The adoption of digital health technology will be on an upward trajectory over the next decade, with a forecasted market exceeding $379 billion by 2024. This projected growth makes the need to integrate these tools into the EHR increasingly critical for health systems. EHR integration brings forward and leverages data and insights from digital health tools to provide relevant information, alerts to threats and opportunities, and financial and operational guidance at the point of care.
Given that the encounter-based EHR is the principal electronic interface most clinicians use today, the path to improved data-driven outcomes is likely to be, at least for the foreseeable future, through the EHR. However, most of the rich array of data analytics, data analytics, predictive analytics, and wellness applications that can drive the target outcomes won’t exist within the EHR. As an encounter-based transactional system, the EHR has not been designed to support real-time, point-of-care clinical decision support and analysis from a range of sources; to do so, health systems must integrate the EHR with many other digital resources. Given the limitations of traditional EHRs, interoperability is top of mind for both health system executives and policy makers.
At its core interoperability is about aggregating the rich data that health plans, health systems, vendors, and patients generate through EHRs, analytic systems, biometric monitoring, and other digital systems, and leveraging that data to improve patient diagnosis and treatment. The focus of interoperability is the point of care, where clinicians can maximize these technologies’ impact.
The Office of the National Coordinator for Health Information Technology (ONC) defines interoperability as, “the ability of a system to exchange electronic health information with and use electronic health information from other systems without special effort on the part of the user.” Users must be able to easily find and use the information on both ends, whether sending or receiving, as well as send to, and receive information from, third-party systems (independent IT vendors). In practical terms, integration is having automatic access (versus manual entry) in the EHR to clinical information from sources within and outside the health systems and using that information when treating a patient.
A recent Health Affairs study found growing evidence of substantial treatment and efficiency gains through interoperability; the authors stated that interoperability “is expected to be a key enabler of population-based alternative payment models, delivery reforms, and improved performance measurement.” However, the study also found that as of 2014, only about one-fifth of U.S. hospitals were engaged in all four elements of interoperability (finding, sending, receiving, and integrating information).
According to the study, fewer than 50 percent of health systems report that they are integrating information. Among the barriers, health systems most commonly cite difficulty for clinicians in viewing third-party information (e.g., worklists or alerts) in the EHR workflow. The study also found that integrating third-party information is more complex than finding, sending, and receiving, and only the more advanced EHR systems support integration. This may explain the slower progress toward integration. Without strong demand and proven use cases (discussed later in this article), integration might continue to make slow progress.
There are currently two main categories of challenges facing EHR integration:
The prerequisite for healthcare digital integration is getting providers to adopt EHRs; this is similar to the way high-speed broadband internet connectivity was a prerequisite to many internet-based services. EHR systems are now largely in place, and data shows that finding, sending, and receiving electronic health information is occurring at significant rates. Integration, however, involves specific technical challenges that may be more difficult than sending and receiving information.
For integration, systems must be able to call up, at the right time and place, the relevant third-party information within the EHR user interface. This requires a technical infrastructure that makes relevant information available in the user interface. The technical infrastructure might involve APIs, which pull in relevant information when certain screens are accessed or provide tabs to link to third-party content for worklists with relevant information. At the very least, integration requires the health system to configure software to share information.
Fortunately, healthcare IT regulators are increasingly encouraging the use of standard protocols to enable the free exchange of health information among digital health tools and EHR systems. Technical challenges should soon become a less significant barrier to integration, as long as parties are willing to enable the right infrastructure and exchange standards.
Many healthcare integration challenges involve a lack of willingness among the key players (health systems, insurers, and vendors) to do the work to make integration happen. Some of this resistance stems from specific objections:
To achieve EHR integration, the healthcare industry must establish standards, prioritize functional integration, develop use cases.
For decades, healthcare IT leaders have promoted the use of common exchange standards to facilitate the exchange of electronic health information. HIPAA put this concept into law and developed it further in the HIPAA transactions standards. The transaction rule adopted the use of the ANSI X12 standards as well as the NCPDP exchange standards for pharmacy-related transactions. This rule, combined with the healthcare exchange requirements in the HITECH Act, have supported significant progress in the sending and receiving objectives of interoperability. Initiatives such as the Direct Project and Blue Button have also advanced the exchange of electronic health information.
Organizations behind recent standards development efforts are attempting to push the boundaries of interoperability further; their focus includes more real-time, or near real-time, exchange of health information and analytics and provisioning the relevant health information for providers at the point of care. APIs are integral to many of these efforts, as they allow third parties to access the data and data models within other software applications and apply their own tools to the data, as well as deliver their outputs or data analysis back into the primary user’s EHR.
APIs can enable platforms that aggregate data across multiple providers or vendors that could ultimately help facilitate a widely adopted, fully integrated digital healthcare ecosystem. As publicly available APIs that allow users to access data with few restrictions, open APIs can support further integration. The U.S. Department of Health and Human Services will likely create a definition of open APIs in healthcare that will include openly published specifications.
From a software vendor perspective, the definition of open API would include critical concepts:
Health systems are widely adopting the FHIR standard, which builds on the HL7 standard, for the exchange of health information. In addition, the SMART on FHIR platform and the CDS hooks specification have made significant advances in providing a framework for the real-time exchange of health information. These standards and specifications provide the framework for rapid advances in EHR integration.
In addition to standards that facilitate the exchange of electronic health information, to achieve true integration, health systems need the will to address the technical and administrative challenges. Even with wide adoption of SMART on FHIR, health systems and vendors must enable and configure their systems for integration; standards alone won’t enable integration.
For example, if a health system wants to include information on social determinants of health affecting a patient’s care that’s available from third party data sources, it must configure its EHR system so that these factors appear in a window within the encounter or use another method that makes the information available to the EHR user. The fact that both the source systems and the EHR are using FHIR does not automatically make the information appear. Health systems must take steps to use the tools and standards to make them a regular feature of the encounter screen in the EHR.
There are many potential use case examples of information that integration would make available in the EHR and that would prompt clinical action:
When clinicians find themselves wondering how they prioritized ICU cases or manage the discharge of patients before they had this integrated information, they’ll be more likely to push for the continued and expanded use of data integration tools.
For the healthcare industry to meet its desired goals of full integration, it must navigate the current technical and administrative challenges. The industry is making significant progress as it unites around standards, administrative processes, and regulatory principles. Health systems can ensure continued progress with optimal industry coordination around standards, administrative processes, functional integration, and the development of compelling integration use cases to drive demand. As the digital trajectory of healthcare continues to rise, full EHR integration that brings real-time, data-driven insight to the point of care is an industry imperative.
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