From Reading to Writing: Next Steps for Patient Data Exchange and Interoperability

William Hersh, MD, Professor and Chair, OHSU
Blog: Informatics Professor
Twitter: @williamhersh

The rationale and implementation for reading data from the electronic health record (EHR) and other clinical sources is relatively simple and straightforward. Especially now enshrined into law in the US by the 21st Century Cures Rule, and standardized by the FHIR application programming interface (API), accessing data for reading by clinicians, patients, and others is here to stay.

Writing data to the EHR or other clinical information systems is a little more complicated. As in all aspects of informatics, the technology part is relatively simple, as activating the API in the reverse direction is not difficult technologically. But writing data into the EHR and other systems raises a number of issues. Earlier this year, the Office of the National Coordinator for Health IT (ONC) convened a workshop to address this topic. The workshop discussed stakeholder knowledge, current usage, potential use cases, and lessons learned on “write-back” API functionality. A report from the workshop was released in November, 2021 and provides excellent insights into the usage and challenges for such technology. Five categories of stakeholders were represented: researcher, technologist, healthcare provider, patient, and financial technologist. (The provider perspective was provided by OHSU faculty Dr. Ben Orwoll.)

The report summarized a number of possible use cases and their data sources for API write-back:

  • Data from devices, such as wearables and remote monitors
  • Questionnaires from patients or care activities
  • Results of risk scores and calculators
  • Patient input of symptoms or reported outcomes
  • Recommendations of clinician decision support
  • Annotation or amending of patient notes
  • Results or recommendations of machine learning/artificial intelligence algorithms
  • Data from transitions of care across organizations
  • Community sources of data, including social determinants of health

Also identified were a number of technology barriers to writing data back into the EHR:

  • Limitations of FHIR standard
  • Accuracy and completeness of the data
  • Security of data from third-party apps
  • Mapping and coding issues for data entering EHR and other systems
  • Patient-matching accuracy
  • Requirements for manual workflow and/or reconciliation
  • Obligations of organization and clinicians for data written back

In addition, the report raised a number of policy, preference, and data use concerns:

  • Data ownership and expectations for patients and clinicians
  • Compliance with HIPAA and other current laws
  • Relationship to designated record set and legal medical record
  • Regulation needed to support open APIs and their adoption
  • Requirements for future policy

The entry of data into the EHR beyond the usual documentation by clinicians and others changes the nature of the EHR, marking the true transition from electronic medical record to electronic health record.

This article post first appeared on The Informatics Professor. Dr. Hersh is a frequent contributing expert to HealthIT Answers.