Executing the Case for Interoperability

The Chaotic State of Health Care Information Exchange

It isn’t just some of the patients in our health care system that are sometimes found to be “inoperable”. These days, with the massive growth in health care information that continues to be generated from individual physicians, hospitals, private laboratories, specialized clinics, insurance companies, and pharmaceutical companies, the IT infrastructure that connects all of this is actually even more inoperable with a growing “Tower of Babel” of different data types, data formats, computer applications, operating systems, and data transfer formats. And it’s getting even more complicated every day.

Consider some of these statistics, for the United States alone:

• There are over 240 million people with health insurance.
• There are over 500,000 office-based physicians.
• There are over 7,600 hospitals.
• Within hospitals, there are over 820,000 physicians and surgeons, 77,000 occupational therapists, 182,000 physical therapists, and 94,000 respiratory therapists.
• There are over 16,000 certified nursing facilities.

With all these patients, facilities, and medical professionals out there, there are, of course, a myriad of laboratory tests carried out every day. In the U.S., in fact, it is estimated that there are over 785 million health care tests conducted per year. Because of the lack of automated interoperable systems to communicate these results back and forth between the various agencies that need to see them, one estimate has shown this results in more than one billion hours of administrative processing time just to get the data in the right place.

There are literally hundreds of major and minor health care insurance entities that also must interact with of these institutions and providers in as efficient a basis as possible, every day; not to mention the many in-hospital subsystems and computer systems which have been acquired over many years and were often never fully integrated into one common system.

And all of the above organizations are generating their own medical data, often in conjunction with the use of sophisticated digital diagnostic and imaging systems, and more often than not with data formats completely incompatible from one system to another.

It creates confusion, chaos, waste, and sometimes-critical human error. In fact, the Institute of Medicine’s much-publicized report, To Err Is Human; Building a Safer Health System, preventable medical errors account for at least 44,000 and possibly as high as 98,000 deaths each year. Additionally, the Agency for Healthcare Research and Quality (AHRQ) estimates that over 770,000 people are injured or die each year from medication errors, costing providers millions of dollars in unrecoverable expenses. Research also shows that the majority of medical errors do not result from individual recklessness, but rather by faulty systems, manual archaic processes, and the lack of congruent or compatible information systems.

Further, because the world of health care information exchange is so complex, the integration problem often is set aside “for later”, in spite of the rapid increase in use of electronic medical billing (used by 79% of physicians in a 2003 study), digital medical records access (used by over 70% of physicians), and computerized medical preventive care reminders sent to patients (used by 54% of physicians in the same 2003 study). Because of the difficulty of integrating information, doctors and hospitals are also less likely than in other disciplines to use such electronic data records for care-giving solutions support; only 25% of physicians use electronic clinical decision-making intelligence at all, and only 6% say they use them on a routine basis.

How much is Interoperability Worth?

There’s no question that making it easier to communicate information from one medical information system to another, automatically, would make a big difference to the efficiency of operations and accuracy of data transfer across systems. With additional business intelligence and decision-support systems in place, it can also guide hospital administrators and health-care professionals to make better decisions in use of specific treatments, eliminating unnecessary or even duplicate medical tests, and allocation of resources.

To put some financial indicators to this, consider some of the following data points, summarized from an analysis that Health Affairs published in January 2005:

• By improving interoperability between both freestanding and hospital-based outpatient clinicians in their use of external laboratories, there could be, depending on the penetration of interoperability systems, between $8 billion and $32 billion in annual savings related to elimination of redundant tests, plus reduction of delays and costs associated with paper-based ordering and reporting of results.
• By improving interoperability between pharmacies and outpatient providers, there could be a savings of as much as $2.7 billion per year just in medication-related phone calls (to clarify prescription data).
• Transactions between health care providers and those who pay for the services (such as insurance companies) could create savings of over $20 billion a year.
• With improved information interoperability, payers also will see paybacks from improved efficiency of their transactions (at $10 billion a year), and from elimination of unnecessary lab and radiology tests (for a total of almost $12 billion a year between those two areas).

The Health Affairs Journal analysis “brings this home” to the level of a medium-sized hospital which, once the highest level of interoperability systems were in place, should see benefits of upwards of $1.3 million annual at a cost of only $250,000 per year to maintain the systems. Both on a grand scale as well as on an individual hospital scale, the savings are substantial.

On a state level, a recent article on a similar study covering the entire state of New York (published by the American Medical Informatics Association in 2006) estimated that implementing improved healthcare information exchange and attention to interoperability could amount to a net savings of $4.5 billion a year, after subtracting the costs of installing and maintaining the necessary IT infrastructure to support this. The study specifically cited as much as $2.5 billion a year in savings from elimination of paperwork and redundant tests, plus payer-provider information exchange savings of over $2 billion a year.

In addition to the absolute dollar savings, the payback to the patients themselves by implementing such systems is both tangible – and incalculable (in the long run) in its impact on family and society as a whole. In a report published in 2007 by the Commonwealth Fund, it was noted, for example, that in Denmark, where a central health information exchange system with carefully-crafted information sharing standards was put in place some years ago, that – at a cost of only 40 cents per patient per year, there has been a significant reduction in cost of medications, substantial improvement in adherence to preventive care regimens, and a lower incidence of cervical cancer (in part because of a 20% increase in the number of general practitioner visits per day – a good thing).

The Importance of Health Care Information Data Standards

Defining common medical information technology standards is, of course, a key to providing some order in all this. The good news here is that there are indeed many such standards that have been agreed upon already, and new ones that add to and refine these further are being added every day.

Some of the majors are:

• The X12N Subcommittee of the American National Standards Insitute. Its health care standards provides good means of managing benefits data as well as provider referrals. See their website at www.x12.org.
• The Committee 31 on Healthcare Informatics of ASTM International. One of the strongest aspects of this group’s standards are its “Continuity of Care” Record uniform patient summary. Visit them at www.astm.org.
• DICOM (Digital Imaging and Communications in Medicine) provides a set of standards for the transmission of medical images reports connected with those data sets. More on these can be found at www.medical.nema.org.
• ELINCS (EHR-Lab Interoperability and Connectivity Standards) is a newer standard covering the reporting and ordering of laboratory tests. They are at www.elincs.org.
• Health Level Seven (HL7) is a standard covering the core clinical messaging standards used throughout the healthcare industry. Their website is www.hl7.org.
• There are two sets of standards put forth via the World Health Organization for the International Classification of Diseases. Currently Version ICD-9 is the standard for diagnostic and procedure codes in this area. A significantly expanded version of this, ICD-10, is also in the works. Learn more about these standards at www.who.int/classifications/icd/en/index.htm.
• NCPDP (The National Council for Prescription Drug Programs) provides standards for managing prescription transactions. Their website is at www.ncpdp.org.

The Role of a True Systems Solution

The development and deployment of effective uniform data communications standards is indeed critical to improving a given health care system’s ability to accurately and efficiently transfer data from one system to the next. Even if you implement such standards, however, that’s only a beginning.

The first reason this isn’t enough is that, like many institutions whose information technology infrastructures have grown over time without at least an initial centralized plan for data cross-communication, there are many different information subsystems in place, few of which were ever designed to work together.

The hospital’s central information system may in fact be the most well-behaved of these, with interconnections between patient record databases and major transactional billing systems already in place. In addition to that, however, there are separate systems for managing the pharmacy (plus drug disbursement and expense management), transcription systems that connect to external vendors, laboratory data management systems, the radiology information systems, digital imaging data systems such as PACS (Picture Archival and Communication System), electronic health records and their management software systems, and even the accounting general ledger subsystem. Add to that, systems for what’s known as ADT (admissions, discharge, and transfers of patients), billing and accounts receivable, patient scheduling, and the patient care system, and you have quite a bit of chaos.

And even if the internal systems were tightly coupled and designed to adhere to standards, web-based and other remote systems not under the control of the hospital must also be included as part of the overall IT communications planning scenarios.

Each of these is likely to run using its own unique software application, sometimes on entirely different operating systems, and with database structures that were never designed to “talk” with one another in any manner.

A second reason for why standards aren’t enough is that, even if there were strict adherence to common data standards and the systems themselves were set up to easily transfer information from one application to the next, there is generally almost no attention to the creation of even the most basic of decision-support and business intelligence systems in most healthcare operations. So even if the data is available to help determine better application of resources within a hospital network, that information is completely unavailable to the healthcare systems executives and administrative teams that could make use of it.

Any truly effective IT solution for this industry, therefore, must simultaneously address three issues:

• Adherence to the latest healthcare information exchange standards
• Provide a means of enabling previously unrelated applications and databases to communicate with each other
• Have the availability of real-time business intelligence data to help manage the day-to-day tactical and strategic decisions o the business.

The Future of Healthcare Information Technology Management –
An Holistic Approach of Managing and Analyzing Data in Healthcare

Fortunately, as technology has evolved to deal with such complex data architecture issues, new systems solutions that can address all three major IT needs are finally becoming available.

Consider the flow of data within your healthcare organization. During a patient visit, massive amounts of data is generated that flows along with the patients “walk” through delivery of care. Even prior to a patient’s encounter with the hospital, Patient Registration systems begin to create data that then must be passed along to other various systems in the Clinical, Financial and Operational departments. As the patient moves through the process, this data flow increases with each step of the encounter. The main Hospital Information System (HIS) or Clinical System needs to talk to the Laboratory Information System (LIS), the Radiology Information System (RIS) must talk to its PACS system, and so on- a mixed bag of vendors, speaking different versions and formats of HL7. We must capture the data, translate and integrate the data between systems, and then present the data for decision support, reporting, and future analysis.

Historically, the approach to solving this problem has been to employ a team of developers to custom program individual one-to-one interfaces between each system. The hospital must then retain at least a portion of that team to maintain these hard-coded interfaces. This is obviously a very time consuming and costly solution.

RHIOs, EHRs, and Consumer Driven Healthcare all add a new dimension to the requirements of records (and therefore data) interoperability and portability. Writing custom interfaces is no longer a viable option for healthcare organizations. Today’s requirement is to integrate these systems in an any-to-any scenario, where information is easily and automatically routed to the appropriate systems at the appropriate time, even across physical, local, and wide area network boundaries. This comprehensive approach takes into account the four phases in the lifecycle of healthcare data:

Data Capture

Patient demographic information is either manually entered into the Admissions system, or captured digitally with “Smart Pen” technology. Also, this could occur when a patient presents their Portable Medical Record for entry into the admissions system.

Data Input/Translation/Integration

Most of the efforts are expended here. As mentioned earlier, RHIOs, the EHR, and the necessity to communicate with other external entities such as labs, 3rd party vendors, etc., are changing the requirements for integration to the extent that patient information must be transmitted outside the Provider’s physical or network boundaries. This of course requires significant advances in integration and security technologies to satisfy regulatory bodies such as HIPAA.

Such technologies have been developed to allow the IT team to easily create real-time interfaces between the Provider and external entities in the form of “Integration Engines”. There are two distinct types of Integration Engines:

• Programmatically-Based Integration Engine As the name implies, the IT team is required to develop the code for each interface scenario. These were developed, and have been in use since the early 1990’s. Hospitals must still have highly skilled (and thus expensive) programmers on staff to implement and maintain these systems. While these engines do greatly reduce the time to implementation as opposed to custom programming, there is still a significant amount of time spent in development and maintenance.
• Configuration-Driven Integration Engine These next-generation configuration-based engines are just that- the system is configured using a drag-and-drop or point-and-click approach. These are highly sophisticated, yet easy to use technologies that do not require highly skilled and vendor-specific engineers to accomplish the integration requirements. In practice, the IT staff selects parameters within the system, and the engine automatically generates the code necessary to perform the integration between any number of disparate systems in real time. Also available in a limited field of configuration-based vendors is proxy software and small network appliances that can be deployed at the external entity to allow direct and secure integration over the Internet, with minimal work required by the third party to have access to their system. This opens up a tremendous amount of flexibility for the Provider to be able to work with RHIOs, labs, etc.

Data Access and Reporting

At the point of care, doctors, nurses and technicians need access to lab reports and other diagnostic information.

The benefits of this comprehensive integrated environment span every department in the organization, and extend to ultimately to the patient.

One of the most promising of these is provided by eTransX, Inc., a U.S. based company with many years of experience in creating and deploying advanced information management systems designed to bring diverse database systems together. With extensive involvement in many aspects of heathcare information technology serving everything from hospital systems to the insurance industries that work with them, eTransX has created a unique set of subsystems that work together to deal with exactly the issues described above.

To support the complex needs of the Patient Information Processing problem, eTransX has developed a product called eTX HEMI, a modular “Healthcare Enterprise Messaging and Integration” that is fully compliant with the full range of HL7 message standards, ensures guaranteed message delivery through the system, provides tight data monitoring to ensure traceability of all communications, and is XML data schema driven (for compatibility with the widest variety of data systems possible). Further, even more importantly for the IT executive is that eTransX’s solution (including both eTXHEMI and its flagship eTXIntegrator product) includes a unique software architecture that minimizes the need for any complex coding to allow it to cross-communicate with all the various data systems in existence in a given IT ecosystem. It’s a little bit of an oversimplification, but basically you “tell’ the eTransX system how you want data from one system to relate to another, and the system dynamically deploys the code to make that happen with minimal intervention by the hospital IT team.

Finally, to support the need for decision support systems within the IT infrastructure, the eTransX solution also includes its eTXIntel module, which literally displays real-time configurable data “dashboards” – available in-house and via the web. These provide a variety of on-demand healthcare system business analytics that simultaneously simplify the complex challenge of understanding what’s most important at any given time while also bringing together many different forms of data at the touch of a mouse – or a few keystrokes.

Summary

Effective management of health care information technology is both the biggest challenge as well as perhaps the most important opportunity area for health care systems executives to focus on in the future. With proper adherence to modern health care IT data standards, implementation of systems that allow for effective data sharing throughout (and even beyond) the enterprise, and installation of appropriate business intelligence data analysis tools, the returns on such investments will be very significant in the long run.

To learn more, contact the experts at eTransX, Inc. to show you how you make this happen for your enterprise. You can find them at www.etransx.com.

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