Cover Story
Game Changer
Interoperability is the key to realizing the potential of electronic medical records.
By Howard Bell
Not long ago, a patient previously seen at North Memorial Medical Center in Minneapolis arrived at an emergency room in St. Cloud with chest pain. With the patient’s permission, staff at St. Cloud Hospital downloaded his EKG report from North Memorial into their electronic health record (EHR), along with his prior diagnoses, medication list, discharge summaries, allergies, radiology reports, and physician progress notes. Within minutes, the St. Cloud doctors had all the important information they needed to care for the patient. “We didn’t have to call and request that documents be faxed and wait while someone searches for the paper records, then faxes them,” says Charles Dooley, vice president and chief information officer for CentraCare, which owns St. Cloud Hospital.
Such a scenario might have seemed far-fetched only a couple of years ago. Now, however, use of interoperable EHRs to exchange patients’ medical records is growing quickly in Minnesota. Many see it as the logical next step in bringing medicine fully into the digital age and to reforming health care. Government mandates and funding are quickening the pace of progress. The Centers for Medicare and Medicaid Services (CMS) has created reimbursement incentives for physicians and other providers who start using interoperable EHRs (see “Money for Meaningful Use”). And Minnesota law says that by January 2015, all Minnesota physicians, even the ones who currently don’t have an EHR, must be using EHRs to exchange patient records with other health care systems.
Why the push for interoperability? Moving patient information electronically increases the quality of care, says James Golden, Minnesota’s health information technology coordinator and director of the Division of Health Policy at the Minnesota Department of Health. When physicians know more about the patient at the time of care, it reduces test duplication, improves compliance with best-practice guidelines for chronic conditions, and decreases prescribing and medication errors, he says. “The idea is to get the right patient records to the right physician at the right time so they can make the best decisions for patients.”
“Interoperability is a game-changer for physicians,” says Alan Abramson, Ph.D., chief information officer for HealthPartners who serves on the Exchange and Meaningful Use Workgroup of Minnesota’s e-Health Initiative, which is orchestrating the statewide use of interoperable EHRs. It’s what gets you the biggest quality and efficiency bang for the bucks you spend on an EHR, he says.
The Paperless Chase
Minnesota’s e-health implementation plan defines interoperability as “the ability of two or more systems or components to exchange information and to use the information that has been exchanged accurately, securely, and verifiably, when and where needed.” That means no faxes, phone calls, paper, or scanning, according to Abramson.
Many of the electronic exchanges of patient information in Minnesota fall short of this definition. For example, exchanging patient records among clinics and hospitals within the same health care system—internal interoperability—is not what the legislation considers system-to-system interoperable exchange.
Nor is it interoperable exchange when a physician admitting a patient to a hospital remotely accesses the patient’s record from another health care system, prints that record, then scans it into his record for that patient. “In that case,” says Abramson, “there is no interoperability between these systems. They are two separate systems being used by the same physician at the same time.”
View-only access to patient records also doesn’t count because digitized data is not being electronically transmitted from one system to another, according to Paul Kleeberg, M.D., an independent family physician who serves with Abramson on the state’s Exchange and Meaningful Use Workgroup.
Although these types of exchanges may not meet the definition of interoperable, they are currently widely used, especially in the Twin Cities metro area, and they are paving the way toward the type of everyone-connected-to-everyone-else purely electronic exchange outlined in the federal and state mandates.
An Epic Challenge?
Interoperable exchange of patient records that meets the legislative definition is happening in Minnesota among larger health systems that use Epic software. Allina, Fairview, HealthPartners, North Memorial, CentraCare, and Hennepin County Medical Center have already begun exchanging such things as radiology and lab reports, and health summaries that include information about immunizations, medications, allergies, and problems. A new Epic product called CareEverywhere lets the EHRs, which have been customized to each institution, “talk to each other.” Currently, only emergency departments at these facilities use CareEverywhere. “We gave priority to emergency because that’s where we saw the greatest benefit,” Dooley says.
Later this year, CentraCare will start using CareEverywhere in all of its clinics and hospitals. They’ll also start exchanging discharge and referral summaries and progress notes once those documents are standardized and in an exchangeable format.
The emergency department at Allina’s Mercy Hospital in Coon Rapids is about to try using CareEverywhere to obtain records for patients coming from nearby HealthPartners clinics. The paperless exchange will allow Mercy to move pertinent HealthPartners outpatient clinic information into the hospital’s EHR, according to Dennis O’Hare, M.D., vice president of medical affairs for Mercy. He says Allina plans to expand this program to emergency departments at all 11 of its hospitals.
In December, Fairview clinics began using CareEverywhere to exchange patient records with North Memorial Medical Center. They plan to do the same with all Allina hospitals and clinics this year. Any Fairview Medical Group physician can receive any piece of a patient’s record from North Memorial, according to Barry Bershow, M.D., vice president of quality for Fairview Medical Group. “Eventually, we hope to exchange records with any Epic user in the country.”
Widespread use of Epic EHR software is one reason Minnesota is ahead of most states in achieving interoperability and record exchange, according to Bershow. “Two-thirds of primary care physicians in Minnesota are already using Epic systems,” he says. “Park Nicollet will be, too, by spring of 2011, so the sharing that goes on will be quite rich.”
The challenge ahead is to be able to exchange patient records between two different brands of EHR, for example, between the Cerner EHR at WinonaHealth and the Epic system at HealthPartners. No one in the state is yet doing this, according to Abramson.
The MN HIE Way
To facilitate statewide interoperability across all EHR brands, many states, including Minnesota, have created health information exchanges (HIEs). Minnesota’s HIE (MN HIE), which was established in 2008 with funding from Blue Cross and Blue Shield of Minnesota, Fairview Health Services, HealthPartners, Medica, the Minnesota Department of Human Services, and UCare, is attempting to become a sort of public utility that will support routing of patient information using a set of accepted industry standards.
Currently, MN HIE gives physicians view-only access to records stored with its subscribers. Any physician who has Internet Explorer and a high-speed connection and is affiliated with a subscriber can view the health plan benefit eligibility information for millions of Minnesotans covered by Blue Cross and Blue Shield, Medica, HealthPartners, UCare, and the Minnesota Department of Human Services. They can also view basic patient information such as immunization records, medication lists, medication history, lab results, problem lists, allergies, care plans, and insurance information—the same type of information starting to be exchanged among Epic CareEverywhere users.
What MN HIE offers over CareEverywhere is one-stop shopping. “Physicians can get information through one connection instead of multiple connections to various health plan or medical care facilities,” says Mike Ubl, MN HIE’s director. “Simplified patient privacy and security is another advantage to accessing records through MN HIE.”
All HIEs must meet state and HIPAA requirements for privacy and security. Patient consent for access to medical information is required at each patient visit. Millions of patient records are currently accessible to MN HIE subscribers. Thus far, only about a dozen patients have chosen to not make their records viewable.
This year, MN HIE plans to offer all emergency departments in the state access to its records and launch a pilot program for nursing homes. By summer, it hopes to receive approximately $6 million in federal stimulus funding to build out its technical infrastructure and integrate with provider EHR systems. Eventually, it may become the hub that connects physicians statewide.
But MN HIE’s long-term fiscal stability depends on having enough subscribers. Right now, providers pay an annual fee to subscribe—the bigger the facility, the larger the fee. “It comes out to about $60 per physician per month or about 10 to 12 cents per patient per month,” says Ubl. The subscription costs are low enough to not be a significant barrier, he says. “But the more subscribers we have, the lower the fees will be.” Ubl hopes to have 5,000 of the state’s 16,000 physicians using MN HIE by 2011. Golden, Abramson, and other e-health leaders believe MN HIE is the most cost-effective way to achieve statewide interoperability. “MN HIE will be one way to provide the technical infrastructure—the highway—by which doctors, hospitals, and health plans exchange patient records statewide,” Golden says.
The MN HIE approach is the lowest cost and best option for the state, according to Abramson, who says having everyone connect to everyone else will result in a tangled mess—like tin cans connected by strings. “Physicians don’t want to be carrying around 25 different passwords and user IDs,” he says.
Not everyone thinks MN HIE is the way to go, however. “We don’t know if a statewide exchange model is financially sustainable or what the governance for it should be,” says Kleeberg, whose e-Health Initiative workgroup is discussing those issues. “It’s far from certain if clinics and hospitals will be willing and able to finance a statewide HIE through user fees.” Utah’s HIE has achieved fiscal sustainability because a wealthy businessman provided the start-up money and the state’s Legislature provided ongoing funding. Most state HIEs, however, rely on user fees from clinics and hospitals.
“Our committee is hearing a lot of push-back on how to go about this,” Kleeberg says. “How will patients feel if they believe that health plans control the exchange of their records? Should we build a national medical Internet that would not require connecting to a specific health information organization? Or should we build regional health information organizations, which then connect to the state HIE? How should we involve the private sector and get bids from a couple health information organizations to foster competition and innovation? There’s a lot we don’t know yet.”
In northeastern Minnesota, the Community Health Information Collaborative (CHIC) is one such entity that could eventually evolve into a regional HIE. For now, it’s a record locator service. Clinics and hospitals in that part of the state use it to find where a particular patient’s records are stored. They then obtain those records the traditional way, by phone or fax. But the CHIC still saves time and gets physicians information they need faster. “It’s a first step toward more comprehensive exchange and interoperability,” says Clark Averill, director of information technology at St. Luke’s Hospital in Duluth and chair of the CHIC board of directors.
Averill thinks regional HIEs should be the building blocks by which Minnesota achieves statewide interoperability. Yet no one knows exactly how these efforts, and those of the institutions now using Epic software to exchange information, will all be pieced together. “Building a statewide HIE is a huge and complex undertaking,” he says. “The best way to eat an elephant is one bite at a time. Start small, start locally, and use MN HIE to connect regional networks like CHIC into a network of networks covering the whole state.”
MN HIE would eventually connect to HIEs in other states, which poses another layer of challenges, according to Ubl. “Each state has its own regulations for patient privacy and security. For that reason we haven’t seen significant progress with interstate exchange just yet.” Indiana and Ohio connected their statewide HIEs last fall—the first states to do so, letting 15,000 physicians and 50 hospitals exchange 12 million patient records. Last month, Kaiser Permanente began exchanging records with the entire VA system, connecting two of the largest EHR systems in the nation.
Remaining Hurdles
While the architects of interoperability forge ahead with building the highway for exchange, a number of technical, policy, and financial challenges remain.
To be interoperable, all EHRs must use the same technical, semantic, and process standards. Hardware and software need to be able to communicate with one another. In addition, there needs to be agreement about terminology and content. For example, you want to prevent having a sender transmit a blood potassium level of 3.5 to a receiver whose EHR reads it as 35. Right now, the health care industry has only islands of standardization, including ICD and CPT codes and SnowMed. No standard exists for describing such things as care plans or lab results. Minnesota’s e-Health Advisory Committee and its Standards and Interoperability Workgroup currently are developing uniform standards.
Achieving technical interoperability is straightforward compared with achieving agreement on policies and rules for exchanging records, according to Abramson. It’s not difficult to set up a secure network connection, he says. “Policy aspects are a bigger challenge.” Participating hospitals and clinics will need to have record-sharing policies and agreements in place for interoperability to occur.
The Department of Health’s e-Health Initiative published guidelines for forging data-sharing agreements between organizations that include how to develop agreements that ensure patient consent, protect privacy, and ensure that exchange standards and protocols are implemented uniformly and consistently. “We’re flooded with ideas about electronic record exchange,” Abramson says. “This surge of innovation will shake itself out, and we’ll adopt a certain set of technologies and standards.” Ultimately, Kleeberg says, the federal government must create national standards “so there can be true interoperability nationwide.” Some states have struggled to get competing health care systems to work together on interoperability because they fear it will reduce their “ownership” of the patient. That might be an issue for a few smaller, independent clinics, Abramson says, but physicians in Minnesota have a long history of collaboration. The patient record exchanges already happening among Epic users are more proof of how willing they are to collaborate. “Everybody can see the benefits of exchanging basic patient information,” Abramson says. “It’s not a competitive issue. It’s a quality issue that benefits everyone.”
Another barrier to overcome is the fact that roughly 35 percent of Minnesota’s primary care physicians still don’t use EHRs adequately or at all. For those clinics and hospitals, help is on the way. A partnership called Key Health Alliance hopes to receive federal stimulus money early this year to set up the Regional Extension Assistance Center for Health Information Technology (REACH). It will help clinics, hospitals and other providers in Minnesota and North Dakota plan for an EHR and make meaningful use of it so they are eligible for incentives from the federal government.
The Alliance, which is composed of the Rural Health Resource Center in Duluth, the College of St. Scholastica, and Stratis Health, is one of 60 groups nationwide invited to apply for the first round of four-year grants, according to Susan Severson, Stratis Health’s director of Health Information Technology. “We’ll help clinics and hospitals do everything needed to get up to speed, whether they have an EHR or not,” she says. Severson notes that Alliance staff will help clinics and hospitals modify their office processes to accommodate an EHR and help them meet patient record privacy and confidentiality rules, among other things. REACH staff will be based throughout Minnesota and North Dakota at what the Alliance hopes will be a ratio of one technical assistant for every 10 clinics in the program. During the first two years, federal stimulus dollars will pay 90 percent of the technical assistance cost associated with implementing an interoperable EHR for those who are eligible. Physicians will pay 10 percent.
The time when state HIEs connect to create a national exchange system is far off, according to President Barack Obama’s National HIT Director, David Blumenthal, M.D., who described national interoperability in an American Medical News article last August as “a tall order and a big challenge.” Years from now, the United States may have a system like Taiwan’s, where every citizen carries a medical “smart card.” Any physician anywhere in that country can insert the smart card into their computer and up pops the patient’s medical records.
But for now, achieving statewide interoperability is the goal and Minnesota is well on its way toward meeting it, despite technical and policy challenges that still need to be overcome. Those working on it believe a basic level of interoperability is only a few years away. Golden predicts: “You’ll be surprised how much patient record exchange is happening by 2015.” MM
Howard Bell is a medical writer in Onalaska, Wisconsin.