Health Interoperability Exposed

Who Wouldn’t Want Life to be Easier While at the Same Time Improving Patient Care?

Providing better care for patients and making the work day easier. All too often, these are opposing goals in the life of a busy clinician. I think that this is the reason why interoperability without regard to semantics will not be widely accepted in the long run.  Every day when I see patients, it seems like there is more and more information that I need to review, but so much less time to do it in.  Which corner will I cut…time spent with patients, reviewing critical data, or getting home on time to my family? 

Let me give you some real life examples of how additional information, if not served up correctly, may actually be a real burden. Suppose I am interfaced with 3 different clinical laboratories and received results for serum glucose and serum sodium.  How might these be expressed?

Sodium	Glucose
Na	Blood Sugar
Sodium	Glucose
Serum Sodium	Serum Glucose

Imagine if all of these were displayed alphabetically along with hundreds of other results.  By expressing each of the labs local terms as a single baseline term, one can easily see how information is more efficiently retrieved, while reducing my chances of “missing” crucial results. Here’s another example: 

This is an actual screen shot from my office EMR a few years ago. You can see that there are multiple “penicillin” allergies listed in this EMR (amoxicillin, Augmentin, ampicillin, etc.) 

This particular patient was seeing 3 different specialists.  It is likely that each recorded similar allergy lists in their own EMR’s proprietary format.  An aggregated view would be unmanageable for me, requiring that I scroll through multiple pages.  Worse than that, notice that all of the “penicillin” allergies were minor. 

Unfortunately, the last item on a long list, in this case “sulfa,” is associated with a life-threatening reaction. By semantically grouping all of the different penicillins under a single heading, the resulting presentation improves efficiency while decreasing a potential for iatrogenic error.

These are the basic first steps in achieving semantic interoperability.  Yet they very clearly demonstrate how the goals of workflow and improved care are now more properly aligned.

Easier work day, improved patient care…life is pretty good.

What about Standards?

“I am not here concerned with intent, but with… standards, especially the ability to tell the difference between a fact, an opinion, a hypothesis, and a hole in the ground.”                                                                                                                                         - Serge Lang, Mathematician

“The problem with standards, is that there are so many of them.”
-Anonymous

Most clinicians would agree that other than gross negligence, transition of care accounts for the greatest potential for medical error.  If only there were standards, both clinical and technical, between venues of care.  Isn’t that the fix we desperately need?

HL7 CEO Charles Jaffe has another opinion:

“There is not a lack of standards, there are, in fact, too many standards and too many organizations writing them. There are some standards that are easy to implement or easy to understand, but which lack coherence, scalability, or broad adoption, while others are difficult to understand or cumbersome to write code for implementation. Some organizations write specifications or artifacts that are useful but painfully limited. Some are built on strict models and development frameworks to improve interoperability. Others meet the needs of the specific domain but are incapable of being used to share data with our healthcare environments. Some are meant to be international while others are simply realm-specific.”

And now we have ICD-10, due for roll-out in 2013.  For those of you who don’t read the blog Better Diagnosis Coding, you should. This Anonymous Ontologist has an intelligent yet cutting view on the subject. His recent posts on the topic of ICD-10 are extremely insightful. Here’s a perfect example:

“The health care industry now has a little more than 4.5 years to find every usage of ICD-9-CM codes in all of its systems, and upgrade and test them to use ICD-10-CM. All the effort spent on that, will not be spent on adopting electronic medical records, devising and participating in pay for performance programs, improving patient safety, automating the reporting of notifiable diseases, chronic disease management, quality initiatives… and the list goes on.”

Several years ago, I was contacted by a lobbying group to solicit my opinion, as a family physician, on the value of ICD-10. Value is a relative concept, particularly when estimates of cost to a typical 3 member medical group for implementing ICD-10 were more than $80,000!   I asked them what practical improvements it might make for me and my patients. They replied “in ICD-9, you can code for just a sports injury, but ICD-10 will allow you to specify whether they were struck by a baseball, a football or a basketball”. After I apologized for laughing, I confessed that they had not convinced me of their value proposition. 

In my previous post, I made an analogy of HIT to roads and cars. The truth of the matter is that there will always be hundreds of different cars and trucks on our highways. Each of them suits individual needs for productivity and efficiency, or just plain human whim and fancy. Our roads and bridges must carry them all.  Some standards are necessary, but mainly for safety and accessibility.

I believe that we must begin the more necessary work on infrastructure. Semantic interoperability is the foundation. To quote Charles Jaffe once more:

“Perhaps the most difficult challenge is to bind the standards to structured vocabularies to ensure that there is the unambiguous transfer of meaning.”

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.

Confusing Theuth for the Truth? Don’t Feel Badly…It’s Been Going on For Centuries!

Imagine being at a meeting, where 100 participant each speaks a different language.  How could they have a meaningful conversation?

Ideally, everyone could learn a common language.  This, unfortunately, is a naïve and somewhat arrogant construct.  I remember traveling to Italy many years ago and observing an angry tourist yelling at the proprietor of a charming trattoria, “The world would be a whole lot better if you people would all just speak English!”

Another approach would be to have an unlimited number of translators in the room—enough to translate each language into any other.  In addition to needing a huge room, the logistics would be staggering.  Think of how many single points of failure would exist.  Finally, even if such a system was operational, it is likely that subtle, but often critical, nuances in meaning would be “lost in translation.”

All of this should serve as an obvious and painful metaphor for the current state of healthcare information exchange.

Now to truly have an intelligent discourse, it is essential that each participant be capable of truly understanding the opinions of others, in the language which he or she is most fluent. This begins to touch on what is referred to as semantic interoperability. In healthcare, all members of the care delivery team must be able to comprehend information in a format that they are most comfortable with, while—and this is the important part—the data retains its original and intended meaning.

A bigger challenge is to convince caregivers that access to data does not equate with having knowledge. In Plato’s Phaedrus, Socrates tells the story of Theuth, the inventor of the written word.  After learning of this new technology, the Egyptian king became upset. For he quickly understood that a collection of facts in a single source would not necessarily make his subjects smarter.  By confusing aggregation of facts with the attainment of actual knowledge, they might in fact lose wisdom.

Similarly, interoperability by itself cannot improve healthcare by merely presenting more system specific data points.  Instead it must present information in a meaningful and efficient way in order for caregivers to fully comprehend and process it as knowledge.

As information continues to increase at a rate much faster than the availability of new medical devices, the imperative to accomplish this goal could not be greater.

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.