For example, among the many unresolved IT-related issues are decisions about coordinating how records and prospective readers of those records are authenticated, the adjudication among the different privacy policies across states so that information exchange can occur, and the creation (and management) of a single glossary or dictionary of procedural and diagnostic terminology to be used by all health care providers. Standard communications and networking protocols also have to be agreed on to permit data exchange, as well as a file format or file standard for interoperability.
Sorting out the standards
At one time, the solution to all these issues seemed simple enough. The Veterans Administration pioneered electronic medical records with its Vista system, and many lawmakers thought the best idea was to mandate the adoption of Vista as the single, national system, making it available at no charge to health care organizations along with subsidies to speed its adoption.
Of course, private medical software providers hated the idea, as it put the government in direct competition with them. They suggested that government couldn't do the job as well as private businesses could, and certainly couldn't be as innovative. A decade later, EHR efforts remain stalled, though vendors have continued to push the technology.
In the meantime, the policy debate has shifted to a discussion over creating interoperability standards using SOA, middleware, and standard file formats, not unlike the idea behind the Open Document Format (ODF) and the Resource Description Format (RDF) standards for information mediation based on extensile but structured meaning, says Jeff Bauer, a partner in management consulting for ACS Healthcare Solutions.
At the moment, an effort is under way to create the Continuity of Care Document, an XML-based standard intended to become the equivalent of an RDF or ODF file that lets the various EHR vendors write to the same file format.
That effort won't be easy. But the stimulus bill does encourage this effort by requiring doctors to make "meaningful use of certified EHRs." The part-private, part-government CCHIT (Commission for the Certification of Health IT) does the certification, and it creates interoperability and definitional guidelines in three key EHR areas: privacy, format, and content.
But agreeing upon an interoperable framework doesn't address another key issue: the creation of a unique glossary of terms to describe both medical procedures done to a patient as well as to describe a diagnosis.
Currently, most hospitals and practices use IDC-9, the International Statistical Classification of Diseases and Related Health Problems9th Revision, which has a highly limited language of about 17,000 terms. Its successor, IDC-10, has about 155,000 codes and will permit the tracking of many new diagnoses and procedures. But deploying IDC-10 will be yet another challenge for doctors, nurses, and IT personnel.