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
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.