While exchanging healthcare records is the darling of the media, it is far from the greatest challenge in healthcare interoperability [1]. The problem of transmission of records is now on the cusp of being solved by Sequoia, CommonWell, and other HIE based initiatives [2]. I stand by the statement that this portion of the problem can be solved in a scalable way within the next two to five years.

For simple cases this is going to be great. If go into an ED and they see I had a scan at urgent care they won’t order a new one [3]. Everyone saves money and time.

For complex cases things are…well…complex, and making sense of the exchanged data will require smarts.

Let’s talk a little about oncology and transplant cases. In my experience, typical outside records for patients in these classes vary wildly. The average number of pages of outside oncology records per patient intake is sixty-five, but the maximum I’ve seen has ranged up into the five thousand page range.

The data that is available today in CDA MU-2 format doesn’t serve the needs of these patients, not because CDA is a bad protocol, but rather because of what should have been renamed “Minimal Use Stage-2” [4]. You see, oncology and transplant patients need lots of historical data and a good deal of it is not available in a MU-2 CDA because vendors and hospitals have not put it there.

The lack of desire to implement beyond MU-2 is usually grounded in cost, legal, and resourcing constraints [5]. Smaller practices are largely beholden to their software vendor and have little voice in asking for change except through institutions such as the AMA. Funnily enough, larger institutions have more sway, but have asked for so many changes that small things like interoperability are low on the totem pole, and as a consequence vendors have built minimal viable product that can be customized if you have a spare CDA expert lying around [6].

This leads us to the stickier question of whether hospital networks want to share data at all, and while we can answer this question with a resounding yes when MU-2 incentives are involved, I’m not sure the same answer applies when it comes to items like all the records from a patient hospitalization, which are considerably larger than the average discharge summary. With minimal templates for electronic exchange of these larger records, the only option is fax, and you might be amazed at what a huge budget line item that is for many hospitals [7].

There are now federal and state level initiatives that prevent information  blocking in the interests of the patient and the payer, but the current concept of information blocking is looser than a new scout’s knots [8]. In federal terms, information blocking occurs “when persons or entities knowingly and unreasonably interfere with the exchange or use of electronic health information”.

Let’s play devils advocate. If an institution exchanges an MU-2 summary, are they out of the woods as far as information blocking is concerned? Exactly how much information must be exchanged to meet the letter of the law, and what exactly is unreasonable? If a hospital’s information system has no template that can be used to send all hospitalization records for a patient electronically, then they certainly haven’t been unreasonable in their attempts to send the data.

If you think you are confused about electronic transfers today, just wait two to five years. Suddenly hospitals will be able to gather inconsistent documents from outside providers that contain inherent contradictions. All of this will be available from within the EMR, and suddenly intake nurses will have more work to do reconciling, organizing, and summarizing data.

So what’s the solution?

In my mind the role of the electronic clearinghouse will become central, but with a subtle change from collecting and organizing records, to summarizing and simplifying collections of records into a package that can be verified and fed directly to the EMR so that the provider can easily comprehend the data during a brief encounter. Only this will garner the confidence that they have not been misled by too much information.

This can be done manually with masses of people or through core technologies such as text extraction, natural language processing, summarization systems, and report engines. It doesn’t matter as long as the economics are right.


“I think the fact that I am not a lifelong IT person will be beneficial, because I will keep looking for how we simplify the user experience as much as possible. I remember one physician telling me, ‘I am not a troglodyte. I will use any technology that helps me take better care of my patients and that works. Give me something that works.’ That is going to stay with me.” –David Bensema, M.D., on being promoted from CMIO to CIO at Louisville, Kentucky-based Baptist Health [9].


In a time that we are moving to value-based care, there will be additional emphasis on how to provide more efficient and higher-quality care. To do that, we need to ensure clinicians can view all the relevant information about a patient, regardless of where they have received care in the past. As Dr. Bensema stated, we need something that simplifies the user experience and simply works.


[1] https://hbr.org/2015/12/the-untapped-potential-of-health-care-apis

[2] http://www.healthdatamanagement.com/news/healthcare-connectivity-set-to-take-off-with-value-based-care

[3] http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2995707/

[4] http://heliometrics.net/more-bad-news-for-interoperability/

[5] http://www.healthcareitnews.com/news/10-things-you-hate-about-your-emr

[6] http://www.hl7.org/implement/certificationdirectory.cfm

[7] http://fee.org/articles/government-spent-30-billion-on-digital-health-records-doctors-are-still-faxing/

[8] https://www.documentcloud.org/documents/2461137-onc-report-to-congress-on-health-information.html

[9] http://www.healthcare-informatics.com/blogs/david-raths/my-favorite-quotes-2014






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