Next Steps for Interoperability

There are some folks in Washington who have made statements that we
should delay investments in EHRs because current vendor products lack
the functionality needed to support a coordinated healthcare system.
Others have said that we lack the standards or security framework to
implement interoperability. Here are my thoughts.

Take a look at
the successes in Massachusetts and New York with commercial EHR
products. We’ve implemented eClinicalWorks, which includes decision
support, e-prescribing, administrative transactions with payers,
clinical summary sharing across the community, and quality measurement
(all the National Quality Forum high priority measures). It’s
web-based, using a service oriented architecture in a cloud computing
environment. By implementing this product at BIDMC, we’re meeting all
the payer guidelines for delivering appropriate, coordinated, high
value care. Vendor products from Epic, Allscripts, NextGen, GE,
Meditech, eMDs, MedSphere, and other CCHIT certified vendors have
similar features.

Should we wait for something better that has more interoperability?

you drive a car? Why? It pollutes, costs a lot, and generally is not
very efficient in traffic. You’d be much better off asking Scotty to
beam you up via the transporter. Should we eliminate all cars, planes
and trains until the transporter is invented? The same can be said of
EHRs and health information exchange.

My definition of good enough

*Support for medication interoperability such as e-prescribing linking providers, payers, and pharmacies
for laboratory and radiology interoperability such as orders and
results integration among providers, hospitals and commercial labs
*Support for seamless electronic interchange between providers and payers for administrative data flows.

In 2009, several EHR vendors will support clinical summary exchange.

can achieve a substantial improvement in care quality and coordination
by implementing the systems available now and not waiting. If anyone
thinks writing a next generation interoperable EHR from scratch is a
good idea, have them look at the UK implementation of the
NPFit/Connecting for Health project. They hired numerous companies to
implement an new scheduling/booking system, a nationwide PACS system
and a coordinated health record. After spending billions, they have
limited success and low provider satisfaction.

On December 18, HITSP completed all the national standards harmonization work for 2008.   This included:

*Biosurveillance Interoperability Specification (IS02)
*Consumer Empowerment and Access to Clinical Information via Networks Interoperability Specification (IS03)
*Emergency Responder Electronic Health Record Interoperability Specification (IS04)
*Consumer Empowerment and Access to Clinical Information via Media Interoperability Specification (IS05)
*Personalized Healthcare Interoperability Specification (IS08)
*Consultations and Transfers of Care Interoperability Specification (IS09)
*Immunizations and Response Management Interoperability Specification (IS10)
*Public Health Case Reporting Interoperability Specification (IS11)
*Patient-Provider Secure Messaging Interoperability Specification (IS12)
*Remote Monitoring Interoperability Specification (IS77)

The documents are accessible through www.hitsp.org

This latest round of work means that we’ve completed the three year AHIC roadmap for standards.   There are no unapproved standards at this point!

course standards will evolve and we’ll keep enhancing this work,
including lessons learned from implementation in vendor products. In
2009, we’ll be given a new body of work including Newborn screening,
and filling several small gaps required to support clinical workflows.

Thus, if we have products that are good enough and interoperability standards, what are we lacking?   Some say security.

HITSP completed security standards harmonization in 2007.

The 2008 CCHIT criteria for security are rigorous. Vendors have described them to me as one of the most challenging aspects of certification.

Although there is still local/state variation in policies, we do have a national framework for EHR and PHR data exchange.

say that they have personal experiences with lack of coordinated care
among multiple providers. Is that an issue with EHRs and standards? My
view is that this is a process and policy issue. In the US we do not
have a healthcare system, we have numerous providers, labs, pharmacies,
and hospitals which do not constituent a single medical home for the

Let’s implement EHRs now and realize their benefits.
Let’s implement the interoperability for administrative transactions,
labs/rads, and e-Prescribing that is robust today. Then let’s implement
the clinical summary exchange that’s coming soon. It’s a journey and we
should start immediately. There is no reason to wait.

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RobgrrrrbarMerle BushkinRyan Howard Recent comment authors
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It is in no company’s interest to cooperate with another. That’s why we have “fabricated” standards, like HL7. Let’s talk about how the “market” worked out such standards as HTML, HTTP, SMTP, DNS and the rest of the global internet standards.
Markets don’t decide standards. In fact, the pressure is more often in the other direction, towards a collection of fetid, proprietary ponds.
Just saying.


There are far too many health care politicians more interested in furthering their own careers by foisting vendor products into the hands of unwilling physicians.
Enough is enough. Let the market sort it out, provide choice, stop fabricating IT standards that further specific IT systems, further vendors greedy desires and further everyone’s needs except for the clinicians using the system.

Merle Bushkin

rbar, I agree with your desire to keep it simple and your solution, as I understand it, isn’t far from what we are proposing. The big difference is that yours doesn’t meet the desires of consumers/patients to control their records and to be certain they are secure (they aren’t on a Web server). Also, from the physician point of view, your proposal merely converts a literal pile of paper into a virtual pile of paper. This is no more useful than if a patient walked into your office and handed you a pile of paper notes — you wouldn’t know… Read more »


I have quite longstanding practical EMR experience (Cerner, IDx, and some experience with the VA system), and to me, it sounds (from reading the OP and some comments) that we might get in the process of creating a complicated, costly monster. To maintain 1 EMR in one health system is already complicated and costly, as I witness every day. To have different EMR succesfully and reliably intraoperate seems to be unrealistic to me at this point. I already wrote it a couple of times here, but again: just put ALL doctors notes/results on a secure server in the internet, filed… Read more »

Merle Bushkin

John, With all due respect, I see the healthcare IT debate very differently. The Issue is the System I submit that the issue we must address is not “interoperability” and whether we should advocate adoption of electronic medical records (EMRs). Rather, it is what system should we adopt to make a patient’s lifetime health record available to care providers when and where they need it? The choice of system will depend upon answers to three inter-related, subordinate questions: 1 How should records be kept (here we can address the issue of EMRs)? 2 How and where should they be aggregated?… Read more »

Ryan Howard

Firstly, eClinicalWorks is not in a cloud (cloud is not synonymous with hosted). While eCW does offer a hosted model, from the many physicians I have spoken using eCW, the vast majority of their installations are onsite in the physician’s office. With installed software, interoperability (i.e. sharing patient records) extremely difficult and expensive, as point to point integration is needed for each installation of the software (physicians need to connect their practices to a community of offices). With today’s technology, buying an EMR and installing it does not mean you will be interoperable, or even close. To correct the car… Read more »

Christine Gray
Christine Gray

Part of me thinks that physicians who protesth HIT innovation too much, focusing solely on flaws, have a hidden political agenda.
Any system will be guaranteed obsolete. So is my i-Phone. Is that a reason to wait? Not if you are the patient and you would like your records now, please.
Oh, the patient! (aka the Residual Payer)
EHRs may not be interoperable, but activated patients are.

Deron S.

Can a family doc with AllScripts efficiently share relevant patient information including a documented patient history with a cardiologist that uses NextGen? If the answer is no, the next quesion is, can the two systems be retro fitted to allow that to happen? If the answer to that question is no, then we must seriously ask whether the spending on IT infrastructure is warranted, or whether it’s better to wait for the next generation to come out.

Dr. Pandey

If anyone wants to take a lesson learned, please look into the enterprise wide systems that SAP and Oracle have. These are monstors. The EHRs, ERPs, all these are needed. The problem is that they create new problems unless the system is well developed and even more importantly well implemented. The EHR system without any doubt is fragmented and quite infant state yet. The implementations have rately delivered on the promise. THe lack of success has been inexperiece in developers in process/product design and implementers missing the mark on roll out. There are a lot of opportunities here…but pouring money… Read more »