Health Interoperability Exposed

Semantics and Interoperability: The Foundation of the Personal Health Record

Much has been written already about the sustainability and practicality of PHRs. 

While a current generation of healthcare users frets about security and privacy, the next generation is much more concerned with availability.  

 Take Mint for example. Since its launch just a few years ago, this on-line banking service is incredibly popular.  In a time of well-publicized identity theft, it is interesting that a younger generation is all too eager to give out banking and credit passwords in exchange for the convenience of a single source of financial information. According to Mint, 65 million people in the U.S. use online banking today, and the average American has more than four bank relationships. Despite individual banks’ long-established on-line offerings, Mint’s success derives from its ability to provide an aggregated view from differing sources.  The analogy to health care is obvious, simple portals to payers or health systems are not sufficient, an interoperable view is an obvious necessity to today’s consumer.  But here’s the problem- unlike the US banking industry, our medical systems do not deal in a single domain (money), with a well-established standard (the dollar). 

What then is the role of semantics in this brave new world of the Personal Health Record?  Let me illustrate some common issues:

1.  Disparate medical records result in similar and/or duplicative data using different vocabulary standards. This ‘raw’ data, presented to the layperson in a PHR will result in misunderstanding.
2.  Lab data from differing facilities may have differing reference ranges. This will likely cause patients to question “normal” results, and limit their ability to accurately follow trends.
3. “Medical-ese” will need to be balanced by layman’s terminology.  A chest X-ray report with the phrase “pulmonary vasculature and cardiac silhouette appear unremarkable, however, one cannot rule-out neoplasm on this limited study” would probably better be listed in the PHR as “normal”.
4. Common laboratory panels with archaic or non-contributory values will need to be reassessed.  These are tests that should only be ordered in rare clinical instances, but for historic reasons are part of automated panels.  Clinicians have long ago learned to ignore such items in the complete blood count panel (eg. RDW, MCHC) or chemistry panel (eg. BUN/Cr ratio).  Patient’s frequently call me when they see their own reports—alarmed by “abnormal” results that have no significance.

I have previously opined that disease-specific clinical views of harmonized and appropriate information will be necessary for clinicians to interpret and utilize voluminous data in a meaningful work-flow. It is even more imperative that the layperson have analogous view in a PHR which will allow them to knowledgeably participate in their health care process.

Finally, we must remember that PHR data will undoubtedly flow both directions. EMRs must be capable of consuming home device or patient-entered data, in a presentation that does not confuse source to the caregiver.

Learn more about how the role semantics and interoperability play for PHR success by registering for this free webinar: Engaging Patients and Families with a Google Health PHR

HIMSS 2010

I am looking forward to the annual Healthcare Information and Management Systems Society (HIMSS) meeting this year. From my vantage point, interoperability is at the forefront. There are literally thousands of vendors present. The incredible display of varied and new technologies only serves to underscore the ever-deepening silos of medical information.

The HIMSS Interoperability Showcase is one venue to see Information Exchange in progress, but in my opinion, it represents only the fledgling state of what is needed to serve the day-to-day workflow of a busy practitioner.

This year will be an important milestone for healthcare IT, and interoperability in particular. There is so much buzz about “the stimulus” and “meaningful use,” and one feels as if we have finally overcome the coefficient of friction needed to push EMR adoption (finally) into widespread use.

When talking to hard-nosed, daily grind, community physicians, they remain extremely skeptical of receiving a single penny for IT adoption.  More importantly, they worry that physicians and hospitals will adopt IT to “get the checkboxes” for meaningful use, but no great improvements in actual patient care will result.

Much of this has to do with a compelling need to practice connected healthcare—a need to improve collaboration and act as a true care team without walls.  Additionally, a population oriented approach to chronic disease management is becoming an ever increasing priority.  However, to accomplish these noble goals, overworked and often underpaid physicians demand tools to markedly improve efficiencies in work-flow, communication, and “closing the loop.”I know that it seems as if I continually beat the dead horse of semantic integration on this blog, but I will again stress that a complete and clinically relevant presentation of data must be the foundation for managing the increasing complex transitions of care that we are seeing in healthcare today.

So if you are attending HIMSS this year, try not to observe these wonderful, yet disparate technology jewels, shining as individual displays; instead try to see the bigger picture and imagine them dazzling vibrantly together. Interoperability as a technology will play a role, but cooperation, and acceptance for change will ultimately lead to a sum greater than its individual parts.

The Medical Home and Interoperability (Follow-Up)

This post is directed to the comment from my previous dialogue on Medical Home and Interoperability as a deeper explanation to encourage a continuing discussion. 

In response to a real world example, diabetes mellitus serves as an excellent model for the need for semantic integration and population-based decision support.

Simple problems, such as comparing blood work from differing lab systems can be troubling. Comparing “blood sugar” to “serum glucose” to “glucometer” for instance; or “HBA1c” to “glycohemoglobin” to “glycosylated Hb” to “hemoglobin A1c” is in itself a daunting task. Let alone the myriad of other tests that need to be directly and indirectly compared.

What about the hurdles of simply identifying new patients in the diabetic population. Take for instance a patient who has a history of gestational diabetes diagnosed during a remote pregnancy. This information might only be present in the obstetrician’s office records or in the labor and delivery information system. If this patient were to have an eye exam years later, which demonstrated retinopathy, clearly we would like to be able to “connect the dots.” The problem, of course, is that the decision making is obfuscated by information silos and translational difficulties that result from differing medical vocabularies.

More difficulty arises from identifying negations of care. It is easier to use information technology to see if a patient has satisfied a particular quality measure, but providing a list of diabetics who “haven’t had a urine microalbumin level checked in 6 months” is technically challenging on many levels.

I believe that the times cry out desperately for improving diabetic care through the use of this kind of advanced technology.

The now famous UKPDS study showed that for every one point drop in a diabetic’s HbA1c level, there was upwards of a 14% decline in morbidity (i.e., kidney disease, blindness, loss of limb, stroke, etc.). It seems obvious to me that we must direct our most intensive efforts on treating those outliers with poorly-controlled disease, if we are ever to have any hope for a healthier, and thus less economically burdensome, population.

As a primary care physician, I am passionate about this subject, and I know my dedicated colleagues compassionately yearn to help this population. What are needed are the proper tools to accomplish this. I submit that a semantically organized interoperability platform, coupled with advanced population surveillance technology is a critical, yet difficult and poorly understood component.

The Medical Home and Interoperability

 

The patient-centered medical home concept has generated tremendous discussion during this dynamic period of proposed healthcare reform. Whether or not this model will finally take hold remains to be seen. It is clear, however, that a new paradigm in chronic disease management must occur. The combination of an aging population, increase in co-morbidity, and an emphasis on ambulatory management, places a heavy burden on technology to come to the rescue.

For those not familiar with the medical home model, it goes like this: a personal physician oversees a team that takes care of chronically ill patients at the practice level. Care is coordinated across the continuum (acute, subacute, ambulatory, long-term care, home care). Adherence to evidence based guidelines are the foundation for a payment model that may support $40-$51 per member per month, depending on illness severity and the physicians level of medical home designation.

The National Committee for Quality Assurance (NCQA) has emphasized the following:

• Access and communication
• Patient tracking and registry functions
• Care management
• Patient self-management support
• Electronic prescribing
• Test tracking
• Referral tracking
• Performance reporting and improvement
• Advanced electronic communications

Success of this crucial shift in healthcare delivery is incumbent on significant financial incentives.Clearly, the infrastructure and resources needed to accomplish the above tasks can seem formidable to primary care clinicians. The ability to automate much of this work can mean substantial dollars remaining in the hands of physicians. 

Electronic data is only a small piece of the solution. Aggregation of disparate information is another small piece. Semantic normalization, however, is crucial for difficult burden of advanced analytics and disease-specific dashboards.

Most important, in my opinion, is the ability to monitor specific populations in real-time, using advanced and meaningful decision support coupled with appropriate messaging and alerts. Semantic interoperability is thus the cornerstone for the long-term success of the patient-centered medical home model.

Avoiding the Seven Deadly Sins

 

I am anticipating the upcoming Webinar entitled Avoiding the Seven Deadly Sins That Can Derail Your Interoperability Strategy. I like this theme as a metaphor. After all, it seems that "Lust, Gluttony, Greed, Sloth, Wrath, Envy, and Pride” all eventually find their way into HIT projects. It is the recognition and management of these traits of human frailty that ensure successful implementation.

“Sloth” seems to me as the most glaring sin today. How long must we continue to wait for meaningful information exchange while those responsible for health and wellness continue to decide whether or not they can adapt to new technology? As a “deadly sin,” the Institute of Medicine’s now famous report on deaths due to medical error certainly places the slow pace of technology acceptance in the limelight. But perhaps I am a bit harsh. Maybe, like my own display of impatience, the slow pace of change is merely a “venial” sin—meaning that they can be forgiven.

But let’s not talk about the sins of omission.  Institutions and clinicians that are embarking on the initial steps of interoperability must be wary of two of the deadly sins—“Greed” and “Gluttony”

When I talk to physicians about information sharing, the truth is that most want “everyone to share with me,” yet many are unwilling to contribute data back. Much of this is due to paranoia that still exists regarding the potential misuse demographics and referral patterns for unfair, competitive business purposes. 

In addition to “wanting without sharing,” most physicians are unwilling to change their own practice in order maintain an HIE. Workflow seemingly demands that each maintain records in his or her own vernacular, perhaps using a proprietary EMR, often with free text. In other words, complex vocabularies and disparate data formats must adapt to their needs.

Think about the consequences of “Gluttony” when it comes to medical data. Why wouldn’t we “want it all?” Yet like many things in life, overconsumption can hurt you. Differentiating critical data can be like finding the proverbial needle in a haystack, if this overwhelming data collection is not semantically organized.  Because it is now “there,” many clinicians continue to worry about the new medico-legal consequences of being responsible for “all the data.” Finally, many conscientious caregivers feel compelled to review the entire record, and worry that interoperability will drastically cut into their efficiency.

The Webinar will be held on October 20 from 1-2 pm (EDT),  is co-sponsored by dbMotion and Initiate Systems and will feature Dr. William A. Fera VP, Medical Technologies & Medical Director, Interoperability The University of Pittsburgh Medical Center (UPMC) and Lorraine Fernandes, RHIA Vice President, Healthcare Industry Ambassador, Initiate Systems as moderator.

I look forward to Dr. William Fera’s take on this.

For more information and to register for the webinar, visit http://www.dbmotion.com/register%20for%20webinar.aspx

 

If You Build It, They Will Come

Much is being written about the current economic stimulus plan and its impact on healthcare IT. This has resurrected an old debate on whether subsidizing EMRs will actually increase adoption and lead to lower overall healthcare costs. Many years ago, I was frequently asked to lecture family physicians on why they should get an EMR. The common objections were: 1) too expensive 2) too difficult to implement 3) won’t integrate with other systems.  Like many others, I showed that my EMR had a positive return on investment and significantly improved my efficiency, while improving care.  Unfortunately, I had to concede on the interoperability issue.

I think it is helpful to use the analogy of cars and highways here. Obviously there needed to be a critical mass of automobile buyers before anyone thought about building interconnected highways. On the other hand, how could one justify buying a car if there was nowhere to drive it?  Similarly, if we really want to increase the number of EMR users, the ability to interconnect them (vis-a-vis interoperability) must be part of the overall strategic plan.

Here are some interesting facts:

• First affordable auto – 1908 – Model T
• First Highway network across the country – 1913 – Lincoln Highway
• Interstate Highway System, as we know it – Federal act from 1956 – completed in 1992
• 56% paid by usage fees – gas tax / tolls – 44% from Federal budget

I think the analogies are obvious, but let us dissect each bullet point a bit.

 

1) The success of the American automobile industry had a lot to do with the Model T being affordable to the masses. I do believe that EMRs have hit an affordable price point. Their demonstrable return on investment means that price should not be a variable.

2) Much like initial highway construction, there was little interconnectivity, and no overarching strategy to build a national system of roads and bridges. 

3) The Interstate Highway System really emerged as a result of a federal imperative to provide infrastructure for natural defense. It was government subsidized. In fact, the initial cost estimate for the system was $25 billion over 12 years; it ended up costing $114 billion (adjusted for inflation, $425 billion in 2006 dollars) and took 35 years to complete. 

4) The last bullet point is more difficult to analogize. In my opinion, usage fees must be borne by those who most benefit—I will not opine on whether this should include payers, employers, hospital systems, pharma, or patients themselves—I will leave this to public policy experts.

5) Interconnected roadways clearly led to the American consumer’s infatuation with automobiles. This led to dramatic improvements in highway safety, better modes of travel and lower overall costs of transportation.

Thus it is my belief that interconnectivity must occur in healthcare if we expect a parallel drive to improve patient care, new modes of healthcare delivery and cost reduction.  

The 15% or so of US physicians that have adopted EMRs probably represents the saturation point without an interoperability foundation. When the majority is convinced that they will be able to do more than glorified word processing, they too will finally be won over. That is why I have been referred to as an ‘Interoperability Evangelist.’ Let us first put effort into building the means to connect disconnected venues of care.  Only then will national projects take hold.  Build it, and they will come.

My “Geeky” Obsession Confession

I have been a Family Practitioner for almost 20 years.  When I decided to implement an EMR in my 4 office, 5 doc practice 8 years ago, the term “interoperability” was not one that I frequently used.  None-the-less, I was increasingly frustrated when patients saw me in more than one office, and I did not have their medical records.  Instead, I had to fax a portion of it.  The sheer coolness of an EMR was surprisingly matched by a first year ROI of $60,000 and a huge increase in productivity.  But “interoperability” between offices was the biggest benefit.
 
Because of my evangelical-like advocacy, I was tapped to be the physician champion and later CMIO for a CPOE project at my community hospital.  We immediately had 100% adoption, resulting in nearly 80% reduction in pharmacy errors within the first 6 months alone.  Don’t let me imply that this was easy, I still have the scars on my back to prove it.  Asking dedicated physicians, who are at the top of their game, to change the way that they practice always requires a leap of faith.  Decision support remains an  unmet mandate.  Alert fatigue and lack of true enterprise-wide intelligent rules continues to frustrate.  Still, it gives me great pleasure to know that 4 years later, almost everyone agrees that they could not go back to paper.

Needless to say, continuing to practice primary care medicine, while having the experience of EMR adoption in both the ambulatory and acute care settings, has given me a rather unique perspective on the needs, benefits, and frustrations of data sharing.
 
In my current role overseeing semantic interoperability projects, I have come to understand the further complexities of incomplete ontologies, imperfectly controlled medical vocabularies and the insanity of multiple standards.   What I used to think was a rather esoteric area of medical informatics, has now become almost an obsession (OK, I admit I’m a geek).  The truth is, many of the problems facing healthcare today, will only be solved when we can easily start exchanging knowledge—not just data—while maintaining a reasonable work-flow.

The purpose of this blog is to shed some real-life perspective on these issues. Hopefully, I can educate a little, while learning a lot.