Data Integration for Electronic Health Records

Introduction & Background

 The emerging use of the electronic health records (EHR) and electronic data capture (EDC) systems, have been rapidly growing in the recent years. Numerous benefits such as accessibility of information, improved communication, higher readability, support in diverse assignments, decline of documentation errors, among others, are reported with the use of such systems (Bruland, Doods, Brix, Dugas, & Storck, 2018). New standards such as the Fast Healthcare Interoperability Resources (FHIR) would release the importance of interoperability by collapsing information silos, enabling correct sharing of high-quality healthcare data together with the patient’s multidisciplinary care team wherever they may be (Hobson, 2017).

Such system would allow for clinicians and other providers ease of access to real time, high quality shareable information for clinical decision support or population-based analytics. Currently, the majority of health information exchange and data interoperability is based on documents. Whether faxed, emailed, or sent electronically, providers normally have to select a set of data to transmit and then create a message that includes only that information. While this method does help institutions effectively communicate, it can be too restrictive for significant care coordination, decision-making, or data analytics.

 This is where FHIR may offer an opportunity to shift paradigm in health information exchange. Situation-specific apps, built on this platform might be able to perform analytics on patient-generated health data and present users with a summary of trends that are relevant to a particular aspect of chronic disease management or patient wellness (Hobson, 2017). Patients who see multiple providers in different health systems might no longer have to worry about having three or four patient portals from organizations using different EHRs. One unique personal health record, which integrates data from different formats to deliver a comprehensive view of all medications, problems, and allergies, could link these systems together to improve care coordination.

Quality of Innovation

One element of the Centers for Medicare and Medicaid Services (CMS) in October 2015 was the establishment of an incentive program to spur interest in developing new technologies such as the FHIR and other application programming interfaces (API) expanding the use of the EHR. New requirements of the EHR software to support these new APIs enabled the development of new functionalities to build bridges across systems and increased data access. Such development will help patients have unprecedented access to their own health records, empowering individuals to make key health decisions (Mace, 2016). Many software developers such as Cerner and Epic, have already implemented several FHIR interfaces in the EHR software currently made.

The Fast Healthcare Interoperability Resources standard has the ability to provide vastly simplified, accelerated and effective clinical information sharing between systems. The inspiration for FHIR came from the desire to see all data from a single point in real time, similar to how it’s done in other industries. Some examples for instance is the way e-commerce operates, Google and social media works, where data is connected through the entire internet system from one place, and users are simply able to see all of the data that they are interested in. That is in essence what FHIR is build on (Leftwich, 2017). FHIR is, or should be, the chosen standard, mainly because it includes accessing data across many systems. This is something that hospitals were not able to do previously. Thirty years ago, about ten pieces of data were needed for complicated clinical decision. Today, there are more than five hundred bits of information that go into a complex clinical decision. Interoperability must facilitate data access across several systems, and present that information to all healthcare entities from clinicians to patients and to those paying in a way that is comprehensible, logical, usable, and actionable. Data represented as FHIR is well suited for this function (Leftwich, 2017).

In March 2018, Apple launched an improvement to its health app in which leverages FHIR-enabling patients at thirty nine participating United States (US) healthcare institutions to access their medical records on their phones after updating to the operating system (OS) eleven point three mobile operating system. The enhanced Health Records section within the app let patients see medical data-encrypted and protected with their phone passcodes-gathered from numerous organizations and presented in a single aggregated view. Patients also get electronic notifications when their records are updated by providers (Slabodkin, 2018).

Another model of collaboration is the Argonaut Project, which is a consortium of health information technology (IT). Vendors and providers are seeking to speed the adoption of FHIR by creating road-tested performance guides accessible to developers in order to assemble interoperability resources according to current internet architectures (Slabodkin, 2018). Such a collaboration is an important lever that can help moving things forward in an industry that is so fragmented. In the case of Apple, what they have done is very helpful for the industry, because instead of implementing a proprietary standard they have adopted the Argonaut implementation guide. The tech giant has in essence become a testing platform for FHIR standard.

Finally, another study performed by Goeg et al. (2018) looked at feasibility of developing telemedicine solutions capable of accessing disease specific and silo-oriented system landscape with limited interoperability. Their focus was on the ease of implementation requiring systems to use the HL & FHIR as the primary standard because it is based on web-technologies. They concluded that interoperable core frameworks for telemedicine can be designed and implemented using the FHIR standard.

Stakeholders

Users across the world can access the same Uniform Resource Locator (URL) and complete the same tasks using standard browser running on any web-enabled device, whether it’s a smartphone, desktop, or tablet running a Windows, Apple, Android, or Linux operating system. FHIR hopes to do the same thing: allow developers to build standardized browser applications that allow access to data no matter what EHR operating system underpins the user’s infrastructure.

Patients must be top priority in the design and evolution of both EHRs and data perspective and approach, both in how we work and the technologies that power it (Raden, 2017). Not all patient data is collected in a single clinic, in a single hospital, or a single office. At the center of these interactions, there is only a single patient. Patient should be allowed to access their healthcare data no matter where they are. Why shouldn’t they expect their data to go from one provider to the other and from one environment to the other in the same way they can access their money from any Automatic Teller Machine (ATM), anywhere? It’s not only their data, but it’s also in their best interest from safety, quality, and outcome standpoints (Raden, 2017).

Institutions are also on top of the list in terms of practice patterns and data-driven approach to determine optimal setting of care. Factors such as relationships, contracts, and previous referral patterns dictate where an acute care hospital would guide its patients upon discharge (Rowe, 2017). They’ve discovered that care delivered in post-acute settings has varied in both outcomes and costs, and often patients were not directed to the lowest intensity setting that would still yield positive outcomes. Many hospitals now use data to improve their clinical processes for surgical patients. Online tools provided through a patient portal or a mobile application also help the patient prepare and stay on track during the recovery process.

Providers and clinicians are also looking at data to make better clinical decisions, and improve patient outcomes using data analytics. There is a growing potential to include genomic and precision medicine data in a patient’s EHR. Aging population and increase in chronic diseases will require precise analytics for a much more proactive approach to population health management which is a top priority for all health systems. In turn, the quality of the analytics reports depends on the availability of high quality comprehensive data. This is something that FHIR enables better than any of previous technologies (Hobson, 2017).

Having access to a consolidated health record, which aggregates data from all settings of care, becomes an important tool for all those involved in the patient’s journey. Third party payers or insurers are also recipients of the FHIR capabilities. Applications build on the FHIR standard will allow access of clinical documents such as discharge summaries, referral letters, or progress notes to speed up payment or reimbursement. Messages will be sent between systems to update information on all different portals.

Finally, the health information technology professionals will be able to appreciate FHIR as an ideal tool for discussions and decision making about technology solutions for healthcare. Prior software development was accomplished through computer engineering and was designed purely as information system with a real disconnect between what was needed by clinicians and what the systems were set up to accomplish. Vendors were empowered to build functionality that satisfied the minimum requirements of the law, and too little consideration was given to facilitating the holistic care of a patient across all providers engaged in their care. For optimum results, FHIR anticipates clinicians becoming much more integrally involved in the delivery of health information technology (HIT) projects. Clinician-led IT projects have a much higher success rate than technically led projects (Hobson, 2017).

Organizational Impacts 

FHIR represents a key standards upgrade in terms of ease of deployment and all-inclusive coverage of healthcare domains, thereby boosting health information sharing. Furthermore, it enables ambitious plans for an app store purpose-built for healthcare use. It speeds application development, enhances interoperability, and enables new possibilities such as mobile access to allocate data (Hobson, 2017). The increase use of healthcare as patients take on more responsibility for their care demands that we enable patient’s access to their personal data. Through proper interoperability, a patient-centered, data-driven, value-based healthcare system is achievable. This pursuit requires substantive challenges related to the collection, storage, management, analysis, and dissemination of data. It can be accomplished via corresponding strategies: a nonbeliever approach to data integration and sharing coupled with the use of novel platforms such as FHIR.

FHIR resources can be used to build documents that represent a composition: a set of coherent information that is a statement of healthcare information, particularly including clinical observations and services. This document is an absolute set of resources with a fixed presentation that is authored and/or attested by humans, organizations and devices. By creating an accessible and standard URL for these information bundles instead of just passing individual documents back and forth between systems, a number of different applications can point to the same version of the same data each and every time.

Institutions are still learning how to navigate in the new world of value-based payments. However, what they know is that using data to sustain the changes needed to succeed is critical. The quantum leap has been access to a patient’s consolidated health record. Understanding all of the patient’s information, which includes clinical, claims, administrative, social and economic data, is needed to drive change. Care is complex; technology is but one part of an overall strategy. But without sharing, integration, and interoperability across many vendor platforms and sources, we will continue to fall short of what we could be doing for patients and their families. As leaders, we believe technology plays a pivotal role in how data is used to treat and cure disease. We also know that modernization rarely comes easily or without trials. True progress lies in collaboration among clinicians, researchers, and vendors.

With the help of the clinical community, expert users can develop a logical model unconstrained by the structure of the resource types and profiles that will eventually represent that information. Therefore, this will make it understandable by any system that also understands the FHIR approach. Once this logical model is completed, FHIR specialists can use it to build profiles and other artifacts needed for effective interoperability. FHIR’s focus on simplicity, extensibility, and interoperability promises to revolutionize the sharing of healthcare information and improve the experience and outcomes across the healthcare continuum.

Lastly, Mace (2016) demonstrates the need to extract the data out of the cumulus repository we have created. Instead of building these silos of information, we now have the possibility to access multiple systems in which we can query while simultaneously updating EHR’s or other healthcare IT interfaces such as analytics dashboards.

Conclusions and Recommendations

The EHR has been growing at a very fast pace in recent years and better interoperability platforms are necessary to fulfill this expanding segment of technology. The FIHR platform is well suited to accomplish interoperability and merge multiple portals. One unique personal health record in which data would be integrated from different formats to deliver a comprehensive view of all medications, problems, and allergies, could link these systems together to improve care coordination.

Such system would meet requirements from CMS on expanding the use of EHR’s in healthcare settings as well as information sharing between systems (Mace, 2016). FHIR came from the need to see all data from a single point in real time, similar to how it is done in other industries such as Google and social medias. Interoperable core frameworks for the expanding field of telemedicine can be designed and implemented using the FHIR standard (Goeg et al., 2018).

Stakeholders such as patients, institutions, providers, third party payers, and IT professionals should recognize the importance of having one consolidated EHR. To increase success rate of new IT projects in healthcare should involved clinical-led teams (Hobson, 2017).  Adding the clinical community will create logical model unconstrained by the structure of the resources types and profiles already established. Once these models are created, FHIR specialists will be able to build profiles and other artifacts needed for effective interoperability.

FHIR represents a quantum leap in healthcare integration for the health information professional, clinician, and the consumer. This platform focuses on simplicity, extensibility, and interoperability. The future is wide open on promises to revolutionize the sharing of healthcare information and improve the experience and outcomes across the healthcare continuum. This is creating opportunities for tremendous innovations in the healthcare IT industry. The platform will be able to allow standardized interactions of specific apps and widgets with multiple EHRs. This will truly bring us one step closer to universal interoperability.

References

• Bruland, P., Doods, J., Brix, T., Dugas, M., & Storck, M. (2018). Connecting healthcare and clinical research: Workflow optimizations through seamless integration of EHR, pseudonymation services and EDC systems. International Journal of Medical Informatics, doi:10.1016/j.ijmedinf.2018.09.007
• Goeg, K. R., Rasmussen, R. K., Jensen, L., Wollesen, C. M., Larsen, S., & Pape-Haugaard, L. B. (2018). A future-proof architecture for telemedicine using loose-coupled modules and HL7 FHIR. Computer Methods and Programs in Biomedicine, 160, 95-101. doi:10.1016/j.cmpb.2018.03.010
• Hobson, C. (2017). Achieving your FHIR share of interoperability. Health Management Technology, 38(4), 22.
• Leftwich, R. (2017). FHIR’s role in supporting risk-based care models. Health Management Technology, 38(10), 13.
• Mace, S. (2016). FHIR fuels innovation, interoperability. Health Leaders Magazine, 19(5), 53.
• Raden, J. (2017). A patient-first approach to EHRs and data integration for value-based care is HIT’s next act. Health Management Technology, 38(11), 19.
• Rowe, L. (2017). Exploring outpatient connections connecting records, FHIR’s role. Health Management Technology, 38(10), 12.
• Slabodkin, G. (2018). Info exchange, standardized fast-rising adoption of the FHIR standard means potentially swift advances in patient-focused data interoperability and access. Health Data Management, (2), 40.