Web-based EHRs and the Health Internet

Medical information systems need to talk to each other – whether that data sits in a physician’s ambulatory Electronic Health Record (EHR), or in a hospital system, or in a patient-centered Personal Health Record (PHR), the data should flow back and forth easily. That is the hope and vision of the Office of the National Coordinator (ONC) for Health IT, as it has elaborated on health data interoperability.

Exactly how we go about doing that has been the subject of widespread discussion, which can be thought of as falling into two different approaches: the Health Information Exchange (HIE) approach and the Health Internet. A recent article by David Kibbe and Brian Klepper reviews these approaches quite well.

The HIE approach to interoperability is one that builds local and regional data-exchanges, and then attempts to tie them all together into a Nationwide Health Information Network (NHIN) – a “network of networks.” This approach represents an older model, which relies on functional, local regional networks, whether they be Regional Health Information Organizations (RHIOs) or e-Health Collaborative networks. These networks are privately owned and operated by large provider organizations (e.g. hospitals and health systems), and have been slow to evolve, and expensive.

One of the criticisms of the HIE/RHIO approach has been that the networks are not particularly accessible to patients using the Internet. Such exchanges generally rely on large database management systems housed in large data centers (hence the cost), typically run on proprietary software, and result in closed networks – there may or may not have a way of enabling Internet access. In most RHIOs, access to the data is available to participating doctors, nurses and hospitals – as a patient wanting to access personal health data, you’d need to request your data in the traditional fashion from your doctor, and often you will receive that information on paper.

Somewhat independent of the slow and cumbersome HIE-development process, the Health Internet has been evolving rapidly. Health 2.0 companies have been based on the Internet from the outset, and connect using modern technologies – web-service based APIs that allow platform-independent interoperability. Most sectors outside of health care use this approach – e-commerce, banking, social networking, maps, etc. In health care, many consumer-oriented web sites, which may offer niche services (e.g. diabetic calorie counters, or osteoporosis risk calculators) or full stand-alone PHRs (e.g. Microsoft Health Vault or Google Health), work in this way. These kinds of web services can “plug in” to other web-based services (e.g. Practice Fusion’s EHR and connected PHR) in a way much easier to enable than interoperability via the HIE/RHIO approach.

The Health Internet is growing very quickly – it was quite evident at the recent Health 2.0 conference. This growth is largely independent of what is happening at the ONC, though all eyes are on them as Meaningful Use standards for EHRs, and funding for the NIHN are worked out. Clearly, the ONC needs to embrace the kind of modern connectivity that has emerged in the Health Internet.

We have called on the ONC to build connectivity based on web-service APIs, so that EHRs can connect for reporting of Meaningful Use data, PRQI data, Vaccine Adverse Event Reporting – in short, event reporting should all be reportable through this kind of technology. Further, by specifying well-defined standards for health-data API exchange (WSDL definitions), then facilitation of data exchange between disparate systems – Kaiser vs. Practice Fusion web-based EHR vs. local hospital systems – becomes much easier to accomplish.

Our commitment remains to help in the development of this process, so that the “new” Health Internet (which includes NIHN integration) can embrace 21st century technology, and help move healthcare in the direction we all envision.

Robert Rowley, MD – Chief Medical Officer, Practice Fusion, Inc.