EMR standards – the problem of moving data from one system to another

Why can’t I just take my Electronic Health Record (EHR) charts and move them from one system to another one? This seemingly-simple question has vexed builders of a national Health IT infrastructure, and leaves us with the dissatisfying answer of “it’s not that easy.”

Every EHR system uses a different internal way of collecting and organizing its medical data – so simply exporting a series of tables (either as spreadsheets or csv files) won’t work, except for a few areas – like patient demographics and other summary data. But chart notes themselves are handled differently, and are often tied to underlying templates upon which they are built, and cross-linked with other tables like coded diagnoses and medications. The closed, proprietary legacy of EHRs has been a backdrop in this situation.

A useful analogy for understanding all of this can be found if one considers the state and nature of email systems (granted this is not the cleanest analogy, but it should help a bit – apologies if the analogy is sloppy). Standard email (referred to as pop mail) resides on a server (could be your local enterprise, could be hosted), and is downloaded locally into your email client (e.g. Outlook). Exactly how the email data is structured might vary from client to client, and that doesn’t matter too much, so long as the email is displayed in a way that you can read and use. There are certain standards for emails that we all expect – the sender, the recipient, a subject line, the body of the text, and optional attachments. That way, if you send an email from your Outlook email client to someone else using something different (like GroupWise), the sender and the recipient see the same thing. It doesn’t matter how Outlook or GroupWise manage the details of the data in the background – what we are interested in is the content.

This is the result of standards for email transport, which were worked out decades ago. In health IT, analogous standards are just now emerging, hoping to create a standard message format for EHR records, in order that different systems can send “messages” to each other. There are a couple of formats that have been proposed: the Continuity of Care Document (CCD) – favored by larger institutions and hospitals – and the Continuity of Care Record (CCR) – which is felt to be more lightweight and favored by Health 2.0 systems. Both data-exchange formats are acknowledged and accepted by the ONC in their Meaningful Use and HHS Certification criteria.

One aspect of email message-exchange (pop-mail) is that the message itself (a structured text file) leaves the sending computer and travels over public channels to the recipient’s client, exposing the potential for the message to get intercepted. That is why HIPAA security rules require that such emails must be secure (encrypted) to protect unintended disclosure. Same goes for sending CCDs or CCRs between computers – the messages must be encrypted.

Building on the email analogy… in addition to traditional pop-mail email, there is also web-mail (like Yahoo mail or G-Mail). Web mail is entirely hosted, and the messages never leave the hosting system to be copied and downloaded into your local machine – what you see is simply a view of your email, which disappears from your local machine when you look away. This allows for more universal access – you can retrieve your messages from any computer, you don’t need to have a client like Outlook installed, and you can see your messages from computers other than the one that contains your Outlook files. For this reason, providers of secure emails between patients and physicians (like RelayHealth) use a secure web-mail method of doing this.

To bring this analogy back to health IT, legacy EHR systems are like pop-mail, with locally-installed clients and local enterprise servers. Web-based EHRs, like Practice Fusion, are like web-mail, where nothing locally is needed other than a browser (any browser) and an internet connection. And no “messages” (=PHI) reside on a local machine.

So how do you get your medical data from one system to another? Given the differences in how the data is organized in the background (you can’t simply take your local Outlook’s .pst file and copy it to a system running some client other than Outlook), the only way is to move each record across (via CCRs or CCDs). This is akin to moving your Outlook pop-mail into someone else’s Yahoo web-mail: you select the desired emails and send them. Because of email standards, the message will move wherever you intend it.

Looking ahead, that is the only realistic way of moving from one EHR system to another. You can’t simply dump your NextGen tables into a collection of spreadsheets or database dumps, and then move them to Practice Fusion. Some of the data, like demographic or other summary information (analogy: the email headers), is standard-enough between systems that Practice Fusion can create a mapping to bulk-move everything over. But the main way, like moving your Outlook emails to Yahoo web-mail, will be to send each email from one to the other (mass output CCRs or CCDs).

The problem? The standards are still not fully mature, and not everyone uses them (yet). HHS Certification is one impetus that will drive adoption of these transport standards, so that health data can more easily be moved from one system to another. And physicians can more easily move from their $50,000 legacy system to a web-based one.

Robert Rowley, MD
Chief Medical Officer
Practice Fusion EMR