Will Canada be Successful Without Standards-Based EMRs?

I was talking with a colleague last week about EMR adoption. He expressed his frustration at the lack of coding and interoperability standards between different EMRs available in Canada. Frequently over the past few years I have written about the importance of structured and coded data for the analysis, management and transfer of health information. The implications are numerous. If data is going to be transferred from one system to another (whether for clinical or administrative purposes) it needs to have the same meaning in both systems. It goes without saying that if I order a laboratory test which is then reported upon, I expect the result to be imported and stored in the correct patient’s file. Similarly, if I transferred a chart from my system to another, I would expect that the data would be transferred in the right format for import into the receiving EMR.

All of this assumes that data is coded using commonly accepted standards and that all EMR vendors use the same reference measures. Makes logical sense, right? The explosion of mobile smart phones in the past 12 months is only possible because of an adherance to standards for software design and data sharing. Imagine if your mobile phone could not speak to another. If you could only text message individuals using the same network or send Gmail only to other Gmail users. It would not be very effective or satisfying.

I would like to point out that this is not the fault of the EMR vendors. While they can be criticized for developing systems that have proprietary databases or data structure that make it difficult to move from one EMR to another, this is not unique to EMRs. The software industry has been built on having closed proprietary systems that provide a unique competitive advantage to a specific vendor. When a vendor becomes dominant (as Microsoft did with the Office suite of products), their document/data format can become the de facto standard for the industry. However that is unusual and although one company becomes highly successful, many others fail as a result.

The bottom line is that there is a delicate balance between maintaining a proprietary advantage in the market and ensuring that data is able to move efficiently between one system and another.

A bit of historical background. EMRs in Canada did not evolve from a need to collect and share data. Early EMRs in Canada grew from billing and scheduling systems with the need to collect basic clinical data and code it using ICD9 codes for billing purposes. There was (and still is) no requirement for a clinical user to code diagnoses accurately. For example, if a patient is seen with an obscure GI diagnosis and the treating physician does not know the exact ICD9 code, a generic code such as 787 — “symptoms involving digestive system” can be used without fear of penalty. Without a stringent requirement for accurate diagnostic coding, the historical diagnostic data might be useful to the individual physician, but completely useless for population analysis or even sorting of patients within a practice for recall purposes. Garbage in ... Garbage out.

There are efforts underway to establish standards for data sharing between different EMR systems for the purposes of sending and receiving referral requests and consultation reports. However, is this sufficient? Should all EMR systems in Canada be migrated to use the same data structure and coding standards (e.g. by 2017)? Or should the focus just be on specific areas such as ePrescribing or Referrals?

Comments are welcome from clinicians as well as the EMR industry. Share your thoughts by clicking on the “Comments” link below.

Comments

[Ray Simkus]

I am glad to see this issue raised and the simple answer is NO. We need to get the physician users to recognize that 'eyeball integration' is not sufficient. Just being able to exchange documents has certainly been found to be useful with programs like eCHN in Ontario. If you want a machine computable record then you need standards for medications, lab results, terminology and the information model. With this in place clinical decision support rules can be put into place that would make it easier to do the right thing and harder to do the wrong thing. Even without the fancy stuff it would still be useful when exchanging information between physicians to be able to download the list of current medications and problems rather than having to retype them into your own system.

[Dr Dean Brown]

Cutting the Gordian knot of ehr: 'One Health Record'. Create one unique central record, 'owned' by the patient. All organizations and providers see it and contribute, according to structured privilege levels. Replace our Tower of Babel, with its endless data in countless systems, none of it current.
Banks, universities, big employers have done it for years. Time for health care to catch up.

[Ray Simkus]

There have been a number of efforts in the past and some current ones. The banking analogy fails to address the volume and complexity of clinical information. Another common analogy is to compare the healthcare system to the airlines but neglect to point out that airlines do not have to change the engine while the plane is in flight. There is not one number that would be the equivalent for your bank balance. There are various open source EMRs that range from EMRs like OSCAR, to VistA running the VA system in the US and OpenMRS that has been used to run a national EHR. There is Clinical Groupware and the SMArt Project based in Harvard that is pushing the plug and play approach.

To be able to have a plug and play type EMR requires considerable consensus on what should be done and how it should be done. The only way of doing this is through standards that would define what is required and how it should function. The good thing is that a lot of work has already been done on these things. The problem is that EMR users and developers are largely unaware of all this and continue trying to take the DIY approach. There are not many people that would even consider building their own airplane or banking system.

[Eric Gombrich]

Perhaps important to note the convergence of themes here with the subsequent Blog Dr. Brookstone opined about regarding feeling "boxed in."

Again, bring on the standards...