HIMSS: Specialty EMRs flood the market, challenging interoperability
ORLANDO, Fla.--Because each medical specialty has unique information needs and data types not represented in "standard" EMRs, John H. Varga, MD, physician informaticist with the Department of Veterans Affairs (VA), illustrated the diversity of process workflow, analytic requirements and available tools among the various specialties in an exclusive interview.

Varga and Raymond H. Aller, MD, director of informatics, department of pathology at the University of Southern California in Los Angeles, presented on these topics Feb. 23 at HIMSS11.

In attempting to distinguish informatics characteristics of various medical specialties, Varga and Aller found that, for example, drawings were particularly common in dermatology, ophthalmology and some surgery subspecialties. “While there are some specialties, like plastic surgery, where photographs best depict a clinical situation, drawings are more appropriate in other complex conditions,” explained Varga, who is an ophthalmologist.

Graphic creation tools that are on virtually every computer could ideally be attached to existing standard EMR systems, using creation of handwritten diagrams, but those functions are lacking from current EMR platforms. “Unfortunately, drawings and photos are often scanned in and attached to the EMR, if they are included at all,” he said. “This creates a much more tedious workflow, and often times, physicians do not have the time to undertake this process.” The alternative is that providers maintain "shadow records," so these photographs or drawings are kept on paper in one place—outside of the EMR.

Likewise, specialties, such as psychiatry, require free text entries as opposed to structured text entries or numerical data, which is more common in internal medicine or family practice. In addition, radiation oncologists need to match entries made from human guidance, as well as radiology images into computer modeling, so the system knows where to direct the radiation.

Varga pointed out that the free text field available in most EMRs will accept pictures, but this takes awareness and a willingness to take the time for a work-around on the part of the physician because it’s not currently an integrated part of the EMR. If you place an image in this field, it will appear as a thumbnail in the EMR, which can be opened by double-clicking on it, but if the files are too large, it can cause storage problems with the system.

Likewise, surgical pathology systems have very complex workflow and tracking requirements, and also must seamlessly incorporate diverse sets of images--some in the gigabyte range.

“Of course, dedicated clinicians can find a means to get the proper information into an EMR, but it takes many more steps and the process shouldn’t be that difficult,” Varga suggested. “The more steps required to complete a task, the less likely it is to take place.”

Currently, there are approximately 35 multi-specialty vendors advertising specialty EMR systems, along with 42 single-specialty vendors and 36 non-aligned vendors, totaling 113. This “voluminous number doesn’t include the ambulatory EMR vendors without specialty templates.” In addition, there are more than 20 vendors who just have EMRs that cater to niche specialties. For, example, ophthalmology alone has seven or eight niche vendors.

“Therefore, we have about 100 different systems, which just complicates situations and integration with an enterprise EMR,” Varga said. “Also, due to this flood of the market, how do providers differentiate between these various vendors and systems?”

He added, “If a provider chooses to go with a larger EMR vendor, which also offers ambulatory options and various specialties, integration is a little easier, but very often the various departments will obtain separate systems from different vendors.” Therefore, if an individual physician practices at three to four locations, they could be using as many systems.

“These issues are confounding interoperability across an enterprise. In order to attain true interoperability, there will need to be greater standardization within the various specialties – with their different vocabularies, workflows and documentation requirements. Agreement first needs to begin within the specialties, then the vendors can cater to these needs.”