NeoTool — Singular Focus, Healthcare Integrated

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
• Get the Workflow Right First
• Comparing HL7 Messages to HL7 Documents

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

As noted in HIS-Talk and HANYS News, CMS released an advisory opinion that allows for hospitals to pay the cost of EMR interfaces without violating the Stark Law. Hospitals are restricted under the US law regarding compensation arrangements between physicians and hospitals. HANYS News wrote:

Specifically, a hospital system can pay for the creation of an electronic interface between unique electronic health record (EHR) systems of individual physician practices and the hospital network’s EHR system. The interface would allow physicians, from their practices, to order and communicate the results of tests and procedures performed.

The CMS news was delivered in “Advisory Opinion No. CMS-AO-2008-01″. There are many words used in the advisory; here is a quote that is the meat of the opinion:

The Requestor … owns and operates … hospitals … [and] contracted with a third-party … Vendor … to install a proprietary health care software information …System …, customized to the Requestor’s specific requirements, including a software interface engine that facilitates access by the custom Physician Practice Interface(s).

Pursuant to the contract between the Requestor and the Vendor, the Vendor provided software licenses to the Requestor that permit the Requestor and its controlled affiliates to use the System.

Currently, the medical staffs of Requestor’s … hospitals have the option to view laboratory reports for the Requestor’s patients over a protected internet connection to the System. The Proposed Arrangement would permit also the ordering or communicating of laboratory tests or procedures performed by the Requestor using the Physician Practice Interface(s).

Numerous physicians on the Requestor’s medical staffs have begun to purchase and use electronic health records (“EHR”) systems for their private practices. Requestor would like to integrate its System with individual information systems maintained by the Affiliated Physician Practices to promote the secure transfer of patient data between the parties. Integrating the System with each Affiliated Physician Practice requires the custom development of an interface that can extract data from the System and transfer it to the Affiliated Physician Practices’ EHR systems. The Requestor may need to develop several versions of the Physician Practice Interface to accommodate the various EHR systems. The Requestor would limit the functionality of the Physician Practice Interface to the ordering or communicating the results of laboratory tests or procedures furnished by the Requestor.

Under the Proposed Arrangement, the Vendor would develop, and the Requestor would pay the development cost of, a Physician Practice Interface customized to the Affiliated Physician Practice’s existing EHR software. … Physician Practice Interface would be used only to order or communicate the results of tests and procedures furnished by the Requestor and could not be used for any purpose other than the ordering or communicating of the results of tests or procedures furnished by the Requestor.

…

Therefore, we have determined that the Proposed Arrangement does not meet the definition of “compensation arrangement” for purposes of the statute’s prohibition on physician self-referral
…

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 Stark Law is potentially changing the landscape in the adoption of healthcare IT in physician practices in communities across the US. What change actually happens is still up for debate.

A recent article in Government Health IT entitled Picking Up the Check for EMRs does a good job of outlining the differing perspectives:  hospital, physician practice, and vendor. Outlined below is a brief summary of each perspective.

Hospital Perspective.  Although some hospitals may implement strategies and programs to offer EMRs to physician practices, there is skepticism that it will work. Hospitals like Partners Healthcare System do not have plans to start paying for local systems. Other hospitals note that they would have to offer physician practices more than one EMR option in order to meet the differing requirements. The bottom line, though, is that many hospitals are not in the financial position to fund EMR adoption in physician practices.

Physician Practice Perspective.  Doctors are independent and do not want to take hospital incentives which may compromise their independence. Also, what if a physician practices at more than one hospital and each hospital has a different supported EMR application? There is also some concern about patient data security.

EMR Vendor Perspective.  Essentially, the vendors like the possibility of additional funding to support EMR adoption. However, there are concerns this would benefit the larger EMR vendors more than the mid-to-small sized ones.

A recent HIS Review blog post also provides a good overview of recent updates to the Stark Law and what hospitals need to be considering.

The most detailed outline of what a hospital will need to do around the Stark Law changes comes from a hospital CIO blog post. In Life as a Healthcare CIO, John Halamka describes the top ten planning items for hospitals to consider as they implement a strategy and program that leverages the Stark Law changes.

Obviously, how this all plays out is still up for debate. There are many elements to consider, not the least of these being how to integrate the patient data flow together between the different EMR applications, physician practices, and hospitals. In many respects, the debate is happening at the right level – the local level.

If healthcare IT is to be adopted by physician practices, the issues and plans will need to be resolved between the players in the communities.

Or, as is being done in some instances, the connections are being made between the different healthcare providers and their applications by leveraging interface engine technology.

The driving forces in these electronic transaction interactions are streamlined workflow, increased referrals, and faster turn around times to support quality patient care. There are several case studies that highlight specific providers connecting to various EMRs successfully and exchanging patient information. Business or operational drivers, not the Stark Law, are moving “connected healthcare” forward in these examples.

Health Data Management published an article entitled CIO: Get the Workflow Right First. At the Medical Group Management Association Conference, Phyllis Schuck, CIO of Pinehurst Surgical Clinic, spoke about their EHR implementation experience and highlighted that the key tip is to focus on your workflows first. As she stated, “Technology really doesn’t fix broken processes, but it can magnify broken processes.”

Focusing on your workflow is critical to any healthcare IT project or initiative. Once the workflow is documented and understood, then determining how technology can be applied to streamline it, increase its capacity, or otherwise improve it can be determined.

Other tips offered by this CIO should be applied in evaluating healthcare software purchase decisions, whether it is an EHR or healthcare integration platform. The tips include:

• Only consider vendors who’ve been in business at least seven years, so they have a track record.
• Make sure the vendor has successfully deployed interfaces to the practice management and lab systems in place at your practice.
• When hosting demonstrations of software at your practice, require the vendor to demonstrate how the application would handle your specific workflows.
• Schedule site visits to organizations similar to yours, and bring multiple users from various departments, such as nurses, schedulers and cashiers.

HIStalk posted an interview with Eric Fishman MD, President, EHRConsultant. This is an interview worth spending a few minutes to read. Dr. Fishman’s site is EHRScope.

The HIStalk interview spans several topics including:

• EMR vs. EHR terminology
• Implementing EHR insights
• CCHIT and their impact
• Insurance companies providing EMR software to physician practices
• General physician practice trends

One missing question that would be interesting to ask:  What are physician practices doing to implement effective interfaces to their partner providers, such as labs, imaging centers, and hospitals? EMR connectivity plays a key role moving patient data effectively through their complete cycle of health care interactions.

In your EHR efforts, HIStalk and EHRScope are great resources for healthcare IT professionals and physicians.

In my previous post, I highlighted an article that outlined success with Electronic Health Record (EHR) adoption and what the healthcare innovators were doing next. I came across another article today that illustrates the darker side of EHR adoption. The article appeared in Information Week and is entitled Why Progress Toward Electronic Health Records Is Worse Than You Think.

This article represents an important insight into EHR, RHIOs, and the importance of connected healthcare. As the article states, ” RHIOs are critical to watch because they take on one of the vexing problems in health care: Clinical data is scattered across labs, pharmacies, hospitals, and the paper files of individual doctors’ offices.”

Some important points in the article include:

• There will be - and have been - ”stumbles” in RHIOs being successful. Community or government funding creates challenges, and gaining healthcare provider buy-in adds to it.
• “Big bang” approaches to healthcare integration may not be the best approach. Incrementally building healthcare interoperability or connections may be a better approach. For example, start with lab results then move to radiology patient reports, pharmacy, etc.
• Push vs. Pull:  Letting doctors pull data on their patients may be a better approach than pushing patient data to a doctor.
• “IT won’t solve the health care problem, but you can’t solve the problem without IT.”

The various models will be tested and tried, and one may work better for one community than another. We see healthcare providers building their own electronic clinical data exchanges without community funding.

Identifying the motivating factors along with a sense of urgency and practicality may help achieve greater success. Don’t wait for a RHIO or an EHR to take hold; begin to build your healthcare connections with willing partners and the momentum may build.

There is a very informative article on what the first-movers in Electronic Health Records (EHR) are doing next. The article is in Health Data Management and is entitled “EHR Pioneers Try to Stay Out Front: Latest projects include adding decision support, improving connectivity and developing PHRs.” 

Several months ago, I had written a post about All Healthcare Integration Is Local. The EHR pioneers article illustrates how EHR successes are occurring in various locations around the country.

The next level of value that the EHR pioneers are striving for is greater interoperability between providers. As the article states, “Connectivity is the next step; we have to go beyond ‘electrified’ paper. Every hospital should be able to electronically deliver to physicians on Monday morning all the details of their patients who were treated in the emergency department over the weekend.”

There are several initiatives that are facilitating greater connectivity between healthcare providers, including:

• The Certification Commission for Healthcare Information Technology (CCHIT) now has introduced an EHR interoperability certification for vendors.
• The HL7 and ASTM have “harmonized” the continuity of care standards to bring together the HL7 CCD and ASTM CCR standards.

Although there is so much more work that needs to be done, momentum is gaining through the efforts of the EHR pioneers and the support of the people involved in the standards developing organizations.

There is an interesting statistic hidden in a posting this week from Healthcare IT News:

… CCHIT spokesperson Sue Reber … estimated that more than 40 percent of companies with ambulatory EHR products have been certified.

That’s a huge percentage and represents real market acceptance of the CCHIT standards. Why should we care as HL7 integration experts? Here are three reasons:

1. The CCHIT criteria started life as HL7’s EHR standard. The goal was to spell out what it means to have an EMR and what features / functions it must support. These are high level goals such as “maintain list of allergies” or “supports outcome Measures and Analysis.” Think really big picture concepts - the devil is in the details.
2. With market acceptance of the base criteria, CCHIT has leading US market mind share. Good, bad, or indifferent, it seems like it will soon be a requirement to be “CCHIT Certified” in order to sell an EMR in the US market. This means there could be a rush for EMR vendors to get certified quickly.
3. Going forward, CCHIT is raising the bar and adding interoperability requirements. This is critical to the integration world as it effectively demands that EMR vendors support certain interactions, data models, and work flows. As an example, CCHIT is adding the requirement to support ELINCS, a lab result reporting standard. This will drive lab result interfaces to be “more standard” and they will, over time, move towards using the LOINC code set for the “typical” lab tests.

The HIMSS annual conference has now passed. The presentations are over; the exhibitor booths are gone; and the attendees are back to work. It will be interesting to measure the impact of HIMSS on initiatives with the thousands of healthcare provider attendees or with the hundreds of healthcare vendor exhibitors. What will change? What new thoughts will be considered? What new solutions will be considered? What existing solutions will be re-considered?

From our vantage point, there were several themes evident in our various discussions with attendees.

• EMR / EHR: How do we integrate to hospitals, clinics, labs, and imaging centers? What is the best approach?
  • Read a best practices white paper entitled What Is Your EMR Connectivity Strategy? Defining the Best Attributes to Approaching a Connected Physician Community.
• Continuity of Care Record (CCR) and Continuity of Care Document (CCD): How do these new standards impact EMR integration efforts?
  • Read blog posts on CCR, CDA, CCD, or just search our blog site.
• For vendors, buy or build a healthcare interface solution? There is so much flexibility with the “healthcare standards” so how do we focus, adapt, or handle integration?
  • Answer five questions outlined in a white paper entitled Before You Build a Healthcare Communication Subsystem…
• Simplicity, speed of healthcare interfacing: How can we build healthcare interfaces simply with limited or hard-to-find resources and build them quickly?
  • Review solutions available to speed the healthcare interfacing process.

The themes that you heard or championed may be different. Please feel free to post your insights as a comment. We welcome the interaction.

We found the dialogue at HIMSS extremely valuable. The important element now is to do something with what each of us learned and apply it in our initiatives. Next year, we can revisit how much progress was made.