Electronic interoperability (also referred to as "interconnectivity") is the exchange of information between your EHR and other healthcare entities, and even patients. For example, electronic prescriptions, which are widely used, are a form of electronic interoperability between your EHR and the pharmacy. Similarly, most healthcare clinicians send electronic claims to payers, and many clinicians receive electronic explanations of benefits back from payers.

Electronic interoperability may be a direct connection between two parties (eg, your practice and a hospital), or between you and an electronic clearinghouse. Electronic clearinghouses serve as electronic post offices that can receive a variety of electronic information that may be addressed to different healthcare clinicians and organizations. The electronic clearinghouse will route each electronic message or transaction to the proper destination.

Many health information exchanges (HIEs) support electronic interoperability between the healthcare clinicians in the area served by the HIE. For example, the HIE may maintain a centralized repository of patient information that can be accessed by appropriate clinicians.

What Is the Goal?

The healthcare system incurs additional costs for delays in diagnosis and treatment of patients as well as costs for duplicative services. The goal is to promote better communication that will lead to better patient care and eliminate duplication.

For example, patients who have personal health monitoring tools available on smartphones and wrist devices may not have the ability to forward information for review and analysis by their physician.

Referrals from primary care doctors and specialists are frequently not followed up on because the specialist is unaware of the primary care provider's recommendation and the patient does not follow through with the specialist. Delays may result in more serious and expensive problems for the patient and healthcare system.

Doctors may order a test because they cannot get access to the diagnostic results performed by another clinician. In addition, the inability to access previous test results may prevent or delay the discovery of clinically significant trends that are reflected in the results of tests ordered by various clinicians serving the same patient.

The goal of electronic interoperability is to use computer-to-computer communications to support and improve collaboration between healthcare clinicians and patients. The free flow of patient and treatment information through electronic interoperability is expected to improve patient service, enhance clinician productivity, and save money.

Why Is Electronic Interoperability So Important?

The exchange of patient information among physicians caring for a patient is challenging and difficult in the paper world. A doctor's referral of a patient for treatment or consultation may be written on many pieces of paper, but the doctor can't easily ensure that the information was received by other physicians serving the same patient. Similarly, ensuring that all physicians have the same base of information about a patient is logistically impossible with paper. Just as important, compiling information spread among several documents within a patient chart requires shuffling paper to find the relevant documents and then analyzing several pages of information.

The movement of paper between healthcare organizations has been a continuing problem for years. Several initiatives have drawn attention to improving healthcare information flow through electronic interoperability.

Many patients use smartphones and computer systems that allow clinicians to track adherence and monitor patient issues. A smartphone app could be used to monitor the occurrence and severity of various patient problems.

If your practice has an EHR and is communicating with another practice that has an EHR, why should you print or fax information that has to be scanned or posted as an image? The resulting image may suffer degradation through the faxing process as well as through the scanning process. In addition, classifying the scanned image with related documents is a challenge for many healthcare organizations.

Also important, specific information from a lab test or procedure note may be presented as an image and not properly displayed in the patient's EHR summary of lab results or list of previous procedures.

The lack of information from the appropriate EHR feature may prevent full clinical analysis of trends and issues. Remarkable lab results may be highlighted on the patient's flow sheet of test results, but buried in the list of images associated with the patient.

Large healthcare systems have a vested interest in more effective patient service and engagement with their physicians. Many large healthcare systems have at-risk agreements with insurance companies and employers, or even a healthcare insurance unit within the healthcare organization. Such agreements are based on better patient engagement and tracking by individual clinicians and among clinicians serving the same patient, to improve patient adherence and save resources.

Electronic interoperability helps physicians coordinate patient care. Both the primary and the referral physicians will have updated information on patient adherence to the referral recommendation and the updated care plan. Such coordination is possible with all types of patient services, including lab tests, therapy, diagnostic tests, procedures, and even surgery orders.

The collaboration of physicians and healthcare organizations is effective if electronic interoperability allows healthcare organizations to exchange and use the most recent and complete set of information to serve a patient. Electronic interoperability also allows the EHR systems to automatically "file" the information in the appropriate area of the electronic chart, as well as route a message to the appropriate clinician. The messages allow clinical management to ensure that incoming information was reviewed and addressed on a timely basis.

How Does It Work?

Electronic interoperability is based on a complex set of standards and requirements that are programmed into certified EHRs.

Initiating the transmission of electronic information depends on the type of transmission. For example, prescription transmissions are built into EHRs with accommodations for the drug information and the patient's pharmacy. The EHR formulates the electronic prescription and sends the information to the clearinghouse, typically Surescripts. The electronic prescription is automatically routed and posted to the pharmacy system for fulfillment.

Other electronic transactions vary, because the clearinghouse function is not as well developed as electronic prescriptions.

Here's how the actual exchange process works:

For outgoing information, electronic interoperability requires the ability to create an electronic transaction from the information in your EHR, and a method to transport the electronic transaction from your EHR to the destination clinician's system. The destination could include a pharmacy system, a lab system, or another EHR. For example:

• A clinician may send an electronic referral (known as a "transition of care record" under meaningful use and PI) to another clinician. The EHR may proceed to transmit the electronic referral to your local HIE, which will put the electronic transaction in the inbox of your intended recipient.

• Or, a clinician may send a message to the patient about test results through the patient portal. The patient portal will send an email to the patient to review the message through the patient portal.

For incoming information, your computer system receives the electronic transaction, decodes the electronic transaction into information usable by your EHR, and posts the information to your EHR with a message to the relevant clinician or staff person. Lab results may be downloaded into your EHR, and the EHR will use the electronic lab results to populate the EHR lab flowchart as well as send a message to the clinician prompting him or her to review the lab results.

The decoding of incoming information and the loading of information into the EHR can be a complex process, because the nature and structure of information can differ between EHR products and how the EHR is used. For example, if a practice created an EHR field to flag abnormal Pap test results, the incoming lab results would require a specific way to trigger the EHR flag.

The electronic interoperability process has to meet HIPAA security standards to protect the confidentiality, accessibility, and integrity of patient information. Therefore, an HIE would be preferable to an email to meet HIPAA security requirements.

The electronic transaction uses a very specific structure or format. Certain codes must be used, and information must be organized in a very specific manner. For example, an electronic prescription has detailed information on the patient and his or her insurance coverage, the National Drug Code for the prescribed drug, and the pharmacy that is to receive the prescription. Nonetheless, there may be several options to convey information, which may be used differently by practices and healthcare organizations. That is, not all electronic exchanges are as widely used and standardized as electronic prescriptions.

The transmission of the electronic information may be supported through a clearinghouse or through a direct connection to a large healthcare organization, such as an integrated delivery system. The actual mechanics of interoperability may be achieved through:

• Real-time exchanges: EHRs maintain a constant link to the electronic clearinghouse. This link is mostly through a secure Internet connection. For example, insurance eligibility confirmation and pharmacy transactions are frequently exchanged on a real-time basis through an Internet connection.

• Batch transactions: EHRs or the supporting communication software will periodically contact the appropriate Internet site to download incoming information and upload information to be sent to other clinicians. For example, diagnostic reports from a radiology center may be sent hourly to the practice from the hospital radiology department. Typically, the exchange is done through a file transfer system that downloads the file to the practice, and the EHR software posts the relevant information to the patient records.

• Online access: In some cases, physicians can access a website and review materials to be downloaded to the practice's EHR. For example, some HIEs maintain patient information for access by clinicians. Clinicians can go to the HIE to review information from other healthcare organizations and optionally download information to the practice EHR.

Electronic exchanges with patients are supported by most EHRs with a patient portal. The patient portal is directly connected to the EHR, and practices do not have to contend with variances in structure and form that are problems for interoperability with other healthcare organizations.

Challenges to Electronic Interoperability

Electronic interoperability works for physicians when the creation and transmission of transactions is "out of the box." Electronic claims, explanations of benefits, and prescriptions are examples of interoperability that work today and work well. Many new electronic transactions lack the use levels and clearinghouse facilities to handle and manage some of the interoperability included in meaningful use, PI, and other initiatives.

A serious challenge to new interoperability is that the benefits of electronic interoperability are not aligned with the parties that have to do the work. For example, clinicians enter prescription information, which saves the pharmacy staff the time required to enter information from paper prescriptions into the pharmacy systems for fulfillment. Or clinicians and staff coordinate surgical services with hospitals, other clinicians, and implant manufacturers through websites. Thereby, these other healthcare organizations do not have to staff call centers to accept your orders and information into their surgery and/or order systems.

From a technical perspective, new electronic interoperability initiatives have been a challenge for physicians, because few physician practices have the technical staff or time to deal with the wide array of connectivity issues that can occur. From testing the connection to changing the workflow within the practice, practices do not have the time or resources to establish interoperability with the many different types and the number of practices and healthcare organizations that clinicians work with daily.

From a nontechnical perspective, most practices are at a significant disadvantage. For example, some electronic interoperability issues pit the practice against much larger healthcare organizations. For example, some hospitals will only support electronic interoperability with selected EHR products. And some EHR vendors require additional payments for each electronic connection.

The only practical interconnection strategy is for practices to use out-of-the-box connections that have a reliable transmission options. To support such efforts, there are some actions that you can take:

• Contact local practices that use your same product to work with your EHR vendor as a group to support interoperability you need. The group of practices will have more influence over vendor support (and charges).

• Work with your key healthcare organizations and your local HIE to engage your EHR vendor in supporting the interoperability strategy that you need for your practice.

• Work with practices affiliated with your local hospitals and integrated delivery systems to advocate for interoperability strategies that are workable and practical for the practice.