Everyone knows that interoperability is key to realizing the improved outcomes that technology and data can produce. But once a healthcare provider organization has some interoperable systems in place, how usable is that data to the clinical end users? With more data available, and from various sources, what happens to ease of use?
Three physician IT leaders from high profile provider organizations offered their perspective on the challenges and opportunities for physicians and nurses as interoperability matures. They offered healthcare CIOs and others some advice on how to ensure interoperable data is optimally usable.
There are many challenges caregivers face when first faced with data from different information systems or from different healthcare organizations. Some of them can be tough to overcome.
Health systems often use different conventions for clinical data elements, and so when they’re aggregated across systems, even though they might be described using the same term – for example, “problems” – they might connote different meanings, said Dr. Daniel Nigrin, senior vice president and CIO at Boston Children’s Hospital and assistant professor of pediatrics at Harvard Medical School.
“For example, one organization might have staff who more diligently ‘inactivate’ a problem on a patient’s problem list, whereas others leave a problem on the list long after it’s been resolved,” Nigrin explained. “So when aggregating a patient’s problems across these two organizations, what does one do with this particular entry? Does it get added to the combined list? Does it perhaps reflect a reoccurrence of the problem that was marked as resolved at the first organization?”
Another challenge extends to lab studies, he added. Different labs routinely maintain different normal reference ranges for labs, based on the type of assay or equipment used.
“This means that a sodium level, for example, obtained in one organization isn’t really the same test as one done across town in another facility,” he said. “So aggregating those two together on a lab flowsheet, for example, can generate clinical challenges.”
Interoperability and EHRs
On another front, every EHR has a different data schema.
“The goal of meaningful use was to exchange data between EHRs using a common format – the CCDA,” said Dr. John Halamka, CIO at Beth Israel Deaconess System in Boston and International Healthcare Innovation Professor at Harvard Medical School, referring to the consolidated clinical document architecture. “However, the CCDA has a great deal of optionality, which means that every vendor’s CCDA contains different amounts of information despite having a common format.”
Some CCDAs are very useful while others are filled with large quantities of “noise,” for example, every vital sign from an ICU stay.
“Thus, the major challenge is to incorporate the data received with spending too much time filtering and curating it,” Halamka said. “Of course, there are other issues such as the lack of nationwide patient matching strategy, so it’s often unclear who the data refers to.”
When it comes to interoperability, caregivers are initially shocked that information is available across the walls of unrelated health businesses, said Dr. Terri Steinberg, chief health information officer and vice president of population health informatics at Christiana Care Health System.
“We saw this initially with HIEs, and again when Epic rolled out its Care Anywhere capability for one health system to have access to a patient’s records in another unrelated facility,” she said. “Caregivers, however, tend to quickly acclimate to this improved data landscape and display even less tolerance for unavailable data.”
In general, as providers become exposed to data from unrelated health businesses, their tolerance for inefficiencies and data deserts tend to increase, she added.
“I previously thought that data normalization would be an issue, but caregivers are smart and well-trained, so in most cases a provider’s brain can normalize data in real time,” she said.
So what can healthcare CIOs and other related executives do to make all of this data more usable for caregivers? What are some solutions to these challenges? The physician IT leaders have some ideas to help healthcare organizations with the interoperability push.
“Moving from CCDA to FHIR using the Argonaut implementation guides will help reduce the optionality and noise,” said Halamka. “Adopting a national patient matching strategy using biometrics, a voluntary identifier – think something like TSA pre-check – or referential matching using data outside of healthcare to help matching, for example, what cars have you owned.”
It is essential to develop interoperability workflows, added Steinberg.
“These sort of projects need to be staffed by experienced clinical IT personnel who understand the needs of knowledge/data consumers within their workflow,” she explained. “It’s silly to think that a caregiver with an information need will log into a system that is outside his or her foundation workflow – yet this is how we develop and roll out systems.”
Healthcare executives need to understand that data must be concentrated within a user’s workflow, and that the system that generates the data is less important than delivering the information to those who need it, she added.
Healthcare still is at a point where the biggest problem is the lack of data exchange; so for the time being, the best thing that CIOs and other leaders can do is to continue to push for more data to flow from organization to organization, said Nigrin.
“Yes, using our current systems it will create some new challenges as I described, but those pale in comparison to the inaccessibility of the data that we struggle with now,” he said.
The future of interoperable data being brought together for caregiver use is looking good, with many technological and standards advances being made. So what will healthcare CIOs and other leaders see happening in the years ahead? How will things work for caregivers?
“Numerous tech startups are creating novel visualizations of data that help clinicians find the information they need rapidly,” said Halamka. “For example, we work with Amazon on machine learning interpretations of data and Google for electronic health record search. My prediction, which sounds radical, is that in 5 years, the brand of EHR won’t matter since it will be a back-office function surrounded by mobile apps and cloud services from third parties providing agility and usability. Soon, patient-provider visits will be completed without a keyboard.”
Progress is being made, said Nigrin.
“The CommonWell/CareQuality announcement from a couple of years back is now a reality as of late 2018, with organizations beginning to exchange data across both networks,” he noted. “Although still rudimentary, it’s a great start, and I predict that we’ll see more and more organizations taking advantage of this capability, especially those that need to operate in a mixed-vendor environment, and that don’t have the bandwidth to maintain multiple point-to-point interfaces between organizations.”
The other important development is the ongoing adoption of FHIR, and especially the mandate in the 21st Century Cures Act regarding its use, he added.
“Although FHIR in and of itself does not equate to interoperability, it certainly does provide an important step for exposing patient data in standardized ways from the various EHR platforms,” he explained. “And I have no doubt that more and more third-party vendors will begin to tap those FHIR APIs to provide fluidity of a patient’s data between healthcare organizations, and even to the patients themselves.”
Steinberg of Christiana Care Health System is excited about the future of information integration. She is working on interoperability projects in three categories.
“First, current; identify the future state workflow and ask identity methods to enhance today’s workflow with additional information using low-tech tools or workflows,” she explained. “Second, near-term; what additional features can the organization roll out in the short-term to fortify the data stream. And third, future; automate the future state workflows using FHIR or other technologies so that every provider can stay in his or her ’foundation’ workflow or system yet receive information in that workflow that was generated elsewhere.”
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