The Road to Interoperability

John D'AmoreStage 2 of Meaningful Use

By John D’Amore, MS, President and CTO of Diameter Health

The data on avoidable waste and medical error in the US healthcare system are well-established (see IOM’s Better Care at Lower Costs). While there’s a lot to fix, one critical need is interoperability. Better coordination, less redundancy and improved care quality all require the fluid interoperability of clinical information. Meaningful Use has focused heavily on improving data exchange, and in Stage 2, interoperability is heating up.

While Meaningful Use cites several standards for data exchange, the primary document standard in Stage 2 is the Consolidated Clinical Document Architecture (C-CDA). C-CDA documents transmit common clinical data from EHRs in a typical web format (XML). They are both human readable in a web browser and structured with standard vocabularies for machine processing. As part of certification, EHR capabilities are tested for the ‘view, download and transmit’ of care summaries and for batch exports of C-CDA documents, known as ‘data portability.’ For physicians and hospitals, C-CDA use also becomes a requirement. In Stage 2, C-CDA documents must be exchanged for at least 10% of all care transitions.

A common clinical scenario for C-CDA data exchange is a patient referral. When a primary care physician refers a patient to a specialist, a C-CDA document can encode why the patient was referred along with current problems, medications, allergies, social history, lab results and vital signs. The receiver of a C-CDA document could view the document, or more importantly, incorporate the data into any certified EHR. This reduces order duplication for common lab tests and prevents accidental omission of important information, such as a medication allergy.

The potential for C-CDA documents, however, goes beyond care transitions. Since C-CDA documents can be parsed and used by software, medical apps for both patients and providers could be fueled by these extracts. This potential motivated an initiative, known as the SMART C-CDA Collaborative, to examine C-CDA extracts to examine data quality within these documents. Results from the SMART C-CDA Collaborative were recently published in the Journal of American Medical Informatics Association, on which I had the opportunity to be a technical lead.

Several positive findings emerged from the research. First, participating EHR and HIE vendors were all capable of producing C-CDA extracts that were syntactically correct and usable. This uniformity allowed us to quickly parse thousands of structured data elements from C-CDA samples in seconds. We did this using a parser developed as part the BlueButton initiative, which is aligned with the C-CDA. That’s significant progress in comparison to current unstructured text or scanned images. Moreover, several medical apps using C-CDA documents have already been developed, despite the fact that Stage 2 is just getting started.

As expected with any new standard, we also documented improvement opportunities. While the syntax of C-CDA documents was generally valid, the clinical content showed variation among vendor collected samples. For example, consistent terminology for some data groups can be tricky. An example is medication allergies. Should the information be encoded as a drug ingredient (‘penicillin’), a drug class (‘penicillins’), a precise ingredient (‘penicillin g benzathine’) or an actual administered product (‘penicillin 125 mg oral tablet’)? Normalization of some C-CDA content will be required in the coming years. But that shouldn’t dissuade people from C-CDA exchange. Data normalization is fundamental work required of all industries that pursue interoperability.

Interoperability is a journey, not a destination. The first and hardest step has been getting technology vendors on-board, which Meaningful Use has successfully done. Now is the time to create an environment where providers actively share C-CDA documents to support the new care delivery models like Accountable Care Organizations and the Patient Centered Medical Homes. With over 80% of hospitals and providers already using certified EHRs, it’s not too distant a future.

About the Author: John D’Amore, MS, is President and CTO of Diameter Health and a primary author of a recent C-CDA study. He has over a decade of experience in health IT and medical informatics. John was previously Vice President at Allscripts, a leading vendor for electronic health records. Before then, he has served as a health industry consultant and Director of Decision Support at Memorial Hermann, winner of the 2009 National Quality Forum award. John is a published researcher and national speaker on the use of interoperability and analytics to improve clinical care. He holds an undergraduate degree from Harvard University and graduate degree in clinical informatics from the University of Texas, School of Biomedical Informatics.

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