Helping data move
FHIR and similar projects are necessary because data do not move in pieces today. Instead, information is often trapped in various silos, and when it does move between them, it's in unwieldy documents.
It's not like this in many other parts of life. "In the financial world, in the retail world, in the social world, data is not held hostage for the benefit of someone else," said Kerry McDermott, vice president of public policy and communications at the Center for Medical Interoperability. "You're kind of the digital center of the universe, because if companies don't treat you that way, you're going to abandon them, because you have a choice."
Often, providers and others wonder why EHRs can't be more like ATMs. The answer, Jaffe said, is that "medicine is more complicated than an ATM."
EHRs and standard document formats are certainly steps toward interoperability. Though fax machines are still exceedingly—and shockingly—common in healthcare, records are increasingly stored on servers, not shelves. The government essentially required the use of EHRs with the CMS' meaningful use program, which mandates, among other technological requirements, that providers electronically transfer patients' summaries of care for at least half the transitions of care.
"Meaningful use and the rules have pushed the market and healthcare systems to do things in a different way and drive toward that culture of sharing," said Lana Moriarty, director of the Office of Consumer eHealth at the Office of the National Coordinator for Health Information Technology.
That will help ease the burden on providers, which is currently significant: Primary-care providers now spend about equal time—three hours or so—on office visits and "desktop medicine," according to a recent study in Health Affairs.
That proportion may change now that the ONC is working on implementing the 21st Century Cures Act, enacted last December. Notably, the act contains a prohibition of "information blocking," as well as requirements for EHRs to transmit, receive and accept data.
Eric Helsher, Epic Systems Corp.'s vice president of client success, worries that more regulation might increase the already significant burden on providers—the very thing the ONC and others are trying to avoid. For one, the language about information-blocking is vague enough that it might lead to "frivolous claims," he said. As for EHR certifications, in the past "well-intended requirements created unintended consequences that lead to burdens on providers."
He thinks the government should let the private sector solve the problem. Epic, Cerner Corp. and other EHR vendors say they're working on it. They've formed groups such as Carequality, from Sequoia Project (Epic is a founding member); and the Commonwell Health Alliance (Cerner is a founding member) to promote interoperability.
"We have a moral obligation to fix interoperability and not compete on that piece," Cerner President Zane Burke said. "Today the information doesn't flow very easily, and the obligation is on the patient to provide that information again and again." That can lead to multiple tests and bills. "If you can't get something easily, the easiest way to get it when you have the patient in front of you is to reorder it," Northwestern's Moran said.
Carequality and Commonwell recently began working together on interoperability projects, including tackling record location so that patients could be connected to their data from different sources. "We want to get to the point where clinicians just expect to see everything, local and outside, and they don't necessarily have to know the difference anymore," said Dave Fuhrmann, Epic's vice president of research and development.
For that to happen, providers—or their software—would have to know where to pull records from. Commonwell's record location technology—which creates a "virtual table of contents" that points to the locations of patient information—is one way. Another method—that some see as the interoperability solution of the future—is blockchain, a technology borrowed from the financial industry's bitcoin.
In healthcare, blockchain could involve a super-secure "distributed ledger" of everywhere a patient has received care. Every time you get medical care, a record of your receipt of that care would be added to the ledger. The ledger, in turn, would point to places providers need to check to create a more complete medical record.
The blockchain is mostly an idea at this point; for the technology to be useful, it's not enough for the blockchain to simply point to where the data are. The data must be able to be transmitted—they must be interoperable.
When that happens, doctors will be able to be better at their jobs. "If it were all there in front of you," Tcheng said, "you'd spend a lot less time shuffling through paper or clicking on different tabs," he said. "You could spend more time actually thinking about what you're looking at."