How poor interoperability affects patients

I spent the past month working on an inpatient medicine team at our tertiary care hospital. As a referral center, we often care for incredibly complex patients who require multiple consulting services. One of the most vexing parts of caring for our patients is attempting to track their care through many previous hospital systems.

Unless a patient is both extremely vigilant about his or her medical care and highly health literate, the lack of a central repository of clinical information is an impediment to patient care in many ways. The multitude of electronic medical records (EMRs) make it nearly impossible to provide efficient, timely and considerate patient care.

For example, the mental health system in San Francisco alone uses over ten different EMRs. Members of this patient population are particularly at risk for being unable to communicate their health histories to providers. We have a system that almost guarantees errors from incomplete information.

Unnecessary duplicate testing

As an example of an error that can occur, I recall a patient who was with our team for nearly four weeks. He had multiple complex medical illnesses and, unfortunately, had not been forthright with (or perhaps had not been knowledgeable about) any of his previous hospitalizations. He had spent 70 to 80 percent of his earlier six months in and out of several hospitals in the Bay Area.

It took nearly four days before we discovered several tests that he had received in other nearby hospitals. These were tests that were not only costly (e.g., CT scans), but also invasive and not without risk to the patient (e.g., bronchoscopy, biopsies). It’s likely that we would have repeated some of these tests if we hadn’t found out they had been performed elsewhere. Fortunately, we were able to discover this information before too much of the workup was repeated.

However, this is not always the case. Studies have shown that duplicate testing often occurs when EMRs are not interoperable. The costs of repeat tests have not been well documented, but when 20 to 30 percent of studies are unnecessarily repeated, it’s not difficult to imagine this leading to high costs.

Missing important clinical information

The lack of shared clinical information not only affects costs, but also has significant impact on patient care. We are currently caring for a patient who is severely ill from several infections due to an immunocompromised state. Other providers had diagnosed this immune compromising disease two to three years prior, but it was not in our electronic medical record.

Our patient had presented our emergency department three months prior with complaints of a cough. Without information about the patient’s weakened immune system, the patient was sent home only with antibiotics. That presentation was likely the start of a pneumonia that has now resulted in the patient being life-threateningly ill in our intensive care unit.

Since the patient did not report this diagnosis to us, as health care providers, we were unable to appropriately triage and care for the patient in a way that could have prevented the current illnesses.

Still searching for solutions

These are just two of innumerable ways that the lack of interoperability and data sharing between EMRs negatively impact health care and patient outcomes. Most of the physicians I speak with (granted, in my very left-leaning state), feel that a universal EMR would solve many of the frustrations we feel when multiple EMRs result in poorly coordinated care.

However, even if a universal EMR is not in the future, we must find ways to stem the tide on the harm of multiple EMRs.

There have been several proposed solutions. One is the idea of asking patients to carry their medical history or personal health records (PHR) with them at all times. Several products have been marketed (e.g., Google Health, HealthVault) but as a whole, PHRs have been unsuccessful with very low adoption by patients.

The Office of the National Coordinator for Health Information Technology has invested significant funding in urging the adoption of health information exchanges (HIE). HIEs enable multiple health care systems to share important clinical information in a timely manner. Initial studies have shown that HIEs reduce repeated tests and health care costs. But again, despite the wealth of HIE-related products, providers (and more importantly, patients) still feel the adverse effects of multiple EMRs.

While health care leaders and policymakers continue to stumble through addressing the challenges of poor interoperability between EMRs, patient care continues to suffer. For the sake of patients (and in all honesty, our own sanity), I hope that we find a way to move forward soon. Otherwise, despite all the advances in the 21st century, we will continue to ask for faxed records the way that physicians had done several decades ago.

Elaine Khoong is an internal medicine resident. This article originally appeared in the American Resident Project.

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