Much has been made of the challenges we face regarding the pursuit of interoperability in health care. In concert with reporting quality data and using an EHR in a meaningful fashion, interoperability represents the third fundamental requirement for the meaningful use program. In the words of Dr. Farzad Mostashari, the national coordinator for health information technology, the goal of a national health IT system is to make sure “information follows the patient regardless of geographic, organizational, or vendor boundaries.”
The stage 2 meaningful use program was recently chastised by four ranking members of Congress as not doing enough to reach this goal. A number of sources have since suggested this memo was motivated more by election year politics than by concerns that we were moving too slowly to attain our goals. Actually reaching the Holy Grail of seamless information exchange will require a substantial amount of work. Among other things, interoperability requires a motivation to utilize common vocabularies along with a common set of transport standards. Private sector competition is a marvelous thing in many regards, but without a nudge from CMS in the form of the meaningful use program, EHR vendors would have little incentive to harmonize vocabulary and transport standards.
It is one thing to talk about interoperability, quite another to experience it in real life. Last week my wife became acutely ill while I was 2,500 miles from home. Fortunately, our next-door neighbors were able to get her to our local community hospital. She was quickly evaluated and a series of tests soon determined the nature of her illness. She required an urgent surgical procedure, a procedure that was outside the scope of services offered by our community hospital. She was transferred via helicopter to a nearby academic medical center and shortly thereafter had a successful surgical procedure.
How might interoperability have facilitated her care? For starters, the ER doc in our local community hospital noted she had a murmur. Had it been there before? I did not know the answer to that question when asked over the phone in the middle of the night. Her primary care physician’s records were “trapped” in a paper chart and locked up tight in his office. Her creatinine (a number near and dear to every nephrologist’s heart) was mildly elevated. Was this a new finding? The absence of this information did not prevent her from receiving IV contrast, but her care team would have benefitted from timely access to this data point. Finally, when she arrived at the referral center, paper copies of her brief ER stay along with a digital copy of her CT scan accompanied her. Of course those records also made the trip via helicopter.
My wife did remarkably well in the face of a life-threatening event, and by the time you read this post she may actually be out of the hospital. But her success is perhaps colored by three factors that few patients have access to. First, she is a physician with over 20 years of clinical experience. That experience provides insights that very few patients’ posses. Second, the next-door neighbor I mentioned is a board-certified pulmonary and critical care doc. His understanding of the differential diagnosis suggested by her presenting symptoms, coupled with his knowledge of how to efficiently navigate the medical system substantially contributed to her rapid diagnosis. Third, the academic medical center is one that she and I have historically referred patients to. We know them and they know us. When offered the choice of where to go, she answered without hesitation.
Interoperability will not replace the value clinical judgment brings to the practice of medicine, nor is it a substitute for effective process management. But it will certainly facilitate the delivery of better care. Improving quality while decreasing costs is increasingly recognized as a national healthcare goal. Creating the opportunity for the medical information to follow the patient is a fundamental requirement to achieve this vision. My wife and others do well today in the absence of interoperability, but imagine how many more patients will meet success when the information truly follows the patient.
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