Tuesday, February 1, 2011

IHE 'Connectathon' 2011: A Preview of Challenges Facing EHR Compatibility

Every year in January, hundreds of engineers gather in Chicago at the Hyatt hotel with their medical devices and/or simulators on their laptops to test interoperability as specified by Integrating the Healthcare Enterprise (IHE) profile definitions. This year was the 12th annual event, and was somewhat larger than last year as there were 95 organizations testing 160 Systems with 350 engineers. It requires seven project managers who oversee more than 50 monitors, including myself, who validate the interoperability tests during the week. 

The week itself is pretty amazing, seeing rows and rows of computers with engineers frantically trying to make things work. The major advantage of participating, from a vendor perspective, is that it provides an opportunity to test a device and/or system against peer systems in a neutral environment. It is amazing that even though these systems are designed to meet rather well defined standards such as DICOM and HL7 and tightly specified profiles in the IHE definition, there are still a lot of details that can cause potential interoperability problems. Again, the good news is that all of this happens in a neutral environment rather than in front of a customer in a clinical environment. 

If one looks at the evolution of these events, it mirrors the transition that takes place in healthcare institutions. We struggled initially to connect medical devices in radiology to a PACS, then worked to facilitate the corresponding workflow over the next few years, followed by making sure images are displayed consistently and persistently, and meet specific modality requirements such as for nuclear medicine and digital mammography. 

Now we are at the point of integrating other departments and specialties and trying to exchange documents between labs, primary care physicians, specialists and healthcare providers using electronic health records. We even have standards for exchanging this information from a patient personal health record. 

As an illustration, I was testing a particular use whereby a patient would carry a flash drive containing his personal healthcare record to a physician, who enters vitals, and other observations and transmits that in the form of a medical summary note to a specialist. The specialist then sends back his observations to the physician, who stores all the information, including new medications and findings in the patient's personal health record. These transactions cross boundaries of five systems from different vendors using a data registry, repository and patient identification system of yet another vendor. 

Amazingly, it all worked, but as with so many standards, the devil is always in the details. To exchange information such as a ED report between a physician and a specialist is not that hard, but to make sure all these systems use the same document templates in exactly the same manner, and even more importantly, use the same vocabulary and codes is going to be a major challenge. It will take an enormous amount of testing and validation on a very detailed level to make sure that all the information is exchanged in the way it is intended. To illustrate the degree of difficulty, imagine exchanging data from one hospital using the ICD-9 coding to encode diagnosis, with another one using ICD-10, and yet another using a local extension. 

With regard to consistent terminology, we are just scratching the surface in radiology right now as we try to organize images on a viewing station from an imported patient CD in the same manner as the new exams, using a different study series and protocol descriptions. 

It was good to see the involvement during the testing of many PACS administrators as monitors for the IHE event. In my opinion this experience will be an invaluable resource as we tackle these interoperability problems. The issues will be very similar, albeit on a much larger scale, as we begin to develop interaction between personal health systems, multiple institutions and local and federal health care entities, all providing directory and patient identification services. 

Another area to watch is Canada as they organize their healthcare management and storage systems on a province-wide (similar to state) basis. I was pleasantly surprised to find that they are already planning to implement some of the IHE documentation and imaging across enterprise profiles as early as this year. There are obviously many disadvantages of a federally organized healthcare system, but no one can deny that the implementation and sharing of images and documents is a major advantage, which can easily be achieved at this level. The same applies for the institutions of the US Veterans Affairs as they have implemented the most comprehensive electronic health record in their 170 hospitals and more than 1,000 clinics and nursing homes. They have documented billions of dollars of savings through the use of this technology. 

Overall, the IHE "Connectathon" provided a good picture of what is coming: an environment whereby healthcare IT standards and profiles provide an excellent framework to integrate multiple systems from many vendors to achieve higher efficiency and better patient care. The complexity of integrating these far exceeds what we have done to date, as we need to go beyond radiology to other specialties and outside institutions. It will be quite a challenge, but by drawing on our experience with integrating imaging and facilitating workflow, we should be able to meet this challenge.