There are really two aspects of sharing of patient information—directly with patients and between providers. We are going take a look at both in the next couple of blogs, but let’s start with providers.
Provider-to-provider sharing is by far the more crucial dilemma to be solved. Nothing against the average patient, but the overwhelming majority are ill-prepared to fully consume and act on detailed and often confusing medical information (although the concept of shared decision making may help—but more on that in another blog).
Providers are pretty experienced at sharing with each other. Every time a referral is sent from primary care doc to specialist there is some degree of information exchange. And the technology that they use—phone and fax—are pretty good. User friendly, reliable, ubiquitous—a hard combination to beat.
So what’s the problem? While fax and phone are Steady Eddies, there is plenty of room for improvement. Phones are wonderful for nuanced conversations, but very inefficient for quick logistical tasks. Faxes are reliable but can only be stored within an electronic medical record as an image as opposed to discreet data. Both phone and fax are foundational elements of the old world, not the new world. You can’t do big data with fax machines.
We’ve making progress. Prodded by Meaningful Use incentives and new EHRs, healthcare providers large and small doing a much better job of electronically communicating within their own organizations. But electronic exchange dramatically breaks down when providers attempt to communicate with providers across the street. The problem is that the infrastructure for conversations between organizations is woefully incomplete.
Part of the challenge is a HIPAA security artifact—providers don’t have the freedom to send a traditional email and with an attachment of the last progress note.
Also, communication systems don’t work unless the overwhelming majority of providers have them. That’s why telephone and fax have been so successful and persistent; they are easy to use, everyone has one, and they are cheap. This is tough competition.
The current nascent efforts are a mixed bag; secure email is cumbersome, poorly integrated with EHRs, a pain in the neck to use, and has spotty penetration. The Continuity of Care document (CCD) provides a reasonable standard for electronic patient summaries that can travel back and forth between EHRs.
However, before I can send a CCD from my EHR to your EHR, a CCD integration needs to be built between our two systems. There appears to be no universal CCD integration. Each EHR to EHR CCD interface is built one at a time. With 200+ EHRs out there, that’s a ton of integration work—hardly the recipe for universal and seamless sharing.
Health information exchanges (HIE) offer the most promise. Conceptually, they are right on; a secure, digital infrastructure, broadly designed for information exchange among trusted parties all seeking to manage patient care. HIEs are not perfect. Business models are problematic (public exchanges will probably flop when the government money runs out and the privates exchanges will have to morph to be more inclusive). HIEs also have room for improvement on the work flow side (i.e. referral management tools), so that average provider can perform specialized information sharing tasks quickly and easily.
Despite these issues, some form of HIEs will be the information highway for health care, allowing much improved provider communication and care coordination. But just like the real interstate highway system, it will take a lot of money and time to build. Don’t throw away that fax machine just yet.
What do you think?
Bruce Kleaveland is President of Kleaveland Consulting and a sponsored health IT correspondent for Intel