Epic, Meditech, Surescripts showcase interoperability with regional HIE
One of the most encouraging real-world object lessons in data liberation emerged at the HIMSS16 Interoperability Showcase last month in a demo called "911 Continuity of Care." The scenario showed how IHE and HL7 specifications could make IT systems of all types talk to each other, across the U.S. – and even abroad.
The imaginary use case involved one "Robert Hartman," a 40-year-old male who is an Italian citizen visiting the U.S. In St. Louis, he receives care at a community hospital for one of his chronic conditions. Later, while visiting Philadelphia during the Papal visit this past September, he is in a car accident.
As he's transported to the emergency department, paramedics stabilize him and gather clinical data that's communicated to the ED. Clinicians at the hospital are also able to gain access to his historical medical data once he arrives. A summary of his care is shared with his doctors in St. Louis and also in Italy.
EHR vendors Epic and MEDITECH took part in the demonstration. As did Surescripts, Zoll – the maker of emergency medical services technology – and HealthShare Exchange of Southeastern Pennsylvania, or HSX, the region's health information exchange.
It showed the promise of seamless data exchange – from the ambulance to the ED, from the primary care office to the HIE, and back.
"At every place along the way, you can use interoperability standards to get the outside data and take care of Robert better," said Epic technician Zach McQuiston.
The journey starts in St. Louis, where Robert is treated for diabetes at a MEDITECH-equipped community hospital. "We see that his condition is a bit more serious than expected, so we eventually admit him," explained MEDITECH Senior Project Coordinator Joe Wall. "Eventually when the patient is discharged, we generate the continuity of care document," using HL7's Consolidated CDA standard.
It's an example, he said, of "leveraging work we've been doing with the Argonaut Project" – a collaborative of major EHR vendors, as well as health systems such as Intermountain and Partners HealthCare, to speed the development and adoption of HL7's FHIR framework – "with all of us playing in the same sandbox."
All the discharge packet information, all that structured data, gets put into the continuity of care document on the MEDITECH side. Since everything is structured, "we're able to display right on the Epic side," said Wall. "On the ambulance side, they'll capture additional information so that will be available for the ED as well."
During transport, paramedics interview Robert and learn he has hypertension, for which he takes medication. They assess his head laceration and examine him for neurological symptoms and take his vitals. They document the treatment rendered: oxygen, lead monitoring, fluids, wound care. At the end of the ambulance ride, they document that he was transferred to an emergency department.
When the record is complete, it's packaged into an HL7 CDA patient care report. When Robert arrives in the hospital ED – which uses Epic – care providers there already have the preliminary information they need.
"I open this chart and can see I don't know anything about this patient," said Epic's McQuiston. "He's never been here before, he's from out of state. But what I do have is this information here that Zoll has captured. All the information that they documented I have right in my normal workflow in Epic: I can see the concussion, can see my patient is diabetic, and a lot of other things."
As Robert is being cared for, the ED staff is also able to query Surescripts' record locator service in an effort to learn more about him; meanwhile, they can also check in with Philadelphia's health information exchange to see what else they might find out.
"All of these transactions are standards-based IHE transactions, they are all being piloted or are live," said McQuiston.
Surescripts' Bryan Nelson said that they can do three things with those queries.
"First, we're going to pass along the IHE standards, the XCPD patient demographic lookup and the PLQ patient location query, onto other IHE-connected participants. These might be other hospitals, clinics or technology vendors who are connected to our network,” Nelson said.
The next step is to look at Surescrpits master patient index, Nelson added, which contains 140 million patients.
"By doing this we've identified two instances where Robert has received care during his travels across the U.S.," he said. "We're able to compile those locations into a patient care CDA that we then send back to Epic via the IHE profile so that can be presented at the point of care.”
The last step is to adapt the IHE profiles to the HL7 FHIR resources to communicate back to Robert’s doctors in St. Louis.
“We're translating the IHE transactions into the FHIR resources so we can query the MEDITECH system and pull the CCD that was compiled at the outset of this demo from the urgent care visit; we're then taking that CCD and adapting it back into the IHE profiles to send back to Epic at the point of care so the provider can make the most important clinical decisions."
Meanwhile, Rakesh Mathew, HSX program manager at Philadelphia's HealthShare Exchange, explained how, during the the papal visit, it set up an international exchange with Italy – one of the first times an HIE in the U.S. has set up an international exchange, getting clinical data from other countries: "We've received a CCDA document from Robert, and we share that with Epic."
Back in the emergency department, a look at Robert's chart shows it more populated with critical data than it otherwise might have been.
"Before, we didn't have anything," said McQuiston. "Now you can see all the external data I've received. I have the MEDITECH information that Surescripts told me about. I can see the information returned to me by the HIE, the Italian system. Because this is standards-based structured data I can also interact with it – so as I go through and review the information I can see that Robert is allergic to morphine and penicillin; he's also diabetic and suffers from hypertension."
Thanks to all of this outside information, "I'm able to take really good care of Robert," he said. "I can avoid aggravating his allergies and I can release him in just a couple days. He makes a really quick recovery."
During the discharge process, "the documentation I've done in the ED is going to be packaged up in a CDA discharge summary – a standards-based document with discrete data – and sent back to the patient's primary care provider and to the HIE so it might be available to other people who might treat Robert in the future."
It's all very impressive, to be sure. And encouraging. The key now, said Philip DePalo, who oversaw the HIMSS16 Interoperability Showcase as senior technical project manager, is to take these real-world accomplishments and see them spread more broadly in the real-world, beyond the walls of a demonstration pavilion.
"It all looks great here," said DePalo. "But the uptake of some of this stuff is not as large scale as we make it appear. If you went to 10 different places, maybe three would have this technology. Or one has it, but the next part of your healthcare system doesn't, so you really can't exchange anything.
DePalo said the industry now appears to be at an pivot point that could see these advances proliferate faster than ever.
"The strides we're making on restful APIs, such as FHIR, are making it a little easier for people to incorporate and to use this technology on a cheaper budget," he said. "It isn't about the technology, it's the uptake of that technology. The technology is growing, for sure – how could it not? But they're creating more than people are actually using."