Coordination of EMR networks lacks ‘common infrastructure’

In the fifth installment of a series, OSN examines initiatives aimed at integrating regional and state electronic medical record systems.

Issue: October 15, 2007

ByMatt Hasson

Ophthalmology advocates are calling for a stronger, more unified framework for information exchange before any further steps can be taken toward a national electronic medical record network.

A federal initiative to launch what is known as the Nationwide Health Information Network (NHIN) has been met with some skepticism by the American Academy of Ophthalmology and other experts in ophthalmic practice management.

Lloyd Hildebrand, MD, chairman of the AAO’s Medical Information Technology Committee, voiced reservations about efforts on the part of the federal Office of the National Coordinator for Health Information Technology (ONCHIT) to develop a national network without a mature infrastructure and definitive standards in place.

“The effort to try to coordinate all of this is laudable, but I think it’s fairly self-limited,” Dr. Hildebrand said in a telephone interview with Ocular Surgery News. “[ONCHIT] has a big challenge under them. They’re under pressure to show some results, and yet the infrastructure is fairly immature to do that.”

A “common infrastructure” across various specialties and regions and the implementation of standards are critical to the development and coordination of electronic medical record (EMR) networks, Dr. Hildebrand said.

“Until that happens, until we get true adoption from the vendors and the user community, I think it’s going to be difficult to do any coordination or any of this work in a meaningful way,” he said.

Coordinating efforts

Early this year, a consortium of technology companies developed and tested four “architectures,” or sub-systems, that will make up the NHIN, according to an executive summary. The consortium includes the companies Accenture, Computer Sciences Corp., IBM and Northrop Grumman. Each company was contracted to develop and test one component.

The NHIN will not be a centralized national database. Rather, it will use shared services, standards and requirements to connect health information exchanges and users from throughout the country. It will be a “network of networks” designed to help those individual networks “support additional information exchange beyond their own bounds,” according to ONCHIT.

When completed, the NHIN will encompass four basic types of organizations: care delivery organizations; consumer organizations that operate personal health records and other consumer applications; health information exchanges within regions or non-geographically oriented groups; and “specialized” participants, such as public health, research and quality assessment organizations.

Flora Lum, MD, AAO policy director of quality of care and knowledge base development, echoed Dr. Hildebrand’s concerns about moving too quickly toward a national coordinated effort.

Dr. Lum pointed out that “heterogeneity” and “innovative approaches” depend on a “narrow base where you really define tightly specified standards for interchange, privacy and security.”

Further, despite the successful tests, the development of networks will likely progress at glacial speed, OSN Practice Management Section Editor John B. Pinto said.

“It’s interesting to observe how health information modernization and reform is moving in tandem with health care payment reform efforts,” Mr. Pinto said in an e-mail interview. “There are bottom-up, decentralized efforts at one end and top-down, command-and-control efforts at the other end. Both ends will eventually meet in the middle. However, like payment reform, I think that IT efforts will continue to be characterized by false starts, overly rosy expectations and too much top-down mandating. I’d forecast we’re going to be muddling along in this arena for at least the next 20 years.”

Stages in the evolution of EMRs

The Pennsylvania eHealth Initiative report outlined four stages in the evolution of patients’ electronic medical records:

Phase A: Create improved care processes using EMRs. Many providers are in various stages of switching from paper records to electronic records. “Providers should be encouraged to move toward implementing standards-based electronic health records.”
Phase B: Make patient data available. The first “future” phase involves “freeing clinical data from silos by creating secure, robust information delivery pipelines,” or facilitating the seamless, secure delivery of patient information at the point of care.
Phase C: Aggregate each patient’s data for care, quality and patient safety. Clinical summaries of patient histories would help providers facilitate and improve care.
Phase D: Empower Pennsylvania citizens. Patient-clinician collaboration would be enhanced, and patients would have access to information on disease prevention, drug interactions, research programs and mental health facilities.

The annual operating cost of operating a Phase A health information exchange network in a large region of about 500,000 patients was estimated at $2.5 million to $4 million.

Source: Connecting Pennsylvanians for Better Health: Recommendations from the Pennsylvania eHealth Initiative

Bridging gaps between states

In October 2006, the Department of Health and Human Services and ONCHIT joined with the National Governors Association Center for Best Practices to form the State Alliance for e-Health, a program designed to bring state officials together to build medical information bridges across state lines.

The State Alliance is designed to coordinate state laws, standards and practices to make state and regional health IT initiatives more efficient and effective.

Some states have launched their own initiatives to develop health information networks. For example, the Pennsylvania eHealth Initiative (PAeHI), a public-private, nonprofit coalition of 160 organizations and state agencies, was established in 2005 to improve care, reduce costs and improve access to health information.

The PAeHI released a “blueprint” for EMR networks identifying key issues, including patient privacy and confidentiality, interoperability of health IT systems and clinical decision support.

The report also focused on state and federal laws concerning privacy, security, consumer rights, electronic prescribing, fraud, taxes, abuse and antitrust.

Implementation should be encouraged only for EMRs that meet basic interoperability standards, such as Certification Commission for Healthcare Information Technology criteria and PAeHI interoperability standards, the report said.

Dr. Hildebrand again cited the lack of a concrete IT infrastructure to support an effective information exchange network.

For more information:

Lloyd Hildebrand, MD, can be reached at 1000 Stanton L. Young Blvd., Suite 390, Oklahoma City, OK 73104; 405-271-1096.

Flora Lum, MD, can be reached at P.O. Box 7424, 655 Beach St., San Francisco, CA 94120; 415-561-8592.

John B. Pinto can be reached at J. Pinto & Associates Inc., 1576 Willow St., San Diego, CA 92106; 619-223-2233.

References:

The Department of Health and Human Services’ report, “Summary of the NHIN Prototype Architecture Contracts: A Report for the Office of the National Coordinator for Health IT,” is available at www.hhs.gov/healthit.

The Pennsylvania eHealth Initiative report, “Connecting Pennsylvanians for Better Health: Recommendations from the Pennsylvania eHealth Initiative,” is available at www.paehi.org.

Matt Hasson is an OSN Staff Writer who covers all aspects of ophthalmology. He focuses on regulatory, legislative and practice management topics.