Editor’s Note: The following article is a Guest Column from Colin Rhodes, chief technology officer at eHealth Technologies. You can contact Colin on Twitter @CTOandITGuy. To learn more about submitting a Guest Column, Click Here.
Nine years ago, when the eHealth Technologies clearinghouse was conceived, the world of electronic health records was a very different place. Data was still almost exclusively in paper charts and interoperability was achieved using a fax machine.
Some things have changed. Much has not.
Consider the definition of Continuity of Care from the Merck Manual:
Continuity of care is an ideal in which health care is provided for a person in a coordinated manner and without disruption despite involvement of different practitioners in different care settings. Also, all people involved in a person’s health care, including the person receiving care, communicate and work with each other to coordinate health care and to set goals for health care.
A key phrase here is “without disruption.” This applies both to the patient and to their providers. The patient’s care must be continued in a unified manner with a coherent overall set of goals. The provider must have the ability to work as a member of the patient’s overall care team with access to relevant information from prior encounters, within their clinical workflow.
Continuity of Care revolves around the concept of relevant information. Providers do not need, nor do they want, access to the lifetime healthcare record of the patient for the purposes of Continuity of Care. They want to know the information that pertains to the question at hand.
This might seem obvious, but it’s important to our discussion of interoperability. I read on a daily basis about the need for the patient to walk into their provider’s offices with a complete healthcare record on their phone. Armed with these reams of information, the provider can hardly fail to arrive at a better diagnosis, right?
I don’t think so.
Unfortunately, the provider cannot possibly hope to process all this information. They’ll probably take a brief look to humor the patient, and then move back to the work at hand. Access to too much information is as bad as access to no information.
So, if the goal is not the patient’s entire record, but rather just the “right” information, then who determines what’s “right?”
The short answer is that only the provider to whom the patient was referred really knows what they want to see, and the data can be highly dependent on specialty.
Now, think about the CDA continuity of care document specification. There’s a basic problem at play here that is somewhat inevitable, due to the fact that the CDA document is a summary of care at a point in time. Permit me to ask the obvious question. Who determined what information should go into the patient’s CDA document, and for what purpose was that information intended?
The person who made the CDA gets to choose. Ah. That’s not quite what we’re looking for, is it?
Put simply, CCD’s work well in the simplest case when you have a straightforward linear transition of care. Wikipedia summarizes it nicely:
“Provides a means for one healthcare practitioner, system, or setting to aggregate all of the pertinent data about a patient and forward it to another practitioner, system, or setting to support the continuity of care”
In this situation the patient sought treatment for a problem and is being referred to a referring physician, who, presumably is providing an opinion or care. The source provider has all the records that the destination provider needs and the visit is closely related in time so the data is current.
In a more complex case, such as transplant, historical data can be critical. A continuum of information is required that usually rarely exists in the source system, and as such the source CCD from the referring provider won’t be sufficiently complete.
This is where the clearinghouse comes in. We go out to find places the patient thinks they might have been at, like “the blue building down the road from CVS” that can’t be automatically discovered from a directory. We exchange electronic records, receive faxes, cajole providers into sending pathology and imaging and aggregate it all together into a clinically useful unified data set.
We appreciate HL7 for the formative work in getting us access to data. We’re looking forward to FHIR and a web services approach. The outcome of these projects is crucial to us being able to deliver true continuity of care
To conclude, it’s my view that interoperability will drive a greater need for clearinghouses. After all, being able to exchange more information is of no value unless it’s aggregated into a coherent form and presented in the clinicians workflow.
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