Off the record

Even among health care providers with electronic medical records, interoperability remains an issue.

Although there has been much talk about electronic health care records among health care providers, the fact remains that most health care providers still rely on paper. Only about 18% of doctors use an electronic health records system today, according to the Health Information Technology Standards Panel (HITSP), a government-sponsored nonprofit organization with a mandate to tighten and harmonize the industry's many different standards.

Even among providers with electronic medical records, interoperability remains an issue. Although standards are finally getting some traction with vendors and providers, there's still a long way to go before broad interoperability is achieved.

The ideal is to exchange electronic health care record data to provide an all-inclusive view of the patient. But before that can happen, health care providers need to get their own internal systems -- from lab and radiology systems to ambulatory systems -- fully online and interoperable. Only then can they begin to contemplate sharing electronic medical record data with other institutions.

Even larger institutions may not have every system fully integrated. "We have to get to a better platform before we can talk about data sharing," says Joshua Lee, medical director of information services at the University of California, San Diego, Medical Center, noting that UCSD's efforts are about 70% complete.

Square One

Getting to 100% isn't easy. "We're starting from a basic place of no interoperability between health records," says Mark Leavitt, chair of the Certification Commission for Healthcare Information Technology (CCHIT), which works with the Health Information Technology Standards Panel (HITSP) to certify vendor compliance with interoperability standards.

At Duke University Health System, it took a staff of 25 people to pull everything together, says CIO Asif Ahmad. That's because even the biggest vendors' products don't integrate easily. "You can't send information from a McKesson system to a Cerner system," he says.

Duke ended up pulling the data out of the proprietary systems and feeding it into a data warehouse. "It shouldn't be this hard to do," he says.

What's worse, even within a single vendor's product line, different offerings are often sold separately and don't play well together, says Ahmad. "The vendors segment the market to make more money, rather than integrate systems," he says.

"They make more money on services than on software," says Dave Hammond, chief technology officer at Dossia, an employer-funded organization that is developing a personal health record service.

Robert Smith, associate chief of staff for health care analysis at the Veterans Administration San Diego Health Care System, agrees that getting a single consolidated view of the patient's health record isn't easy. "The real issue is that there is proprietary software, difficulty integrating platforms and software into an integrated record, and too many standards," he says. But that may be starting to change.

Standards Soup

Until recently the health care industry has been unable to come up with a unified, truly interoperable set of standards for specifying the data structures and exchange methods among applications for all medical disciplines, including radiology, pharmacy and ambulatory care.

Even the most basic questions haven't all been resolved. For example, there is still no unique, industry standard patient identification code. "We still rely on probabilistic matching" of names, says Charles Jaffe, CEO at HL7 Inc., a health data standards development organization.

And until this year no common identifier for doctors existed.

Even different systems within the same provider organization may use different codes to identify an individual. At the Cheshire Medical Center/Dartmouth Hitchcock in Keene, N.H., inpatient and outpatient systems use different methods to identify the same patients. The hospital ended up with the two incompatible systems because no vendor offers the best system for both, says Don Caruso, associate medical director and chief medical informatics officer.

Rebuilding the systems around a single patient identifier would have been cost prohibitive, so the medical center relies on work-arounds. "It's costly. There has to be a better way to do that," he says.

Other issues are even more fundamental: No one has created a uniform view of what an electronic health care record should look like. "Sharing becomes difficult when you're not sure of what you're sharing," says Smith.

The National Alliance for Health Information Technology, working with the U.S. Department of Health and Human Services, has parsed the problem. It had developed definitions for electronic medical records (not necessarily shareable), electronic health records (shareable) and personal health records for patient use, health information exchanges and regional health information organizations.

The definitions aren't being created in a vacuum, says vice president Jane Horowitz. "The anchoring point for all of this is the concept of interoperability. It is the linchpin for anything we define," she says.

The organization circulated draft definitions in February and expects to finalize them as early as this summer, she says.

The complexity of the health care business has lead to the development of many standards. "You name the business process, you name the technology, we need it in medicine. It's a real patchwork," says Shaun Grannis, medical informatics researcher at The Regenstrief Institute, an Indianapolis-based research organization that spearheaded one of the country's first citywide health information exchanges.

Unfortunately, most of those standards efforts were developed in silos, and many are overlapping or competing. Until recently clinical summary documents on an individual could be sent using one of two industry standard formats: One from HL7 or another from the American Society for Testing and Materials for health records. "It was like Blue Ray vs. HD DVD," says Leavitt of the CCHIT.

The HITSP eventually blessed HL7's Continuity of Care Document (CCD). "CCD is the biggest and most important capability. That's the start of having portable electronic records for people," Leavitt says.

John Halamka, CIO at Harvard Medical School and Beth Israel Deaconess Hospital in Boston and a Computerworld columnist, says he's been able to achieve a high degree of integration with a staff of three using the HL7 message and document formats. But others say that even commercial systems that comply with that standard aren't necessarily interoperable.

"Not everyone applies HL7 in the same way, and there are 10,000 naming conventions that you still have to work out," says Lee.

Too Many Options

Another problem, Halamka says, is that standards have been influenced by vendors to the point where too many aspects became optional.

Therein lies the problem. "A standard full of options isn't a standard and doesn't let you connect systems in a plug-and-play fashion," says Leavitt.

The HITSP's job is to act as a "harmonization body," a "trusted, transparent convening organization to bring stakeholders together" and create interoperability specifications that are unambiguous, says Halamka, who chairs the organization.

The HITSP has the backing of the Department of Health and Human Services, which has made compliance with HITSP specifications a requirement for doing business with the government. "Since the government buys half the health care in this country, that tends to end the competition," Leavitt says.

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