Remember when you called to book a ticket with your travel agent? The agent would search available flights, seats, rental cars, and hotels. Your paper ticket could be picked up or mailed to you. That piece of paper got you a paper boarding pass — after you stood in line. If you accidentally lost your boarding pass or left it in the seat-back pocket of your first flight, you were stuck and had to repurchase the ticket for the next leg of your flight, since your original boarding pass could be used by anyone to claim the original seat.
Now, you go online and find the flight, seat, hotel, and car you want. Your itinerary, boarding passes, reservation confirmations, notices of delays, and upgrades appear magically on your iPhone, including weather information, great places to eat, and the closest gas stations. So much for the good ol’ days.
How does that scenario compare with today’s level of interoperability?
Our October 2015 interoperability findings confirmed that 91 percent of providers participating in information exchange were exchanging patient records with outside organizations. About three-quarters of those were pushing records (TOC documents) to others, typically in the form of CCDs. One third reported they were actually requesting and pulling records that were potentially consumed by their resident EMR.
What does “consumed” really mean? That is the rest of this story, and it ties to our travel agent analogy. It would be terrific to have electronic records how, when, and where needed with appropriate peripheral information as desired. The reality is that faxing is the primary way that records are exchanged today. The move to electronic sharing is typically found in the use of the CCD, which is considered a step up from faxing, even with the complaints around the context and size of the document. Consuming the appropriate information is a challenge, whether the information comes as discrete data or in a CCD.
In a perfect world, like one where you have your boarding pass and reservations travel with you, the relevant part of a patient’s record would show up in the doctor’s workflow at the right time. We are not even close to that yet, but there is progress, and some vendors are leading out as they facilitate the absorption and review of outside relevant clinical patient data. Cerner and Epic are the most proactive as described by their respective clients. The ability to parse a CCD and select allergies, medications, and so forth that can be absorbed into or replace an existing element within the EMR is of solid, ongoing value, even though it is a manual activity on the frontend. One Cerner client clarifies by stating, “There is a tool within the Cerner system… that combines CCDs by pulling them apart and bringing them back together in a logical view, no matter where the CCD came from. The Cerner workflow brings in the CCD so that the clinician can actually move medications from the CCD over to the medication list and the allergies to the allergy profile.”
Similar comments abound with Epic: “When a doctor sees a patient, there is a notification that there is new outside data. A simple user interface compares what is in the CCD with what is in the patient chart and quickly points to any new information or differences in things like allergies, reactions to allergies, problems, and medications. The users are asked what they would like to replace, add, or discard. The doctors can promote things or demote things. All CCDs from any other vendor’s EMR get treated equally.” athenahealth clients don’t have the same utility for consuming CCD elements, but confirm great value in the utility and placement of electronic faxes for ease of use by the clinician.
Electronic consumption described by clients of most EMR vendors (such as eClinicalWorks, GE, Greenway, McKesson, and NextGen Healthcare) is simply the practical placement of a pointer within the patient chart to the PDF or other icon relating to the CCD (we have specific data regarding this on Allscripts and Cerner [Siemens]). A Meditech client describes this approach in the following description: “The system comes up with a little flag that says there is external medical data available. When that flag is clicked on, the system displays a formatted C-CDA. The clinician makes the decision to accept that information or reject it. If the clinician accepts it, we consume that C-CDA as an external medical-summary document, and it is flagged permanently as part of the patient’s medical record.”
This approach is comparable to an electronic picture of the old-fashioned ticket in our travel analogy — you know, the one that was about the size of an IBM punch card — and for good reason. That is where the dimension started. Yes, vendors are taking steps in the right direction, and progress is picking up steam. One day, we will wonder what people are talking about when they make comments about faxing patient records and looking at a C-CDA online — the sooner the better.