Shared EHRs: Beyond initial deployment
Over the last few years, the healthcare system — including the federal government, state jurisdictions, media, technology companies and the general public — have jointly placed a major emphasis on eHealth initiatives. While various models and strategies are still being discussed and debated, there is a core principle upon which most in the healthcare industry can agree: That stakeholders along the entire care continuum need readily accessible, patient-centric clinical data that transcends systems and geography.
The ongoing debate around the exact design and priorities of the Personally Controlled Electronic Health Record (PCEHR), which was well articulated by the likes of Medical Software Industry Association, the National E-Health Transition Authority and HealthLink in the previous edition of this very magazine, is a critical step towards finding the golden path — the EHR approach suitable for Australian patients and providers alike.
In this article I will try to look beyond this area of discussion and share some perspective on things to come. This view will encompass what we have seen happening when the rubber hits the road as Shared EHRs projects are deployed, and what becomes of them as they inevitably progress to their second and third release.
So if we close our eyes for a moment and imagine the fully functional PCEHR as described in the concept of operations, we should ask ourselves, “What’s next? Will the PCEHR be sufficient as-is?”
Applying the experience gained from Shared EHR implementation in the US, Canada, Europe and the Middle East, we anticipate several likely next stages of progression.
Building out the EHR
First, as with every Shared EHR, we will see growth of its reach. To understand this we need to recognise that PCEHR is simply the federal piece of this equation; it is not the national silver bullet. Multiple jurisdictional (or Local Health Network, or Area Health Service or be the organisations what it may) Shared EHRs will need to gather information from a variety of locations, including hospitals, clinics, specialist offices, laboratories, pharmacies and other sources, and interface with the PCEHR. By doing so, they will serve both to provide access to integrated patient information from sources within the jurisdiction together with PCEHR-provided information, and as conformant repositories for the PCEHR. Building out these conformant repositories will enable greater volumes of data from a wider range of sources and, more importantly, make meaningful use of this information in care delivery.
One key to this success is ensuring that data Shared is semantically harmonised, i.e. that data originating from a hospital clinic in Victoria can be integrated with data about the same patient generated by a hospital in Queensland, and that the meaning of that data is understood by its recipient — human or machine. This could theoretically be achieved by forcing everyone to standardise their coding and clinical nomenclature. Realistically however, this will take generations. A more practical approach usually entails building Shared EHRs that offer semantic interoperability and can accommodate a plurality of nomenclatures, making sense of the incoming data while preserving the original meaning of the information to ensure its integrity in the host system.
Healthcare providers will be much better equipped to impact a patient’s care when they have the capability to review harmonised, patient-specific data via a Shared EHR platform, PCEHR or other. As such, the use of mobile devices including smartphones and tablets must be supported and encouraged as long as the appropriate measures are taken to secure the data. In fact, one health system we’ve worked with in the US is currently leveraging its Shared EHR platform to deliver data to clinicians on BlackBerry smartphone devices. Clinicians are afforded a single, comprehensive view of patient data — allergies, medications, lab results and physician notes for example — critical to the medical decision-making process.
The Workflow Conundrum
The second area of challenge and growth for Shared EHRs comes in the form of the need for data to be integrated within all stakeholders’ familiar workflows. Notably, these solutions must ensure clinicians and other users need not exit day-to-day workflows and applications. Providers seek finger-tip access to comprehensive information, and baulk at adopting technologies that require they open and close multiple programs to get the information they need.
Some solution vendors are partnering with third‑party EMR providers to develop strategies by which data is integrated into clinical workflow to ensure clinicians have the right information delivered to them to properly handle the immediate episode of care. Furthermore, these caregivers must have the ability to drill into greater detail on the patient when necessary by accessing information from a variety of clinical or other systems as the situation demands.
Without semantic interoperability, clinicians would likely find themselves wasting time searching for data in disparate information systems that incorporate various workflows and presentation formats. And once they have the information in hand, they must still interpret data that was likely compiled over a period of time and by many different individuals, resulting in values that aren’t aligned. EMRs of the future will thus likely incorporate EHR-aggregated data directly into users’ preferred workflows without them being aware of ‘vendor dependencies’.
Having said that, the road to getting the various EMR vendors to play ball is largely bumpy and unpaved. As a result, Shared EHR vendors like ourselves need and have begun to develop tools to get the EHR data into the clinician’s workflow without requiring EMR vendors to actively enable the integration.
Secure, Secondary Data Use
Perhaps the greatest area of variability across Shared EHR deployments is how they ultimately ensure that medical data is highly secure, yet available and useable by authorised individuals. Technology exists today to lock individual health information tightly away in databases. A strategic combination of secure yet accessible technologies and strong policy guiding who has access to the information must be in place before any Shared EHR solution is deployed. This commitment enables greater control over whom has access to which data sets and under what circumstances.
When this is achieved, opportunities to provide information to patients in a secure and appropriate environment — the tenets of the PCEHR — promise to create a consumer-friendly atmosphere in which patients have greater control over decisions related to their care.
The Shared EHR platform should also facilitate the extraction and use of de-identified information to be used to advance the health of populations and the community as a whole — including for research into care plans and treatments that exhibit greatest value — and analytics to measure efficacy and outcomes. When rolled up to an organisational level or beyond, healthcare leaders will be able to view medical trends, and apply the knowledge to managing diseases and overall population health.
With Shared EHRs, healthcare consumers and providers will have access to relevant and timely data where and when it’s needed to drive informed medical decisions. As these solutions are deployed they typically gain considerable uptake, and in turn create broader demand for increased reach (both data sources and outputs) and increased integration into clinicians’ workflows. Future stakeholders realise that by creating secure yet ubiquitously integrated information, they have the potential to make use of this information for applications that could only be dreamt of in the past. That’s where real challenges will lie in term of medico‑legal and ethical considerations. But we have a few years to prepare for that debate. It’ll be interesting, I can tell you that much.
Vice President Asia-Pacific
Ilan Freedman, a member of dbMotion’s executive management team since the company’s spin-off from Ness Technologies in early 2004, heads dbMotion’s Asia-Pacific expansion and operations. dbMotion is a focused on developing and delivering Shared EHR and health information exchange (HIE) solutions. The company’s products have been selected by states, regions and healthcare organisations in the US, Canada, Europe and Israel.
Posted in Australian eHealth