Archive for the ‘EMR’ Category

Vendors race to certify their applications to ensure certification by 2011 and meet Meaningful Use requirements. Have doctor’s (i.e., potential customers of these EMR/EHR applications) shifted the requirements from new, innovative functionality for their practice and patients to a focus more on how to gain access to the Federal stimulus money?

One could argue that the government, along with the certification commission, have determined which pieces of the standards and requirements for interoperability and functionality every vendor must provide to a customer. This is now done in conjunction with “Meaningful Use” requirements to ensure stimulus money will be accessible by the doctors. The thought is that a certified EMR/EHR will lead to better patient care and lower costs, yet I wonder if this has stalled innovation somehow.

While speaking to people in the industry, this question comes up frequently, and vendors seem to have shifted their focus to make their software certifiable, although their customers may not find it “meaningful.” The result:  losing the focus on innovation which set vendors apart. There are many niche vendors with great innovative software who do not fit into the current certification program or simply do not have the funds to alter their software to meet the general requirements. Will doctor’s using software from those vendors sacrifice functionality that fits them to get the incentive money instead?

I am interested to start a discussion on this topic as I am sure many of you have great points on this topic.

In the September 2009 edition of Hospitals & Health Networks, an article entitled “Connecting All Your Docs” appeared highlighting a survey that was conducted with all hospitals – Most Wired and the rest. The interesting finding was on the question regarding the ability to accept Continuity of Care Documents (CCD). From the article:

“The difference in the results is obvious from the data. Nearly 70 percent of the Most Wired can accept continuity of care records prepared from a physician office EMR regardless of whether the record is coming from employed or independent physician practices… That’s more than double the rate for the typical survey respondent and more than 11 times greater than the least wired.”

In the chart, it shows the numbers:  53% of all surveyed cannot accept a CCD from a physician office EMR, while only 16% of the Most Wired 2009 cannot accept a CCD from a physician EMR. Going to the least wired, the number that cannot accept a CCD jumps to 87%.

Two observations:

1. Yes, it is logical that organizations focused on being “wired” should be able to do more than those that are not.
2. There is a difference between having the ability to accept a CCD and actually accepting one. It would be interesting to know how many healthcare organizations are actually accepting a CCD from another provider. Today, there is much discussion on CCD, but the real use of it is still really unknown. With HITECH, however, the use of CCD will grow considerably in the next five years. Being prepared is a must.

The poll which is being run on HL7 Standards asks the question on the real use of the CCD today. See the poll at the right and let us know if you are electronically exchanging CCDs today. We know that there are many organizations that have the capability to accept CCDs, now the question is how many really are.

If you have specific experiences with CCD, please share your comments as well.

Explore more CCD topics on this blog.

There is a great article in Physicians Practice entitled “Technology: The Road to EMR Interoperability.” Key points of the article include:

• The article highlights key reasons why there are so many standards in existence today, and it makes several good analogies to explain the state that we are currently in.
• Not only is there a lack of interoperability standards, there is little agreement on basic terminology such as EMR, EHR, etc.
• Why bother with EMR interoperability? Key reasons:  patient safety, accessibility, and efficiency.
• How can you get involved? Collaborate, get on board, be open to sharing…

In the presidential debates, each candidate mentions the need for online patient records, but it is done in such a casual manner that it seems so simple. ”Why hasn’t it been done already?” This must be the thought going through the audience’s minds (if they are really listening). However, reality is different — multiple, differing standards along with confusion over basic definitions and many other barriers get in the way.  It takes effort to dig deeper and strong will to move interoperability forward.

For additional information on EMRs and interoperability, please explore our various blogs on these topics, and read the Physicians Practice article to get a good practical overview.

There are many issues associated with connecting physician offices running EMRs into a hospital or reference lab. In prior postings we’ve covered:

• The use of standard vocabularies or terminologies such as LOINC.
• The challenges of using HL7 Orders and HL7 Results in a standard way — typically via profiling such as ELINCS profile (also described here).
• Communications infrastructure — using a VPN with a real-time, always-on connection or using an asynchronous method such as web services.

Why do I mention this topic? Because it is “readers write” day over at HIS-Talk and there is some excellent discussion about many of these topics.

Selected quotes:

I think the labs agree [more standard integration] needs to happen, but just don’t want to invest in it. It is very painful to get a lab interface up and running. Each lab has multiple regions that act differently, have their own compendiums, etc. Because there is no standard test code, all the codes are proprietary. Testing is required for each and every one.

…

One of the barriers right now is a normal one for our industry: the existence of entrenched systems which would be very costly to change. Since there are many regions with just one or two dominant lab players who control their local markets, there isn’t a great deal of momentum to make the changes happen very fast. However, the ELINCS standard definitely has traction with major players such as the Markle Foundation, CMS, HL-7, etc. and it is also the standard for results for CCHIT certification which is obviously a major force.

…

By their very design, the use of a standard will require the implementer to jump though at least a few hoops (some of which may be on fire). Also, the device-to-EMR interface you complete today will probably not work for the same device and EMR in a year from now.

…

Nobody dislikes standards. Interoperability is usually good for business. There are two primary reasons why a company might not embrace communications standards:

1. The compromise may be too costly, either from a performance or resources point of view, so a company will just do it their own way.
2. You build a propriety system in order to explicitly lock out other players. This is a tactic used by large companies that provide end-to-end systems.

…
I’ve been to many conferences (TEPR, HIMSS, World Health Congress, etc.), and nobody seems to be able to tackle the thorny problem of semantic interoperability. Everyone can speak HL7, but that’s only half the problem. There are so many different entities that need to agree on what each of those data elements MUST ACTUALLY MEAN that I’m not sure we’ll ever see a solution.

HIMSS EHRVA developed a Quick Start Guide for implementing the Continuity of Care Document (CCD). HIMSS EHRVA is a trade association of Electronic Health Record (EHR) vendors. Included in the file are two sample CCDs. The guide seems to be a useful resource for implementers of integrated healthcare systems.

A few past posts and insights that you may want to explore:

• What is the CCD?
• EMR Interfacing Best Practices
• Comparing HL7 Messages to HL7 Documents

Please post any experiences that you have in implementing the CCD or using this Quick Start Guide.

The National Alliance for Health Information Technology (NAHIT) recently released new definitions of certain healthcare IT terms. This project was completed for the Office of the National Coordinator of Health Information Technology; this office was created by the President on April 27, 2004 to promote the adoption of electronic health records by most Americans by 2014.

Outlined below are the definitions published by NAHIT. These healthcare IT definitions were published in the report entitled Defining Key Health Information Technology Terms (PDF).

• Electronic Medical Record: An electronic record of health-related information on an individual that can be created, gathered, managed, and consulted by authorized clinicians and staff within one healthcare organization.
• Electronic Health Record: An electronic record of health-related information on an individual that conforms to nationally recognized interoperability standards and that can be created, managed, and consulted by authorized clinicians and staff across more than one healthcare organization.
• Personal Health Record: An electronic record of health-related information on an individual that conforms to nationally recognized interoperability standards and that can be drawn from multiple sources while being managed, shared, and controlled by the individual.
• Health Information Exchange: The electronic movement of health-related information among organizations according to nationally recognized standards.
• Health Information Organization: An organization that oversees and governs the exchange of health-related information among organizations according to nationally recognized standards.
• Regional Health Information Organization: A health information organization that brings together health care stakeholders within a defined geographic area and governs health information exchange among them for the purpose of improving health and care in that community.

The greatest understatement in the report is: “Interoperability is the common thread running through health IT terms. Interoperability is the essential factor in building the infrastructure to create, transmit, store and manage health-related information.”

For more definitions, check out our healthcare interoperability glossary.

The demand for healthcare interfaces with Electronic Medical Records (EMR) is increasing. This increase is due to the rising adoption of EMR systems, emerging clinical healthcare data standards (HL7, CCR, CDA, CCD, ELINCS), and increasing interoperability requirements, such as CCHIT (Certification Commission for Healthcare Information Technology).

To achieve the most effective and efficient EMR connectivity, the following steps should be included in the process:

1. Understand workflow:  Define the workflow within your organization and between your organization and the organization with the EMR system
2. Document requirements:  Define the data requirements of your systems and the EMR in which you will be exchanging patient information
3. Implement interfaces:  Build the interfaces to facilitate the workflow and meet each application’s requirements

Understand workflow.  Understanding the healthcare data flow within your organization and then the data flow of the organization with the EMR system is critical when you start automating the healthcare workflow. You cannot successfully automate a system or workflow which you do not fully understand.

Document the requirements.  Documenting the requirements for both applications in terms of the standards being used to transmit the clinical data in the specific data format will help identify the gaps between the two clinical applications. The interface can then bridge the identified gaps between the EMR and your application.

Implement interfaces.  A systematic approach to interface implementation should include the basic stages of developing, testing, implementing, and maintaining the interfaces. An effective and flexible approach, that can include tools, will help overcome common challenges such as technology, patient matching, procedure or physician code matching, and lack of cooperation to meet the end goals.

In summary, an interface to or from an EMR application is no different than an interface for any other healthcare application. Connectivity is achieved by acquiring knowledge regarding the workflow and the requirements, plus utilizing effective methodologies or solutions to implement the interfaces.

The EHR-Lab Interoperability and Connectivity Specification (ELINCS) specification provides a profile that refines (or constrains) “standard” HL7 messages to moving lab results from reference labs to physician offices. Like IHE, the ELINCS profile constrains the generic HL7 standard to a specific set of use cases. In addition the ELINCS standard provides business rules that must be followed between the trading partners. Such rules are outside the scope of the base HL7 standard.

ELINCS is part of the 2007 CCHIT Ambulatory Interoperability requirements.

Note that sometimes this standard is misspelled as e-links or elinks.

Resources for ELINCS:

• Accelerating EMR Interoperability with ELINCS: Streamlining Lab Connectivity to Physician EMRs
• ELINCS Standard: Laboratory Results to EMRs
• Why the Increasing Demand for Electronic Results to Physicians?
• ELINCS overview and downloadable documents
• ELINCS Specifications
• Direct link to ELINCS 1.1 PDF file

This diagram shows the most common use case for ELINCS:

The Continuity of Care Document (CCD) was approved earlier this week. The CCD is a collaborative effort between the HL7 standards and ASTM International organizations. To add to confusion, there are multiple standards for electronic patient record (EMR / EHR) integration. They are:

• Continuity of Care Record (CCR) – authored by ASTM
• HL7 Clinical Document Architecture (CDA) – authored by HL7
• Care Record Summary (CRS) – original HL7 attempt at patient care integration standard, later incorporated into HL7 CDA
• Continuity of Care Document (CCD) – jointly agreed to by ASTM and HL7 and endorsed by the Healthcare Information Technology Standards Panel (HITSP)

CCD is a part of the healthcare interface standards “harmonization” effort, which is worthwhile and needed. Regardless, it creates confusion in the marketplace as to which standard to use or ask for when evaluating EMR and EHR systems as well as in determining the overall connected healthcare community strategy for a hospital, lab, clinic, or imaging center.  Which one?  CCR, CDA, or CCD? 

In a Modern Healthcare article entitled CCD Standard Up for a Vote, there is a quote from the American Academy of Family Physician’s Center for Health Information Technology as to why the different standards.

“There isn’t really a rift between ASTM and HL7. I think where the rift starts to come is between legacy vendors and some of the Internet-technology-based vendors. You have the large hospital vendors (more or less in the HL7 camp) and the smaller physician office system vendors (using CCR). That’s where the controversy starts to explode.”

Peter Waegemann, chief executive officer of the Medical Records Institute, adds to this in a subsequent Modern Healthcare article entitled Standards Rivals’ Collaboration Could Have Major Impact:

“Vendors and users of large IT “legacy” systems that are backers of HL7’s Clinical Document Architecture will gain the most benefit from the CCD because they will be able to use the CCR format in their systems, Waegemann said. But the collaboration with HL7 on the CCD further establishes the CCR, he said.”

Both are valid points. The good news in this announcement is that CCR and CCD will work well together. This will facilitate a more integrated healthcare environment. As clinics, hospitals, labs, and imaging centers move forward, they will need to continue to be adaptive in their integration approach. Flexibility is essential in the near term.

The HL7 Continuity of Care Document (CCD) is the result of a collaborative effort between the Health Level Seven and ASTM organizations to “harmonize” the data format between ASTM’s Continuity of Care Record (CCR) and HL7′s Clinical Document Architecture (CDA) specifications. 

The CCD will enable greater interoperability or healthcare integration of clinical data and “allow physicians to send electronic medical information to other providers without loss of meaning.”

With CCD, the CCR is represented and mapped into the HL7 CDA. These are structured XML standards for clinical information exchange. The harmonized standards should support greater streamlined exchanges with Electronic Medical Record (EMR) and Electronic Health Record (EHR) systems as well as various healthcare providers.