With the current healthcare atmosphere emphasizing both efficiency and quality, physicians are faced with constant pressure to do more in less time
“You have an admission,” said the ER physician on the other end of the phone. “Fifty-six-year-old male with a history of atrial fibrillation with rapid ventricular response and chest pain. Troponin is elevated. I cardioverted with 20mg IV Cardizem. Oh and he’s visiting from North Carolina and was recently admitted at a hospital there.”
I hung up the phone and immediately went down to see Mr. H., a middle-aged gentleman resting somewhat uncomfortably on his stretcher. His face was flushed and he explained that he’s had a few beers since he’s on vacation with his girlfriend. “Doc, I have to leave tomorrow. I know my heart rate is all out of whack, but I have a bus to catch and I can’t afford to stay another night in New York City. I feel fine. I will follow up with my cardiologist.”
We talk about his recent hospitalization in North Carolina, but he is unable to offer me much useful information. He tells me he was admitted to the cardiac care unit and that he underwent “some procedure,” which makes me feel even less confident in letting him leave. After some self-deliberation, I decide I can’t discharge him safely without further studies, so I reassure him that we will try our best to get the results we need in the timeliest manner possible.
I left the exam room and headed to the computer to check over all of his results. Unfortunately for Mr. H., the odds are not in his favor. Given his diagnosis and the preliminary results I have, he requires an inpatient admission until more ancillary information can be provided. “Unless you sign out against medical advice,” I told him, “you are going to miss your bus tomorrow.”
Further reading: EHRs are ruining the physician-patient relationship
This scenario is a common one for healthcare providers. Every day we meet new patients, gather important information from the history and physical exam, and make informed medical decisions based on the data we obtain. Physicians depend largely on the reliability of the patient when taking a history, but in many cases, the patients have been admitted to our healthcare system previously, which allows us access to records from prior admissions that may help in our decision-making process.
With the current healthcare atmosphere emphasizing both efficiency and quality, physicians are faced with constant pressure to do more in less time. In the case of Mr. H., obtaining data from a prior hospital stay would have been helpful in decreasing length of stay and avoiding unnecessary tests. Though he was admitted to a hospital that used electronic health records (EHRs), I could not get timely access to the details of his recent hospitalization. In order to obtain the data I needed, I would either have to ask for his consent to have medical records released and have them faxed to me, or I could attempt to call his physician in North Carolina directly and hope that he or she is on call on the Saturday night. Mr. H. was admitted.
Physicians experience communication gaps and data-sharing challenges such as this on a daily basis. In recent years, healthcare systems have moved from paper records and filing cabinets to EHRs, all in hopes of improving patient care and coordination. Despite the rapid increase in EHR adoption, the real issue preventing direct health data exchanges between providers is that most EHR systems aren’t compatible with each other and therefore can’t exchange patient information efficiently.
In many large healthcare organizations, multiple interfaces need to be utilized internally in order to access a patient’s data in its entirety. The system used to admit a patient is not the system used to access and review imaging studies; the system that stores electrocardiograms is separate from the one that keeps discharge summaries and pathology reports; etc. The burdensome task of integrating all these data sources distracts physicians and healthcare organizations from the goal of progress and innovation. More importantly for physicians, time spent utilizing multiple interfaces and obtaining patient data could be time better spent with the patient.
The greatest challenge to interoperability is that there is not just one challenge. Although an increasing number of providers and developers are working to achieve interoperability, long-standing challenges have become better understood and new challenges have been identified.
As described by the Health Information Technology Policy Committee in its December, 2015 report to Congress, the most notable barriers to interoperability include lack of universal adoption of standards-based EHR systems, complex privacy and security challenges associated with widespread health information exchange and lack of incentive to develop interoperability in the private sector.
Exchanging health information between organizations as in the case of Mr. H. requires multiple systems and parties to cooperate simultaneously. After the widespread adoption and use of EHRs to manage health information, the next major challenge is to safely and efficiently exchange critical information across health systems in order to coordinate care among all the members of an individual’s health team and to provide higher quality care with more efficiency.
Meeting this challenge requires the interoperability of health IT systems, including EHRs, and presents different challenges than those previously encountered when implementing a standalone system for a single organization. No single component-based recommendation by itself will be enough to achieve interoperability.
Though there is much work to be done toward EHR interoperability, we may be headed in the right direction. In recent months, the nation's top healthcare information technology developers, including Allscripts, athenahealth, Cerner, Epic and Meditech committed to pushing interoperability. Furthermore, the Office of the National Coordinator for Health Information Technology recently laid out a
for achieving interoperable health IT that supports a “broad scale learning health system” by 2024.
In an ideal world, digital health records should include a patient’s clinical story in its entirety: both primary care and hospital visits, payment information and history, patient-generated health data, pharmacy and prescription information, patient and family-health history, genomics, clinical-trial data and so on. Once this information becomes easily accessible digitally for providers as well as patients, the full potential and promise of interoperability may be realized.
In our current system, too often care teams are spending their time calling other providers to obtain patient information, faxing paper records and trying to coordinate care efforts across a disjointed and disconnected system. We need a network connecting this data to create more effective workflows, care coordination, and prevention-based models of care. However, without broad-based coordinated efforts, it is unlikely that widespread interoperability will be achieved fast enough to deliver the health care that Americans expect and deserve.
And as for Mr. H? He ended up signing out against medical advice and catching a bus to his next destination.