NeoTool — Singular Focus, Healthcare Integrated

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.

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.

The EHR-Lab Interoperability and Connectivity Standards (ELINCS) is a national data standard for transmitting results from a Laboratory Information System (LIS) to an Electronic Medical Record (EMR) or Electronic Health Record (EHR) system.

The ELINCS messaging specifications seems to be a practical, real-world approach to solving the application level problem of electronic lab results. ELINCS simplifies and normalizes only the lab results, which are the most valuable piece of data to the physicians. Furthermore, it supports the information required by CLIA (Clinical Laboratory Improvement Amendments) for lab reporting to clinicians. 

The ELINCS standard is based on the HL7 v2.4 messaging standard, specifically, the result message, ORU. It greatly reduces the complexity of the generic HL7 result message by restricting it. The ELINCS specification clearly outlines in detail the structure of the ORU message including supported message elements (segments, fields, etc.) and their associated cardinality, plus code set usage. For ELINCS, the LOINC, Logical Observation Identifiers Names and Codes, coding standard is used to identify the top 100 tests based on frequency of use and value for HEDIS (Health Plan Employer Data and Information Set) reporting.

The only aspect of the interfacing that is not addressed by ELINCS is the communications layer. The lower layer protocols used for data exchange will need to be negotiated by the lab and ambulatory care center. The standard methodology for near real-time HL7 messaging is TCP/IP with MLP (minimum lower layer protocol).

ELINCS adoption is well underway. In December 2006, it was announced that Health Level Seven (HL7) will begin a process to adopt and maintain the ELINCS specification from the developers, California HealthCare Foundation (CHCF). Also, ELINCS is included on the 2007 interoperability certification criteria for EHRs as proposed by Certification Commission for Health Information Technology (CCHIT).

If you are an independent laboratory or EMR/EHR site looking to implement a results interface today, ELINCS v1.1, released October 2006, is the recommended version. Laboratory results interfacing may be a challenge today, but as LIS and EMR vendors begin to comply with ELINCS, the future may be more simplified.

In the late 1990s, the technology industry discovered the importance of customer relationships. Before this time, the sales teams managed contacts, but kept no records on the overall relationship with a customer. The Support team managed their relationships with some software or maybe just a good spreadsheet that someone built.  Several good entrepreneurs identified the disconnected nature of this relationship and created an industry around Customer Relationship Management software.

The healthcare industry is going through a similar evolution. One difference is that the words “relationship” or “patient” do not appear in any of the industry application terms. It is Electronic Medical Record (EMR) or Electronic Health Record (EHR).

While the movement towards Electronic Medical Record software is a good thing that will improve patient relationships, perhaps a more accurate naming convention could have been used. Maybe the term coined should have been:

• Patient Relationship Management
• Patient Care Record
• Patient Care Management

Implementing patient relationship management software is changing the healthcare provider market. There are key benefits to connecting systems and streamlining the flow of patient data. What should not be lost in these efforts is the patient and the relationships built and developed over time. 

In a recent American Academy of Family Physicians article, the author outlined tips for patient-centric interactions when using electronic health record software.  Not only is it vital to keep the focus on the patient in the exam room, it is essential to keep the patient as the focal point when implementing the application. Determining the connections required outside your facility will provide the roadmap for the integrations required with other healthcare providers (e.g., labs, hospitals, imaging centers, clinics).

The focus on the patient interactions in the exam room and the healthcare interactions required afterwards (e.g., x-ray, lab tests, etc.) will ensure a relationship-centered, streamlined approach.

In radiology, the exchange of electronic health records (EHR) translates to access to a patient’s prior imaging history being available to help improve the quality of the patient’s current diagnosis and/or treatment.

At RSNA 2006, the technology to share patient information and images is being demonstrated by vendors using the IHE integration profiles such as XDS-I (Cross-enterprise Document Sharing for Imaging). The profiles and technology utilize the DICOM and HL7 standards to transfer data as needed in the Affinity Domain, the network of care sites. 

The actors of the Affinity Domain include a Patient Identifier Cross-reference (PIX) Manager, a Document Registry, a Document Repository, Document Consumer, and Document Source.  A Source is able to post text, PDF, or KOS (Key Object Selection) documents to the Repository. The KOS document is a manifest that details the metadata needed to access the image from the Source. A Consumer can query the Repository for these documents. 

In both cases, the actors must query the PIX Manager using the HL7 standard to retrieve the Domain’s global patient ID. The Source actor would use this patient ID as a part of the document(s) to be posted. For the Consumer, the next step is to query the Registry to retrieve a list of all the documents associated to the global patient ID. This list would include the location of the document in the Repository. With the needed location information, the Consumer can then query the Repository for the documents. For KOS documents, consumers use the metadata in the document to initiate the image retrieval from the Source, using standard DICOM or DICOM-WADO. 

The technology is ramping up; however, the political and financial hurdles need to be overcome. As with any regional health information organizations (RHIO), provider sites wanting to participate will need to establish agreements for various aspects of the Domain. These aspects include HIPAA related issues as well as access, authentication, and audit trails.  On the financial end, the parties must find the resources to fund the efforts which would include purchasing an EMPI (Enterprise Master Patient Index), a registry or registries, and a central repository plus their on-going maintenance.

With these types of RHIO implementations that utilize the IHE profiles, the vision of a national EHR will eventually be reality.

An interesting article was written entitled “The Evolution of EMR Standards.” Electronic Medical Records (EMRs) are increasingly being adopted by various healthcare practices, and the drive becomes to integrate the EMRs between the different healthcare providers. For example, physicians want to electronically submit test orders to labs or diagnostic imaging centers and then receive the results back into the patient’s EMR. The value is understood - strengthened patient safety (no re-keying of information), faster turnaround on patient diagnosis, and streamlined operations. However, which integration standard to use?

EHR, EMR, CCR … it can get confusing. In its most simple form, an Electronic Health Record (EHR) holds all of a patient’s information while an EMR is the specific patient information from one healthcare provider. Essentially, there is one EHR and multiple EMRs for a patient. The Continuity of Care (CCR) pulls a required subset of information from a patient’s EMR and sends it to another provider that needs to deliver care to that patient.

A “harmonization” of integration standards is underway to enhance the interoperability requirements of healthcare today. Two of the primary integration standards for EMRs are HL7 and CCR. Initially, there was some positioning between the two organizations - HL7 and CCR - but then they came together and consolidated some efforts. CCR will be mapped into HL7’s Clinical Document Architecture, so some standards harmonization is occurring.

The picture may look gray at times, so flexibility will be essential in the integration implementation approach. Being able to deal with HL7, CCR, and other integration standards effectively will assist in the EMR adoption rates as the harmonization of standards process continues.