Interoperability is the buzzword du jour. It is the focus of almost every 2015 conference, white paper, road map, etc. That is why I believe it is important to get reminders from chief information officers and physician leaders themselves of what the actual pain points are. I got one of those reminders at the recent eHealth Initiative conference in the form of a painfully honest presentation by Forest Blanton, senior vice president and CIO of six-hospital Memorial Healthcare in Florida, who spoke about the slow and difficult process of connecting with physicians in the community.
Memorial, the third-largest public healthcare system in the nation, began installing Epic in 2010 and has largely completed implementation in all six hospitals, and its 180 employed physicians use Epic. But the approximately 1,600 voluntary physicians it needs to communicate with for population health efforts use an amazing 65 different brands of EHRs, which vastly complicates the communications process, Blanton said.
In 2010 Memorial implemented a private health information exchange to connect its facilities with the doctors. “That did not meet the promises we had hoped,” Blanton admitted. “It is now technically obsolete.” It chose to use Epic Care Everywhere as the platform for communicating with its doctors as it evaluates its options going forward.
Memorial is making progress on population health management. A physician-led integrated network is currently managing about 45,000 lives in a shared savings model, and Memorial is a co-owner of a Medicaid HMO. “We are applying population health management techniques to lower our costs, and have had some mixed success,” Blanton said. “We have a variety of ways we deliver results to medical staff. None are perfect. Most involve workarounds,” he added. Memorial has been sending physicians HL7 messages on clinical results through the HIE, but they are not bidirectional. “We feed information to the doctor’s inbox, but that doesn’t really benefit us in terms of getting information from their EHRs,” he said, “which we could use for population health purposes.”
“Our experience with integrating those physicians was that it was slow and difficult,” he said. “We have had to negotiate with each individual EHR vendor. Each one has its own strengths and weaknesses and willingness to cooperate.” Each doctor has his or her own timeline for working on integration, he added. Also, the approaches Memorial started with in 2011 are not compatible with meaningful use Stage 2 requirements. “That is a little discouraging,” he said.
“Disappointingly, faxing is the main way we deliver clinical results to these physicians. We have an elaborate faxing engine that sends 5,000 faxes a day to our physicians. We have a team of people supporting it. I hope the faxes go into electronic inboxes of some sort, but I am sure that many are being printed out and stacked up in inboxes in offices.”
As part of compliance with meaningful use Stage 2, Memorial has begun sending Direct secure messages to physicians. “Yet most of our physician EHRs are not capable of accepting them, so we send them to a Surescripts portal, which satisfies our requirements for sending out transition of care documents, but is probably not terribly helpful to physicians,” Blanton explained. “Many of them complain they don’t want the information, but we are providing it to them anyhow because we are required to.”
“All these problems have really increased the transition costs within our organization and lowered the efficiency of our clinical operations, particularly in doctors’ offices,” Blanton stressed. “We have increased FTEs to operate these systems and we have multiple systems we need to maintain. We have many disparate and non-standardized interfaces with the doctors. And the doctors have to set up their own systems to access information. All of this results in incomplete and imperfect movement of data between our various organizations.”
Because it has difficulty accessing EHR data from the physicians, Memorial relies on lab and claims data to help calculate gaps in care. It distributes reports to physicians “but in kind of a cumbersome way,” Blanton said. “We produce that in a PDF file and post it to a separate physician portal that they can access. It allows a motivated physician with the right workflow and training in his office to get at this information. But it takes a lot of initiative on their part,” he said. “I am skeptical that they will go very far out of their normal work flow. I don’t think that it is being used as well as it could be, but it is available to them. The data are late and incomplete. It doesn’t include clinical data. And the information we do provided is not provided as part of the physician’s workflow. We are not able to push data into the EHR as a normal course of business so they can see those alerts and gaps. On the care management side, we are a little weaker. Data are in multiple systems, and not able to be distributed well.” Doctors have to deal with multiple user names and log-ins, he said. “I think we have four separate portals doctors have to access to get information That work flow is not good for the docs and it is going to limit their adoption.”
Another problem, he said, is that there is not a standardized nomenclature for the data contained in each of the EHRs. Different tests have different meanings and internal coding methodologies. “There is very little ability for us to exchange protocols and patient alerts in an effective and timely way,” he said. “So we support the move toward open and standardized public APIs [application programming interfaces]. We think that is a great idea,” he added. “It will take time in evolution, but we think it should be a potentially required standard. We think it should be based on workflows and actual use cases of clinicians. It should include clinical data exchange for episodic care, the ability to pull data for aggregate data analysis across disparate systems, and a standardization of the nomenclature. It should allow organizations to push out alerts in gaps in care across disparate systems within clinical work flows.”
As an understated conclusion, Blanton said, “there is a lot of room for improvement in the current environment.”
It’s hard to disagree with him on that.
