Visualize this scenario. You've added an urgent consult to your medical office schedule - actually you're double-booked at 8AM. The patient, who lives 110 miles away, arrives after a somewhat harrowing 2 hour drive is early morning rush hour traffic in severe (10/10) pain. She's stressed but very grateful for the appointment which was just scheduled the evening before. She describes a two week history of nearly disabling, excruciating left leg pain ("sciatica"). She's already seen two other physicians who offered two very different opinions. One neurosurgeon suggested immediate surgery which is tentatively scheduled next week. The other physician offered an injection and a trial of physical therapy for several weeks. The patient's seeking a "tie-breaker" recommendation from you. Since the appointment was made just 12 hours ago, she was unable to obtain her medical records or copies of her recent spine MRI from the other physicians. Unfortunately, both outside physicians use different electronic medical records (EMRs), neither of which communicates with your's (yet a third brand of EMR). While the patient waits 35 minutes in the exam room, your office staff hurries to call both outside offices to request records be faxed. The surgeon's office is closed for the day (the phone message is "if this is an emergency, call 911). The other office's nurse assures you the records and reports will be sent immediately. After another 25 minutes, the fax machine delivers. Of course, as you explain to the now very frustrated patient, the actual MR images can't be faxed and all you have is a report. To deliver the most definitive and conclusive opinion, you need to see the films. What now?
a) Ask the patient's family to make a 220 mile round trip to pick up
and deliver the records and MRI
b) Order a clinically not indicated repeat MRI adding $2500 to the cost
of the visit
c) Provide a second rate opinion based on inadequate information
Of course, the correct answer is none of the above.
Unfortunately, this vignette isn't a fairy tale. As a spine medicine consultant at Cleveland Clinic, I experienced variations of this story countless times in my practice over the past several years. Currently, virtually all EMRs operate in silos with minimal capacity for sharing of information. Lack of data interoperability of current EMRs contributes to unnecessary duplication of medical testing, miscommunication of critical clinical information, delay in medical decision making, and poor coordination of care when multiple clinicians are involved. The recently published proposal for implementation of the Medicare Access and CHIP Reauthorization Act (MACRA) highlights improved interoperability of EMRs as a high priority.
Focus on Performance, not just Process
Under MACRA, the EMR Meaningful Use program is replaced by the "Advancing Care Information (ACI)" initiative. Since 2013, Meaningful Use has been extremely successful in driving adoption of EMRs in hospital and physician practices. However, by emphasizing primarily process measures, e.g., the percent of prescriptions delivered electronically, many physicians felt the program missed the important objective, improving the quality of patient-centered outcomes. ACI is broadly characterized as an effort to improve interoperability with more user-friendly, flexible technology. In a letter this week to the Office of the National Coordinator for Health Information and Technology (ONC) and the Acting Administrator of the Center for Medicare and Medicaid Services (CMS), the American Medical Association and 36 medical specialty societies including the American College of Physicians, the American College of Surgeons, and the American Academy of Family Physicians urged the adoption of new benchmarks for interoperability focusing on clinical value to patients rather than just the quantity of information exchanged. The organizations appropriately stress that metrics which supports the transformation to increasingly collaborative and coordinated care are required and will incentivize health IT developers to build systems which actually are patient-centric and contribute to enhanced patient wellness. Referring to the current state of interoperability as "little more than digital faxing," the societies also call for measures that don't burden clinicians with additional administrative, data-entry requirements.
Include Patient-facing Metrics
As the ecology of health care evolves, the critical role of patient engagement is increasingly recognized as integral to achieving successful outcomes. The Consumer Partnership for eHealth (CPeH) wrote to ONC suggesting that patients and family caregivers are also key partners in health information exchange and need to be considered in the evaluation of interoperability. The group also emphasized the need to assess interoperability across the entire continuum of care including long term care facilities and community-based organizations. MACRA and other bundling-based CMS initiatives emphasize the need for coordinated, integrated clinical work flows through the full continuum of care. Meaningful interoperability will be essential to ensure efficient, cost effective use of clinical resources to achieve the optimal patient outcome.
What's really being defined at this point is interoperability in the EMR. It needs to represent more than a fancy fax machine. EMR interoperability built to provide clinically relevant timely information is essential to drive value across the continuum of care.