Electronic Health Records Interoperability: Friend or Foe
Zachary Meisel, MD, MPH, MSc, is an emergency physician, assistant professor of emergency medicine at the University of Pennsylvania's Perelman School of Medicine, a Robert Wood Johnson Foundation (RWJF) Clinical Scholar, a senior fellow at the Leonard Davis Institute of Health Economics, and a columnist on health care issues for Time.com. This is part of a series of essays, reprinted from the Leonard Davis Institute of Health Economics’ eMagazine, in which scholars who attended the recent AcademyHealth National Health Policy Conference reflect on the experience.
The standing-room-only crowd at the AcademyHealth National Health Policy Conference’s “Life After HITECH: Health IT Policy 2.0” session was a testament to the big stakes, high emotion and dramatic clinical implications that characterize every aspect of the electronic health records debate.
The session, moderated by former National Coordinator for Health Information Technology David Blumenthal, was one of the liveliest of the entire conference. It impaneled current National Health Information Technology (HIT) Coordinator Farzad Mostashari along with Christine Bechtel, who sits on the Government Accountability Office’s Health IT Policy Committee, and Paul Tang, the chief innovation and technology officer at the Palo Alto Medical Foundation.
Patient Privacy Issue
One issue was the national push for universal electronic health records (EHR) systems—a drive now fueled by HITECH Act funding but tangled in many discussions about unintended consequences. The first and most prominent has pivoted around worries related to patient privacy.
Consumers remain highly concerned about security breaches and the sale and leakage of their personal health information without their consent. Other potential pitfalls involve medical errors—researchers have repeatedly identified situations where the adoption of electronic order entry and other technology-centered health information systems have led to grave mistakes such as drug dosing errors. Most recently, some of the EHR pushback has come from the economic side, as journal articles report that EHRs may have failed to reduce health care costs; in some cases they have even led to higher costs secondary to more robust documentation and billing.
EHR Benefits Outweigh Risks?
Most of these problems are likely due to growing pains. This was the consensus of the AcademyHealth panel: As electronic health information becomes widely adopted, more secure, more accurate, and more transparent (particularly for patients), the benefits will far outweigh the risks related to privacy, usability, and cost.
But I worry about an additional aspect of the push for EHRs that has been, to date, somewhat uncontroversial: the absolute demand for standardized information and complete interoperability.
On its face, it makes sense that information should be fully transportable and transparent. As Mostashari described, the articulation and enforcement of “meaningful use” standards has persuaded many health systems to move toward fully interoperable electronic health records. But what happens when the standards become too blunt? A cookie-cutter approach to requiring health information to be organized in specific ways runs the risk of undermining important and nuanced aspects of health information that are developed specifically to meet the needs of the primary stakeholders: the patient and the clinician who is taking care of that patient in real time.
Local EHR Innovation
Here’s an example. I have worked in a hospital where the electronic health record that is used in the emergency department was one of the first of its kind. It was designed by physicians and tweaked over the years to meet the needs of busy clinicians and their patients (as well as researchers who query the information to answer important questions about emergency care). The information contained in this system can be pushed out in any format, but the other proprietary medical record systems that are used by other departments in the hospital won’t talk to the small, homegrown system. No other off-the-shelf EHR has the capacity to meet the specific needs of emergency care providers and their patients the way the system does. Yet, the push for interoperability is squeezing the better, more nuanced, and more locally tailored system at the expense of these bigger one-size-fits-all platforms.
Information that is standardized can have real advantages for exchange, safety, and familiarity. But it also runs the risk of undermining some of the more salient aspects of how we do our work. For instance, research has shown that if nurses are forced to follow a template when they hand off patients at the end of a shift, they often exclude vital information specific to the immediate circumstances of their patient. In this way, it is possible that the EHR systems that get the federal stamp of approval might strip this salience out of the health care record.
From the stage, Blumenthal mentioned that there is now a real “market” for usability in EHRs. This is great. But are we missing the point that what’s usable for one doctor at a hospital may not be as usable for another? A large hospital, in the effort to meet interoperability and universal EHR standards, will likely select the system that is most cost-effective, and most widely applicable across its many functions. Doubtless, this could stifle small-scale efforts to innovate and customize systems to meet the needs of individual patients and their providers.
If the world ends up—due to HITECH and its implementation—with only a handful of platforms to house and exchange interoperable health care information, we may never know what innovative, local, and customized systems would have emerged to help improve health care delivery.
Let's hope it doesn’t come to that.
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Reprinted from the Leonard Davis Institute of Health Economics' eMagazine.