Dr. Michael Lee, Director of Clinical Informatics, Atrius Health
Over the past decade the health information community has incorporated a number of new technological tools and standards to implement Health Information Exchange (HIE). The goal is simple: Make the most recent and accurate patient information immediately available to care teams and patients. The industry uses standards established at the federal level and models of secure exchange that encrypt the transactions from point to point. The good part is that it works and we are seeing transactions happening between clinicians, even when they involve systems from different EHR vendors. Stage 2 of the Meaningful Use program stimulated a lot of activity, but the requirement to send information never really encouraged development of workflows to increase value over time. We still have not figured out when to move information, who should see it or what we should do with it after receipt. While clinicians are excited about the opportunity to receive patient information, they are already getting frustrated with the limitations. Atrius Health is a large, multi-specialty, ambulatory organization that participates in multiple performance contracts, fee-for-service and global payment arrangements including Medicare Advantage and as a Medicare Pioneer Accountable Care Organization, thus a key element to our strategy is incorporating HIE into many layers of care.
"Atrius Health participates in multiple performance contracts, fee-for-service and global payment arrangements including Medicare Advantage, thus a key element to our strategy is incorporating HIE into many layers of care"
Certain types of HIE have been occurring for years with standards that work well for these transactions. A new document format called Consolidated Clinical Document Architecture (CCDA) helps information travel securely from one entity to another and be interpreted, displayed and even consumed by the receiving system. We are making progress, yet there still remain a variety of use cases that illustrate the gaps that need to close for health information exchange to engender more efficient and better care.
For certain situations, such as when a patient is referred to an ER or is discharged from the hospital, sending a CCDA document with all of the correct information meets the need and improves on the historic fax or postal summary. But, many times patients land in an acute care setting (ER or urgent care facility) without a primary care clinician aware of the event. In this scenario, the acute care facility needs to query another system to request information. We receive automated Admission-Discharge-Transfer (ADT) notifications from many facilities to inform us of these events so that appropriate follow-up can be arranged. In addition, we have enabled “web-portal” access for close clinical partners that allows read-only view access of our EHR from those facilities. However, neither of these automates the sending of a CCDA document. With patient consent or a trusted partner relationship, organizations using Epic’s Care Everywhere product can query and pull over information from another organization but only a few data types are discrete.
Referral workflows are even more complex, since patients travel for referrals from a primary care physician to a specialist in many ways. Suppose a patient is referred to a cardiologist at a neighboring health facility, but after returning home learns that their cousin raves about a different one. If that patient does not require an insurance referral, their care may change paths without their doctor knowing. The same can occur when the receiving doctor has no access or re-directs the patient. Finally, there are times where a patient is referred from one specialist to a third physician. In all of the above scenarios there is no way for the originating physician to know where or to whom they should send the patient’s information and when. Although we may know where to send the information, the patient may not see a specialist for two months so shouldn’t the referring clinician send the summary in two months rather than today?
Another salient illustration occurs in our region which has well over 90 percent EHR adoption. Our Obstetric physicians care for their patients throughout pregnancy in our ambulatory facilities, but deliver them in a hospital nearby using the same EHR vendor but on a different instance of that EHR. All of the records can be moved electronically from our system to the other, but the data is not viewed the same way in both systems, and the lab values from our system are not incorporated discretely into the hospital system. Even though it is the same patient receiving care from the same clinician, manual abstraction must take place at the hospital or the clinician has to view the information in two separate records. Finally, after the baby is born, unless the manual abstraction above has taken place, the newborn record at the hospital is not fully updated with the maternal history automatically, and once the baby leaves, the receiving clinician has another manual abstraction step to put data into the newborn’s records back at our facilities. If one compares this to the old paper process-where we sent a paper printout and incorporated it into a paper hospital chart, then at least the clinician only had to look in one place. The technology makes this process more cumbersome even though it is moving in the right direction.
Unanticipated acute care, specialty care and the transfer of ongoing care all illustrate that HIE is just not mature enough to meet all of the workflow needs of clinicians and patients. Each of these scenarios can be improved or augmented with point-point interfaces or other tools, such as notifications or the view only web portal, but these add cost and require expertise to develop and maintain. Larger organizations are fortunate to have those skills, but for the majority of clinicians, that work is out of reach. Sophisticated patients can assist here by accessing and interacting with their information wherever it lies, but it is too much to expect for the majority of patients to understand, store and transmit their information appropriately. It would be sad to think that after all this effort it is more efficient to simply mail a letter.