steering mechanisms that
guide the development of RHIOs and other health information exchange
structures.
Although far from widespread, the development of regional
health information organizations (RHIOs) and health information exchanges
(HIEs) is certainly accelerating, especially as forward-thinking organizations
realize benefits such as improved clinical outcomes, enhanced patient
safety, and reduced healthcare costs.
In these early development stages, the lynchpin for
successful RHIOs and HIEs has proven to be the technology partner organizations
adopt—individually and as a group—to facilitate data sharing.
The healthcare information systems—particularly electronic health
record (EHR) systems—used by each participating entity must provide
a foundation that will allow information to be exchanged easily. In
addition, the group must agree on and develop a common technology structure
that helps it accomplish the mutual goal of communicating and sharing
health information.
EHR Selection Vital
Successful data sharing is a function of the EHR that each member organization
adopts—and, in most cases, these systems are selected long before
the local RHIO or HIE is established. Physician practices currently
considering or evaluating an EHR system, for instance, should do so
with the long-range view in mind. They must assess each system in terms
of how well it will support their eventual participation in a data-sharing
organization.
One important characteristic is the type of database
that serves as the heart of the system. Some EHR systems are simply
clinical note generators, providing no functionality beyond recording
the provider’s documentation. However, to facilitate information
exchange, the system should feature a structured database, where discrete
pieces of information flow between sections of the record. This allows
providers to have instant access at the point of care to vital information
impacting diagnostic and treatment decisions. With structured data fields,
healthcare organizations can sort and categorize the data for reporting
and analysis purposes.
This level of database functionality is particularly
important when evaluating how well the EHR system and companion systems
manage health information that comes from outside systems, including
lab results, radiology reports, and consultants’ findings. Ideally,
the systems should allow the data to be uploaded and integrated into
the patient chart. If this information is scanned or otherwise appended
outside the medical record, providers are not able to access comprehensive
information in a convenient and timely manner.
Likewise, healthcare organizations must seek out EHR
systems that comply with emerging HIM standards such as Health Level
7, which enables disparate healthcare applications to exchange key sets
of clinical and administrative data, and SNOMED, which standardizes
clinical terms. Models like these create the equivalent of a common
language, so healthcare organizations can exchange information even
if each partner uses different technology.
To ensure that these features are inherent to the system
they ultimately select, healthcare information professionals should
investigate whether the vendor is certified by the Certification Commission
for Healthcare Information Technology (CCHIT).
The CCHIT is a private-sector collaboration between
the AHIMA, HIMSS, and The National Alliance for Health Information Technology.
The organization has been sanctioned by Health and Human Services to
certify HIT products, including ambulatory EHR systems for office-based
providers, inpatient EHR systems for hospitals and health systems, and
the network components these organizations use to share information.
Patient-Focused, Provider-Friendly
Systems Are Ideal
With data sharing in mind, a multidisciplinary team of healthcare professionals
must be engaged in the selection of the EHR system to ensure that technological,
clinical, and administrative objectives are fully considered. Each stakeholder
must be committed to choosing a system that is patient-centric and provider
friendly to optimize benefits.
Of course, provider and administrative representatives
must play an active role. In addition, leaders from the finance department
should be involved. They must, however, guard against automatically
championing an EHR system offered by the same vendor that provides their
practice management system simply because it is an easy choice. In some
cases, the same vendor may be appropriate—but only if its companion
EHR system is designed specifically to support the provider’s
clinical priorities.
Likewise, IT professionals should be at the table because
their assessment regarding technological concerns is invaluable. However,
these experts must acknowledge that an EHR system should not be selected
only on the basis of its technical attributes. They should not make
recommendations based solely on ease of implementation, for instance,
or because a particular system will require minimal interfaces with
other systems. Instead, they must make sure that the application is
compatible with existing or anticipated hardware and software, that
the security of the system is sound, and that it will mimic providers’
workflow, which is vital to successful adoption.
Data Exchange Depends on Technology
Infrastructure
Judicious selection of an EHR system smoothes the path for eventual
participation in a RHIO or an HIE. To this end, clinical, administrative,
and technological issues become increasingly complex when multiple organizations
begin to discuss ways to integrate disparate systems and exchange information.
Stage one of this journey is inviting representatives
of potential member organizations to the table—including various
local physician practices, health systems, hospitals, etc—to the
table. This can be a challenge because it requires competing interests
to put aside their own agendas to focus on achieving a common goal.
Most of the time, however, providers recognize the benefits to individual
patients and the community. Often, these groups appoint or hire an administrator
to help them navigate the maze of issues that face a RHIO or an HIE.
Once an agreement has been reached and the organization
has been formed, the next hurdle is identifying a funding source. While
some federal money is available, most existing RHIOs and HIEs have relied
on local support—communities and state governments have provided
grants, as have private payors.
In other instances, local health systems have been the
driving force behind these coalitions. To be successful, however, these
organizations have needed to address Stark restrictions. A common strategy
has been to establish an independent corporation, or Integrated Clinical
Network, to avoid the perception that the hospital is giving equipment
or technical resources to physician practices. Many health information
professionals anticipate that concerns about Stark will diminish in
the near future, thanks to proposed legislation relaxing regulations
and allowing more extensive joint efforts.
Partners Must Address Technology,
Access Issues
With funding in place, RHIOs and HIEs must tackle the challenges of
building a viable technology infrastructure to support data exchange
among all partners. Typically, the RHIO or HIE hires IT professionals
to design and manage an appropriate arrangement.
As the data exchange is being developed, the partners
must agree on numerous issues. For instance, will they establish a central
data repository, where patient information is collected to be fully
accessed by all? Or will they adopt a federated “gated”
model in which organizations needing information request or are granted
access to discrete pieces of patient information from other providers?
Then, the coalition must achieve consensus about how
it will identify patients. Currently, there is no national patient identification
system for healthcare, although there has been discussion about establishing
a program similar to Social Security. In the meantime, RHIOs and HIEs
often establish a community master patient index (MPI) to which providers
refer whenever they see a patient either to establish a new record or
access an existing one. Alternatively, a RHIO or an HIE may use an existing
MPI—perhaps one developed by a local hospital. Participating members
can then “crosswalk” patient identifiers with their own
internal system for easy reference.
Another significant issue—perhaps the biggest—is
determining what type of information will be shared. Some providers
are highly protective of their patients and loath to share what they
consider to be proprietary information. Others believe exchanging data
can lead only to better care, which will cement their relationships
with patients even when those patients see other specialists in their
community.
In any event, each RHIO or HIE must decide whether it
will share only basic information—such as medication, allergy,
and problem lists—or whether it will make available comprehensive
records that may include even demographic and insurance data. Either
way, it must ensure that data exchange is secure and all confidential
information is protected.
Lessons Learned Drive Future
Development
Developing a RHIO or an HIE is understandably daunting. It involves
bringing strong healthcare leaders into a discussion and asking them
to work collaboratively in an arena where they traditionally have been
competitors. It entails highly complex technological structures that
arise from disparate systems that were selected and implemented by independent
entities. And it requires diligent maintenance to ensure that the system
is functioning as designed and continues to develop to meet emerging
needs.
The trend toward RHIOs and HIEs is still in its early
phases. Nevertheless, several important lessons have been learned:
• The process takes time and setting expectations
too high guarantees failure. RHIOs and HIEs may take several years to
get established and member organizations must be willing to invest in
up-front planning to enhance success.
• From a technological perspective, these collaborations
must be designed from the ground up to make patient information available
quickly and in a usable fashion. If the data exchange is hard to use
or if vital information can’t be incorporated efficiently, providers
will not rely on or contribute to the system.
• The EHR system used by each partner in the RHIO
or HIE must reflect the workflow of its providers. If the member is
unable to get buy-in within its own system, it will be impossible to
convince providers that a broader network is beneficial.
• Each EHR system must exhibit functionality and
comply with interchange standards that allow it to be networked with
others in the community.
Greatest Benefit
When established, the benefits of the RHIO or HIE are enormous. Patient
safety is enhanced because each provider has an up-to-date record of
the patient’s history, medical problems, diagnostic tests, and
current plans of care from their peers. Plus, all this information comes
with a lower price tag because data sharing reduces the number of duplicate
tests performed. When a provider can see results of lab work performed
three weeks earlier, for instance, he or she will not repeat the studies.
Perhaps the greatest advantage is enhanced quality of
care. For example, internists treat a number of patients with diabetes.
Let’s say a patient recently saw an ophthalmologist, who recorded
a significant change in the individual’s vision. If the internist
has access to that information, he or she will be alerted to the fact
that the patient’s diabetic status needs reassessment.
Besides resulting in better care and outcomes, this
knowledge will also prove invaluable as pay for performance influences
reimbursement. It will become increasingly important for providers to
know the breadth of care their patients receive as payors scrutinize
disease management and health maintenance programs.
For example, primary care providers will need to report
annual well woman screenings such as pelvic and breast exams or Pap
smears as part of pay-for-performance requirements. If a patient has
the primary care provider do a portion of her annual checkup, while
going to her gynecologist for the well woman components, neither provider
will be able to report the comprehensive nature of the preventive service.
With RHIOs and HIEs in place, that data will be easily accessible to
improve payor reporting.
In short, the advent of RHIOs, HIEs, and other collaborations
promise great benefits to providers and patients alike. While still
in its infancy, this trend will no doubt accelerate and become a defining
characteristic of the healthcare landscape. Health information and technology
professionals will play a significant role in the development of these
coalitions, since success is highly dependent on the functionality of
each provider’s EHR system, as well as the network infrastructure
the partners will share.
— Sarah T. Corley, MD, FACP, is a primary
care internist in the metropolitan Washington, D.C., area and also serves
as chief medical officer for NextGen Healthcare Information Systems.

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