A fundamental part of Electronic Health Records (EHR) systems is the ability to share data with other, outside sources. Besides simply capturing in-office work – chart notes, prescription writing, scheduling, and the like – an EHR should connect with the “outside world.” This is the ideal, yet this seemingly-simple desire is quite elusive.
As the Office of the National Coordinator (ONC) helps lay the foundation for a Nationwide Health Information Network (NHIN), the challenges for transporting and sharing data have come to light. Even the more-simplified and more-likely-to-succeed version of this, the NHIN Direct, is still a significant undertaking.
Why is this all so difficult? The answer is largely historical – each piece of the healthcare ecosystem has created data and tools that fit its own particular need, independent of a view of how it all fits into a larger picture. A lab system that reports lab results, as well as accepts lab orders, is completely different from an x-ray/imaging system used to view images in diagnostic detail, report the findings as dictated/entered by a qualified radiologist, and accept imaging orders from outside physicians (including obtaining insurance authorization beforehand).
Health data is really not one simple, unified thing – it is a collection of separate pieces, each with separate formats, separate standards and separate places where they are housed. The challenge for EHRs has been to corral all these distinct pieces and tie them together into a single “patient chart” that is accurate, secure, and logically makes sense.
Many EHRs used by clinicians in an ambulatory setting are ones that are centered in a local hospital, and pushed out to surrounding referring physicians. Often, such EHRs are partially or fully subsidized by the hospital, to soften the impact of adoption and hopefully increase usage. In these kinds of settings, the hospital can take the onus of tying their internal systems together, and them pushing them out to the community docs – thus, the local docs can see the xray reports, lab reports, and hospital reports (H&Ps, operative notes, discharge summaries, consults, etc) from their own offices.
This is good, but confines the data to the orbit of the local hospital. Kaiser’s system is an example of a very large such system, but the ability of a clinician outside of the Kaiser system to see that data is missing.
The ONC workgroups focusing on the NHIN have tried to establish standards for such data exchange. The goal is to create a conduit such that a clinician in her office can pull data from the local hospital, from outside systems (like reference labs), from other hospitals and clinics, and from central registries like regional Immunization Registries. Several federal agencies have developed a tool called CONNECT that is intended to address operational details of all this – like locating patients in other organizations, request and receive documents about these patients (after all, each system refers to a given patient in a different way), record these transactions for audit, authenticate network participants, and honor consumer preferences for sharing their information. This collection of tools has been made available as a free open-source toolkit that EHR developers can use to build interoperability in a standardized way.
Local hospitals or similar networks that push a central EHR out to community docs is a limited solution to sharing medical data. It is a bit more challenging for an EHR that originates in the ambulatory realm (like Practice Fusion) to connect with local hospitals from the outside.
Firstly, we should probably not think about “hospitals” as a discrete entity. Our experience is that each hospital is a collection of several discrete systems (labs, medical records, xray/imaging, etc.), and the degree to which they are tied together within the walls of the hospital varies all over the map (literally).
It would be better for us to think about “hospital integration” as integration with hospital pieces. Connectivity with local hospital lab systems, for example, is quite different than connectivity around Medical Records – there is more in common from one hospital to the next around lab systems than there is between systems in a given hospital. With labs, if a given hospital’s lab system can meet certain standards of data exchange (such as HL7 v2.3.1 or v2.5.1 using the LOINC vocabulary), this could be thought of as “one” hospital integration project. A different one would be connecting with a hospital imaging system (their PACS, or Picture Archiving and Communication System) – if a hospital can expose its PACS in a standard way, using the DICOM standard, then a connection with hospital imaging can be done (in many different hospitals).
Likely, “integration with my hospital” will unfold in a system-by-system way across the landscape. A local hospital may be able to connect with an “outside” ambulatory EHR (not one of their choosing) with its lab results only; a different hospital in the next town may have PACS connectivity but not lab; yet another one might connect with labs, medical records and also PACS. This approach is much more likely to be successful than thinking of the “hospital” as a single “thing” which can/cannot be integrated. We look forward to making these kinds of connections as standardization improves, and the opportunities to do so become available.
Robert Rowley, MD
Chief Medical Officer
Practice Fusion EMR