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 Problems 9th 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.
The fact is, the information needed to treat a patient today exceeds what a physician can handle, says ACS's Bauer. "We are moving toward a genetic and molecular understanding of disease, and there is no doctor smart enough to handle all of the data. They need information support systems to make better decisions," he contends. And those systems need a comprehensive, flexible, and manageable way to handle complex health information.
Tackling the information exchange issues
HL-7 (Health Level 7) certification sets the transmission standards among different systems, such as how to transmit lab information, prescription data, and a diagnosis. So this information exchange component is largely in place.
But privacy issues remain, and they are a more difficult challenge. Most states have added their own requirements to HIPAA's privacy standards. Thus, for the most part, if you are a hospital in one state trying to send patient data to a hospital in another state, it can only be done on a one-to-one basis, typically with a phone call and proper identification.