The following is a guest blog post by Brian Levy, MD, Senior Vice President and Chief Medical Officer for Health Language.
Health IT standards and interoperability go hand-in-hand. Going forward, the success of the industry’s movement towards greater health information exchange (HIE) will hinge on the successful uptake and adoption of standards that will ensure reliable communication between disparate systems.
Progress is being made in this area through both messaging and coding standards introduced as part of Meaningful Use (MU). Specifically, MU coding standards that draw on such industry-respected clinical vocabularies as RxNorm, SNOMED CT® and LOINC® have the potential to drive more accurate, detailed sharing of patient information to promote better decision-making and patient outcomes.
Effectively deploying and adopting these standards is a huge undertaking with responsibilities falling to both vendors and providers going forward. To survive in future of healthcare, EMR vendors will have to evolve to support current and future industry standards. Providers will also have to grow their knowledge base and become more aware of how standards impact care delivery—instead of simply relying on vendors to pick up the slack.
The ability to “normalize” data to support all of these standards will be critical to advancing interoperability and communication between healthcare providers. With so many federal health IT initiatives competing for resources, the integration and use of terminology management solutions will become an important element to any data normalization strategy.
As providers assess their current needs and vendors move towards more enhanced offerings to align with new standards, the combined effort should produce significant progress towards improved information sharing. In the meantime, many challenges and opportunities exist along the roadmap to full implementation and adoption.
While the EMR vendor market hit $20 billion in 2012, recent surveys suggest that many will not have staying power for Stage 3 MU. And one of the primary reasons, according to a 2013 Black Book Market Research report, is lack of focus on usability. An earlier report also pointed to 2013 as the “year of the great EHR switch,” pointing to provider frustrations that their current EMRs do not address the complex connectivity and sophisticated interface requirements of the evolving regulatory landscape.
Stage 1 MU created an artificial opportunity for many vendors to enter the market through government incentive grants. Because most initial EMR systems were not designed with Stage 2 requirements for HIE standards in mind, many vendors may find that they are not in a position to fund the infrastructure advancements needed to support future interoperability.
For instance, many EMRs support ICD-9 or free text for the development of problem lists. Under Stage 2 MU, problem lists must now be built electronically using SNOMED CT, requiring EMR vendors to develop and put out new releases to support the conversion. In tandem with this requirement, EMRs will also have to be designed to support RxNorm and LOINC.
It’s a time of upheaval and financial investment in the EHR industry, and when the dust settles, healthcare providers will have designated the winners. The end-result will ultimately include those players that can support the long-term goals of industry interoperability movements.
Minimizing Workflow Impacts
In existence since 1965, the SNOMED CT code set has a long track record of success and international respect. A comprehensive hierarchical system that includes mappings to other industry terminology standards, the code set enables computers to understand medical language and act on it by organizing concepts into multiple levels of granularity.
Few would dispute the potential of SNOMED CT to enhance accuracy and address the detail needed to promote enhanced documentation practices, but the expansive nature of the code set is still not exhaustive. Searching and finding the SNOMED concepts to include in Problem lists often requires further expansion of synonyms and colloquial expressions commonly used in clinical practice. In addition, an accurate SNOMED code may not equate to a billable ICD-10 code, potentially requiring clinicians to conduct multiple searches if EMR workflow is not carefully planned.
The challenge for healthcare organizations is two-fold when it comes to the complicated SNOMED CT conversion process. First, the conversion represents one more complex IT project that healthcare organizations must undertake amid so many other competing initiatives. Second, the success of implementations will be diminished if clinician workflows are negatively impacted. With EMR documentation practices already requiring more time from a clinician’s day, the situation will only be exacerbated if multiple code searches are required to ensure regulatory compliance for MU and ICD-10.
Terminology conversion tools that leverage provider-friendly language can be a great asset to easing the burden by providing maps between ICD-9 or ICD-10 and SNOMED CT problems. Physicians search for the terms they are accustomed to using in the paper record, and terminology tools convert the terms to the best SNOMED CT and ICD-10 codes behind the scenes.
For example, a clinician may add fracture of femur to a problem list, but ICD-10 requires documentation of whether the fracture was open or closed, the laterality of the fracture and whether the fracture was healing. Provider-friendly terminology tools provide prompts for the additional elements needed and guide clinicians to the most appropriate choices without the need for multiple searches.
Improving Mapping Strategies Internally and Externally
Industry crosswalks and maps exist to help ease the transition to new standards like SNOMED CT, RxNorm and LOINC. While these tools provide a good starting point in most cases, there is simply not a gold standard map that will work for every case.
Consider RxNorm, a naming system that supports semantic interoperability between drug terminologies and pharmacy knowledge base systems. Working in tandem with SNOMED CT to improve accurate capture of patient information from external systems, RxNorm codes are now required as part of the CCD (Continuity of Care Document) and HL7 messages for capture of medication information.
While designing EHRs with the capability to send and receive RxNorm codes is the first step, healthcare providers will still require a method of converting codes from RxNorm to internal medicine systems and drug information and interactions databases like Medi-Span, First Databank, Micromedex and Multum. Another challenge to standardizing medication information is the use of free text. Many healthcare providers receive drug information that is not coded at all, requiring a specific, customized mapping.
LOINC, a universal standard for identifying medical laboratory observations, is particularly challenging in this arena. Because the industry is home to hundreds of local lab systems and thousands of local lab codes, creating a single industry mapping solution is nearly impossible. The process often requires that sophisticated algorithms be built by performing an analysis of individual lab tests that are conducted in a particular hospital.
By leveraging the expertise and sophistication of a terminology management solution, healthcare providers can more easily automate and customize mapping of patient data to standardized terminologies. Otherwise, IT departments must expend valuable staff time to build complex mapping systems to address the myriad of needs associated with an influx of new standards.
The healthcare industry has identified use of a common medical language as a key foundational component to advancing information sharing capabilities. By designating such standards as SNOMED CT, RxNorm and LOINC as MU requirements going forward, the industry is taking a progressive step forward to ensuring clinicians have more efficient access to better patient information.
It’s a critical step in the right direction, but the road to success is complex. Healthcare organizations that draw on the expertise of terminology management solutions will be able to achieve the end-goals of this movement much quicker and with fewer headaches than those trying to implement these complex standards on their own.