Interoperability & Standards: Creating a Seamlessly Integrated Enterprise
The creation of an integrated enterprise is becoming increasingly important, not only to successfully manage patient care, but to protect the bottom line. Interoperability strategies will have to adhere to accepted medical and communications standards in order to connect systems—including radiology—and create a seamlessly integrated enterprise.

OhioHealth began its interoperability project five years ago.  The health system—a faith-based healthcare system located in Central Ohio that includes five core and multiple affiliated hospitals, 23 health surgery centers, home health providers, medical equipment and health service suppliers and a physician community of more than 2,000—began the process of implementing a connectivity strategy for electronic medical records, e-prescribing and interoperability in 2005.

A number of core questions need to be addressed when an enterprise is trying to achieve true interoperability, says Mrunal Shah, vice president of physician technology services at OhioHealth Information Services.

Step one is assessing the technology landscape within which the enterprise is working, Shah says. In OhioHealth’s case, “we had the luxury of having a clinical data repository in place that already pulled from 30 clinical systems, and output from that was already pretty straightforward,” he says. “So the first question you need to ask is how much of the groundwork has already been done for you as an enterprise. And if it hasn’t been done, just be aware that normalizing and collecting all that data for purposes of an outbound interoperability strategy is going to be critical.”

In step two, stakeholders in the enterprise must define what the infrastructure is going to look like once they try to pull information back. “How will you house it?” asks Shah. “How will you display it? How will you notify a physician that there are results available for him?” Finally, the enterprise team must ask itself how much it wants to own internally, or whether it wants to use an external vendor to host and manage the project.

Core objectives

The patient is No. 1 at OhioHealth, so it was a core objective that the interoperability strategy be “patient-centric.” The strategy is about providing caregivers as much information about patients at the point of care as possible, Shah says. In addition, practitioners “must be kept in their space,” he says. “If they have an EMR, they can stay in the EMR—they don’t have to look anywhere else for results.”

And how are the results? “Our physicians are delighted,” Shah says. “The results they get are electronic and discrete. So, for example, if they have a flow sheet for a diabetic, and a hemoglobin A1C result comes from OhioHealth, that actually populates the flow sheet. They love that. When you think about it, in the manual world, it’s a four-step process. You have to get the information, sort it, make sure it gets into the right patient’s chart, and then track it in the patient’s flow sheet. Now all that happens in one step.”

The other core objective for OhioHealth is minimizing costs. The interoperability strategy is “cost-conscious and FTE [full-time employee] neutral,” says Shah, meaning the costs involved have been “reasonable” and OhioHealth hasn’t needed to add employees to manage the process.

One of the drivers behind the project was a realization that OhioHealth faced increasing competition from nearby hospitals, outpatient clinics and independent labs and that there was value in developing information sharing capabilities.

“Simply put, if we had a technology that could make results more avidly available to physicians’ practices, it would drive business,” says Shah. “I haven’t tracked it, but I can tell you anecdotally there has been a significant improvement in the utilization of our resources, whether it’s lab, radiology, or otherwise. So our CFO and marketing folks and the physician’s relations department had a big stake in this game, as did our ancillary lab department and our outpatient radiology services.”

Other stakeholders included the IT department, the legal and compliance departments—to handle the HIPAA and Stark law implications of the project—and medical records.

Not only has there been an increased utilization of OhioHealth resources, such as radiology services, as a result of the interoperability project, the project has also resulted in the connection of 30 clinical systems or practices. It has also resulted in the implementation of a radiology ordering tool for physicians and allows OhioHealth to move lab and radiology transcribed data into physician offices.

As for lessons learned, Shah says that “you shouldn’t underestimate the power of the digital interface for shifting business.” In OhioHealth’s case, it resulted in moving business from one reference lab to another.

“So we learned quickly that all of our labs had to be part of that digital feed so that it didn’t negatively impact operations,” says Shah.

Finally, Shah says, “registration is key. If you don’t register the patient properly with the right physician, then you are only going to amplify what is a significant problem in getting the right results to the right person.”

A billion documents

One of OhioHealth’s core objectives was that its interoperability strategy be patient-centric. Bob Dolin, MD, chair of the Health Level Seven international healthcare standards organization and principal of Semantically Yours, LLC, says that reaching that kind of objective will involve the creation and exchange of standards-based clinical documentation that includes dictation and detailed narrative.

The Health Story project’s goal is to create standards that make comprehensive electronic clinical records that make available a patient’s complete medical story available to healthcare providers. Dolin points out that there are about 1.2 billion clinical documents produced in the U.S. every year, 60 percent of which are dictated and transcribed documents.

Health Story has supported the development of four implementation guides using Health Level Seven’s (HL7) Clinical Document Architecture—the history and physical, the consultation note, the operative note, and the diagnostic imaging report—forming the basis that will allow the information in these clinical areas to be shared in an accurate and efficient manner.

The implementation guide for diagnostic imaging reports will help radiology systems capture a patient’s report in a standard, industry-accepted way, that is both human and machine-readable and gives referring physicians much of the detail and narrative needed to take the next step necessary to reach a diagnosis or decide on treatment, Dolin says.

With standards, he notes, these electronic clinical documents can be seamlessly integrated with EMRs and health information exchanges (HIEs) through an incremental interoperability strategy.

“An interoperability strategy that’s incremental builds on where we have been and then moves forward in smaller steps,” says Dolin. “A lot of this involves an understanding of physician workflow, so there’s less of a disruption for the clinician [when the interoperability strategy is being implemented].”

The standards create clinical documents that can with relative ease handle structured data and natural language narratives, says Dolin. The data are structured to support links between EMRs and the clinical documents making it easier to share information across provider boundaries, while keeping those detailed, clinical narratives in one document.

“We have this mass of data,” says Dolin. “We need to make sure this narrative reporting is in the mix as we work towards capturing discrete data.