Healthcare information technologies (HITs) affect virtually every aspect of our healthcare system, bringing technological innovations that are impacting the evolution of healthcare delivery. HIT is increasingly playing a role in almost all healthcare processes—patient registration, data monitoring, laboratory and radiology testing, and home monitoring devices. Pharmacists are seeing this firsthand through the widespread adoption of electronic health records (EHRs), e-prescribing technology, and various mobile devices.
However, in order for HITs to have maximum positive impact on medical outcomes and overall healthcare delivery, it is necessary to ensure that these technological innovations can “talk” effectively to each other, thereby creating a seamless conduit for end users to exchange information. This is termed interoperability—the extent to which systems and devices can exchange data and interpret shared data.1
One of the primary arguments for introducing various technologies into healthcare was to replace paper records with data-exchange solutions to ensure that the right information was given in real time to the end users, enabling them to make sound decisions about healthcare right at the point of care. However, in this regard, some HITs have fallen short. The pharmacists, clinicians, or consumers of healthcare who adopt these technology solutions still see much of the data being segregated into “silos” of electronic data, merely replacing the past silos of paper records. These technologies were also expected to reduce medical errors, but that goal has not yet been realized.2
Although HIT advances may have improved patients’ health outcomes and quality of life, they clearly need to be further refined and optimized so that they can better serve the purposes envisioned when they were implemented. This article will review the current state of the HITs that most concern pharmacists—EHRs and e-prescribing—and discuss some of the functional deficits that remain, with a focus on interoperability.
Interoperability, EHRs, and E-Prescribing
EHRs in healthcare have essentially replaced the paper chart. The U.S. government has spent well over $27 billion to date to digitize patient records, and nearly 70% of physicians now use EHRs.3 In 2009, only 16% of U.S. hospitals were using an EHR; by 2013, about 80% of hospitals eligible for CMS’s meaningful-use incentives program had incorporated an EHR into their organizations.4
EHRs were meant to provide high-quality delivery of data to clinicians using best practices and real-time delivery, so that decisions about treating patients could be optimized. But despite their acceptance, many EHRs have not yet fulfilled their ultimate potential for improving healthcare, in part because of the lack of interoperability. Coordinating care for complex patients is particularly difficult when their information is trapped in EHRs in the various settings where they receive care.5 In fact, nearly two-thirds of doctors would not purchase their current EHR system again because of poor functionality, not to mention high costs; clinician frustration over the functionality of EHR systems has been escalating, in part because introducing any technology (including e-prescribing of medications) requires greater clinician involvement at a time when many healthcare entities continue to struggle to maintain adequate patient volumes and remain financially solvent.3,6
E-prescribing, on the other hand, appears to be a very successful technological solution, with 7 out of 10 office-based physicians e-prescribing in 2013, a 4% increase over 2012.7 With e-prescribing in place, it is easier to track medication adherence, and a patient’s medication history is more complete; abuse of controlled substances can be more closely documented and tracked, and coordination of care is easier when processes are more streamlined. Overall, e-prescribing has been accepted as a positive enrichment in healthcare delivery. This is largely due to the use of very robust standards developed by multiple industry stakeholders, such as vendor and government entities, that allow for interoperable transmission of complex prescriptions.6
The various pieces of HIT need to come together and interoperate seamlessly to provide a total snapshot of a patient’s healthcare in real time. Thus, interoperability plays a key role in the solution needed for this technological advancement.
How Interoperability Works
For systems to be interoperable, they must be able to exchange data and subsequently present that data in a way that can be understood by an end user.1 So, in a practical sense, interoperability is the ability to make different technological systems and diverse organizations that are unrelated work together and exchange data for real-time use. It encompasses the technical, social, political, business, and organizational factors in healthcare that relate to exchange of any type of healthcare data. The end result of interoperable data exchange should be effective delivery of healthcare for consumers and other entities requiring the use of these data. There are three levels of health information technology interoperability that correlate with data-exchange opportunities: 1) foundational; 2) structural; and 3) semantic.8
Foundational interoperability allows data to be transfered from one information technology system to another and does not require that the receiving system posess the ability to interpret the data. An example would be a PDF document that contained a narrative summary of the patient’s hospital stay and discharge medication list. The PDF can be transferred from one machine to another electronically. The receiving machine can store the document, and the receiving clinician can read the document. However, the receiving machine cannot further process the information contained within the document; for example, it cannot parse out the individual items on the discharge medication list in order to perform a medication reconciliation and update the patient’s current medication list. This update could only be done if a person read the PDF and then manually entered updates to the medication list on the receiving system. However, the receiving system is unable to read the PDF and update the medication list on its own.1
Structural interoperability is defined as uniform movement of healthcare data from one system to another, such that the clinical or operational purpose and meaning of the data are preserved and unaltered in the receiving system. Structural interoperability defines the syntax (otherwise known as composition) of the data exchange. It ensures that the data exchanges between information technology systems can be interpreted at the data field level. Structural interoperability requires that both the sending and the receiving machine be using an accepted data standard. For example, if the patient’s discharge medication list is transmitted, the receiving machine will recognize the individual data elements such as medication name, dosage, route, and frequency. The receiving machine can then populate the appropriate data elements in the patient’s current medication list. Another good example of structural interoperability is e-prescribing. The standards for e-prescribing generally ensure that the pharmacy computer system will accurately reflect what was sent from the prescriber’s computer system. Both systems use the same data standards for common elements of a prescription, including the name of the agent, the strength, and the directions for use consisting of dosage, route, and frequency.1
Semantic interoperability is the highest and most robust level of interoperability available today. At this level, two or more systems or elements can exchange information and use the information that has been exchanged. The benefit of this level of interoperability is that it takes advantage not only of the structuring of the data exchange but also of the vocabulary (otherwise known as codification of the data), so that the receiving information technology systems can interpret the data.9 This level of interoperability supports the electronic exchange of patient summary information among caregivers and other authorized parties via potentially disparate EHR systems and other systems to improve quality, safety, efficiency, and efficacy of healthcare delivery.1 The computer systems would have a robust understanding of vocabulary and would know common usage. For example, a receiving system would know that a frequency field stating bid is equivalent to twice daily and to am/pm. A frequency field of bid is not exactly the same as q12h, because q12h contains a more specific timing direction than bid. A higher level of semantic interoperability would allow the computer to recognize that a levothyroxine prescription for 100 mcg, one tablet qam would be equivalent to 50 mcg, two tablets qam. When selective substitution is required, special instructions would need to be provided. Thus, it can be seen that true semantic interoperability could become very complex due to many nuances that pharmacists readily understand, but a computer would not understand unless provided with a very specific knowledge database. Thus, the development of software to provide for semantic interoperability in medical and pharmacy venues can be complicated, and this area is still being enhanced.
Health Information Exchanges
In addition to the interoperability of systems and devices, health information exchange (HIE) is another important component of effective HIT; it is concerned with electronic movement of health-related information among organizations according to nationally recognized standards. HIE is necessary to facilitate access to and retrieval of clinical data to provide safer, timelier, more efficient, effective, equitable, and patient-centered care. HIEs need to support and provide the capability to electronically move clinical information between disparate healthcare information systems while maintaining the meaning of the information being exchanged. An HIE also provides an infrastructure for secondary use of clinical data for purposes such as public health; clinical, biomedical, and consumer health informatics research; and institutional and provider quality assessment and improvement.10,1
Thus, interoperability and HIE are pivotal steps in moving the technological support of healthcare forward. However, in order to provide the most value to clinicians, these technology solutions must be able to exchange data with each other in a manner that not only preserves the meaning of the data, but also harmonizes with the clinician’s workflow. Oftentimes, technologies get in the way of workflow and thus create extra work on the part of the end user.
Good examples of technologies being used efficiently as medical management solutions include the digital innovations being implemented with portable devices, such as home monitors used for oxygen measurements, blood glucose monitoring, and blood pressure control, to name a few. These include devices that monitor vital signs in realtime and some that conduct various tests at home such as blood glucose monitoring. All of these effectively empower the patient and may lead to dramatic healthcare improvements.11 At the end of 2012, for example, 2.8 million patients worldwide were using a home monitoring system. Monitoring patients’ health at home can reduce costs and unnecessary visits to a physician’s office.4
Conclusion
We have come a great distance in reducing paper health records and streamlining medical care processes. We can appreciate the various healthcare-enabling technologies in play today, whether EHRs, e-prescribing, HIEs or others. Incorporating technologies into healthcare is no small feat, and there are great challenges ahead, including making HIE more widely available and solving the problem of semantic interoperability. In the end, clinicians need the support of HIT, including the exchange of pharmacy data in real time, seamlessly and interoperably, without interruption and without missing or inaccessible data.
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www.nachc.com/client/Key%20HIT%20Terms%20Definitions%20Final_April_2008.pdf. Accessed September 19, 2014.
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