One of the most challenging issues facing today’s health care providers is sharing information. Technologically, one might assume that it would be easy to create a system of data exchange between providers. The reality, though, is that providers may be selective with what they will share, who they may share it with, and how they share it. The primary obstacles to sharing of information are security and access, and these barriers are as much a political issue as they are technical obstacles.
Obstacles
Security and privacy of health information is a significant obstacle. Just like breaches in major retail stores that make the nightly news (see Forbes for a list of significant breaches in 2014), health information is also under attack (e.g. Anthem, see CNN). The same technologies that enables modern transactions are also able to be exploited by criminals. Despite recent headlines, however, current technology (when implemented properly) is capable of reliably protecting our personal data, including a digital medical record.
Another significant obstacle is the actual exchange of medical records. All health care providers ( e.g. the physician, pharmacy, hospital and laboratory etc.) maintain some type of patient record. Every procedure, prescription, or visit results in changes in that record. Each change made by one provider (say at the hospital) would, in an ideal system, be updated automatically with the patient’s other providers (e.g. the specialist, the pharmacy and the primary physician). Assuming that security of the data can be maintained without any issue, the remaining problem is a lack of a standardized format for the record. Each repository of patient information is necessarily different because every provider focuses on different aspects of patient care. The format of the records can be very different. At one extreme, paper record (charts) are still in use, while others may leverage electronic medical records (EMRs). In essence, each provider’s records speak a slightly different language.
The Language of Health Care
Among the first organizations to recognize the importance of intercommunication between health care records were hospitals. The laboratory’s electronic records need to communicate with the electronic chart, hospital billing systems, the computerized census system and the pharmacy’s dispensing system. An entire industry was born to help facilitate this data exchange in hospitals, and with this came the creation of several standard languages, one of which is HL7 (Health Level 7).
Using computers as gateways, hospitals use tools like HL7 to link many different systems to provide a relatively seamless transmission of information between systems. But as good as this would appear on the surface, these gateways have significant obstacles of their own. Gateways are labor intensive to maintain and regularly require maintenance to keep them running. Small changes in one system can break down communication between multiple systems. To Make matters worse, there are many different dialects of the HL7 “language” so even if two systems both speak HL7, information can be lost in translation.
Politics
If one accepts that security of the data can be handled by current technologies, and that gateways like HL7 can facilitate the translation of data, one final obstacle exists. The laws that exist to protect the privacy of health information (like the Health Insurance Portability and Accountability Act of 1996 also called HIPAA) also govern the exchange of information between providers. This exchange may or may not require a written release (depending the the relationship between both providers and the patient). The provider’s access to records needs to be limited to only their patients plus any patients. It is also possible that a given provider may still want to control what data is shared, and when it is shared.
The Implications
Because of the obstacles above, providers and patients struggle to seamlessly communicate. The fax, which became widely available in the 1980’s, is still one of the primary means of communication between providers despite the proliferation of communication options available today. The ramifications are significant, and examples of the problems created by the lack of real-time communication are easy to find. From a pharmacy perspective, four common issues are:
- A patient admitted to the hospital. The admit process requires the hospital staff to document an accurate medication history. Hospitals do not have access to the current the prescription history for the patient maintained by the patient’s pharmacy, creating a chance possibility for errors, adverse drug events and improper therapy.
- Therapy changes made in the hospital. These changes need to be communicated to other providers (e.g. the primary care physician and the pharmacy). The lack of standard communication between hospitals, the primary care physician’s EMR, and the pharmacy’s records can lead to discrepancies.
- Routine changes made at a physician office. Patients are often instructed by their physical to increase or decrease doses of drugs they take without a new prescription being issued.
- Medical information related to drug therapy. A pharmacist managing a patient’s drug therapy requires a significant amount of medical and laboratory data to ensure optimal outcomes. Without seamless access to a patient’s relevant laboratory results, relevant diagnosis and pertinent history and physical, pharmacists are limited in their ability to perform Continuous Medication Management (CMM)
Jumping Thru Hoops
Many electronic medical records and other health care provider systems have made their way to the internet. Using secure web portals, providers can access their patient’s records from a variety of locations (office, hospital, home etc). The internet has become an enabling technology for providers trying to share information. If two different systems do not communicate (e.g. the physician’s EMR and the Hospital EMR), at a bare minimum, the provider can access both systems from a single computer to update and check records. Many providers find that they maintain accounts with multiple internet enabled medical records.
A pharmacy with good relationships with several providers might be able to gain access to a variety of records to enable productive collaboration. Besides having access to their own clinical record system, a pharmacy might have access to a hospice’s EMR, multiple nursing home EMRs, and access to records from one or more laboratories. This creates a chaotic environment where information must be gleaned from multiple sources and documentation made across many different records to ensure proper communication between all providers.
Even with great relationships between providers, gaining access similar to that described above is difficult. A pharmacy might serve 10% of a medical practices patients, and access has to be limited properly to prevent improper access. Likewise, a pharmacy would only want grant records access to a provider’s patients.
Today in healthcare, communications between providers is more important than ever before. And today, the fax still dominates communication between providers. It will likely be take a long time before all providers can come to and play in the same sandbox.