Thursday, March 25, 2010

EHR Data Exchange - Where is the Bang for the Buck?

In the past months I have been religiously dialing in and listening to the ONC  Policy and Standards committees meetings. The amount of work done by the members is nothing short of monumental and the combined knowledge and experience is astounding.

Like most of us in the HIT industry, I have spend many hours poring over the IFRs, NPRMs, Power Point schematics and every work product available, and like most everybody else I am a bit lost in the sea of acronyms, harmonizations and network diagrams.

The bottom line, though is that we are hopeful that physicians will adopt and use EHR technology which is built to the standards defined by ONC. The promise for physicians is that the eventual interoperability will facilitate meaningful exchange of clinical information, which will in turn provide the ultimate ROI in the form of better, less wasteful care.

In order to validate this assertion, let's examine the most common occurrence of the need to exchange clinical information in private practice: Referrals. Below are three diagrams of a typical referral process from PCP to Specialist and back, one for paper offices, one for offices on current EHR software and one for the futuristic EHR capable of exchanging standard driven discrete data.

Let's note first that the efficiency offered by Patient Portals or PHRs (shaded in pink) is mediocre today, but should become significant as online patient access to records and bi-directional physician-patient communications become common practice. Meaningful Use is correctly encouraging that.

The gray shaded areas show steps that are made more efficient by the introduction of EHR technology. A conventional EHR for example, eliminates the need for printing, scanning and filing exchanged documents in the physical chart. The futuristic EHR will further eliminate the electronic faxing (directly into the EHR) and replace it with discrete data transfer.

These particular tasks are only a small part of the referral workflow and not even the most time consuming.
None of these tasks are performed by Physicians. 

Of course, there is more to Interoperability than just referrals. There are prescriptions, laboratory tests, radiology and administrative transactions, for which we have pretty good standards. Then there are surgeries, admissions, discharges, transitions of care and more, which need some more work, but just like referrals, basic document transfer is very acceptable from a physician point of view and already electronically occurring in practice.

While the change from paper to the currently available, non standardized,  EHR technology can be shown to provide significant time saving for office staff, the transition to standards based EDI for referrals offers only incremental benefits to the practice, while requiring major and complex technology retooling. Not to mention the elaborate infrastructure of intermediaries  of every form, shape and governance, which deserves its own separate analysis.

Granted, the capture of, and ability to report on, discrete clinical data, promises great advances in research and quality measurement. It may also be offering tangible benefits to a variety of other stakeholders. However, we are asking physicians in private practice, most practicing solo or in very small groups, to make a significant effort, in both time and money, to purchase and use certified EHR technology with all the complexity and expense of harmonized acronyms.

Shouldn't we be able to at least show them where THEIR bang for THEIR buck is?

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