Tuesday, June 24, 2008

Electronic Health Records for Non-owned clinicians - Sharing data among providers

At times, the business case for interoperability is not entirely clear. If data sharing reduces the volume of redundant lab tests, then the healthcare system as a whole wins, but someone loses revenue.

Over the past year, I've seen a remarkable change in attitude among clinicians in Massachusetts communities. They are demanding data sharing. Here's the history, the specifics of the clinician requests, and the plan for making it happen.

When we first conceived our hosted software as a service model to provide electronic health records for non-owned clinicians, we designed one way interoperability. BIDMC has an ambulatory record called webOMR which contains the problem lists, medication lists, allergy lists, notes/reports, labs, and imaging studies for 3 million patients. We worked with our community EHR vendor, eClinicalWorks, to create a seamless web service that links eClinicalWorksto webOMR such that community physicians can securely view BIDMC data from inside eClinicalWorkswithout having to login again or use a separate application. However, we did not design a link between eClinicalWorksand webOMR to enable a BIDMC hospitalist or ED physician to view individual patient identified private practice data.

We did design aggregate data sharing such that the medical director of the Physician's organization could query private practices to retrieve performance, quality and outcomes data in support of pay for performance contracts.

As we began to communicate the vision of a community EHR, our private practice clinicians starting asking three questions:
1. How does a Primary Care Provider send a clinical summary to a Specialist?
2. How does the Specialist close the loop with the Primary Care Provider by sending an electronic consult note?
3. How does a hospital-based physician such as an Emergency Department clinician, hospitalist, or anesthesiologist retrieve patient summary records from private practices?

My initial response was that private practice data sharing is such a novel idea, that it would have to wait until after our EHR rollout was complete to formulate a strategy.

Clinicians were not satisfied with that approach. Thus, we've decided to accelerate our work on private practice data sharing sharing by creating a clinical summary repository for all our eClinicalWorksusers using the eClinicalWorks EHX product.

Here's how it will work.
1. Whenever a patient visits one of our BIDPO community clinicians, the documentation of their visit will be done in our hosted software as a service eClinicalWorksapplication.
2. Patients will be consented by the clinician for community data sharing via opt in consent at the practice level. Consenting at one practice implies that data from that practice can be shared with other practices, but not visa versa.
3. When the encounter is complete, a summary record including problems, medications, allergies, notes, and labs will be forward to the eClinicalWorks EHX repository using the Continuity of Care Document format.
4. Other clinicians, who are credentialed members of BIDPO will be able to view summary records from this repository, assuming the patient has consented to sharing that data.
5. An audit trail of all such lookups will be available to enforce security

Such an approach solves the PCP to specialist clinical summary issue, the specialist to PCP communication issue, and the hospital-based viewing of private practice records issue. From a technology perspective, it's an elegant solution that reduces the number of interfaces. All practices send their summaries to a repository in a standard format, then all exchange is done from that repository.

A similar approach has been used in the Massachusetts eHealth Collaborative pilots in North Adams, Newburyport, and Brockton to enable secure, patient consented data sharing in those communities.

This approach needs one additional architectural element - how do you share data among EHX repositories, with non-eClinicalWorks EHRs or hospital information systems like Meditech.

MA-Share provides the grid infrastructure in Massachusetts to enable community to community data sharing. Today, MA-Share's Gateway can push Continuity of Care Document Summaries from one organization to another. Over the next two years, we'll work with eClinicalWorks to expand this capability to push clinical document summaries between instances of EHX. This means that BIDMC will be able to push a discharge summary or other clinically important information to a community repository, where with patient consent, the clinicians of a community caring for the patient will be able to view the data, ensuring continuity of care.

I expect all of this bidirectional data sharing to be a journey. We're purchasing the EHX product as part of our licensing of eClinicalWorks software and will use it initially for performance reporting. But we'll configure it so that sharing of data between clinicians and among communities will be possible. I expect all these features to be implemented by 2011.

I'm hopeful that our BIDPO clinicians will be satisfied by our strategy to embrace bidirectional data sharing in this incremental way - sharing data from BIDMC, sharing aggregate private practice data, sharing data among private practices using eClinicalWorks, then sharing data among communities and hospitals.
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