I’ve been hearing a bit of discussion about ICD-10 really helping to solve some of the problems of interoperability. Their contention is basically that ICD-10 is more precise in its description of the diagnosis and so therefore the information that is coded using ICD-10 will then provide more specific codified information that can then be rather easily shared. If you haven’t read about the transition from ICD-9 to ICD-10, here’s a good article about the transition.

In theory, this is completely accurate. If everything went as outlined, we could really get a lot of interesting information for studies and for interoperability of health data out of our ICD-10 codes.

The problem is that in reality ICD-10 is just going to cause even more problems for sharing quality data. Not because we can’t share the data. That’s a topic for a different discussion. The problem is that we’re never going to achieve quality input of diagnosis codes.

I’m not a doctor and so I’m not going to give a specific example here. However, I think all we have to do is look at the current ICD-9 diagnosing patterns. I’ve seen from first hand experience that often a doctor gets stuck searching for the right ICD-9 code. Right or wrong, they end up picking a code that may not be exactly the right code for what they’ve seen. Maybe they choose NOW (Not Otherwise Specified) instead of the specific diagnosis that would be more appropriate. Add in the complexity of diagnosis requirements for getting the most out of your insurance billing and I don’t think anyone would disagree with the assertion that ICD-9 code entry is far from accurate.

I’m not trying to place blame. I believe this is a chronic problem in our health system that those in the trenches have known about for years. My point here is that if we can’t get the rather “simple” set of ICD-9 codes right, then how can we ever expect the much more complex set of ICD-10 codes right?

Everyone knows the common phrase of garbage data in produces garbage data out. When we’re talking about interoperability of EHR software, doctors really have to think if they want other people’s garbage in their system.

ICD-10 really could produce some awesome information if used properly. The challenge we face is producing systems that codify the data properly so we have meaningful interoperability of healthcare data.

A lot of talk has been done lately on the importance of interoperability of EHR software. Many people point to health information exchanges when talking about this EHR interoperability. I must admit that almost all of the interoperability and health information exchange discussions I’ve seen recently leave me lost. Maybe I’m just not that smart, but I also think it’s possible that people are trying to bite off more than they can chew.

I’d like to see a simplified method for exchanging health information. Let’s break it down into bite size increments where we can actually have achievable goals and solvable problems. For example, let’s start with something like prescriptions, allergies or labs. Let’s get those right and then add on top of those functioning standards.

I previously posted the comparison of the Transcontinental Railroad to EHR interoperability. The reason it was so successful with the railroad was because they only had to standardize the gauge of the railroad. We should apply that same type of simplicity to exchanging patient information and we’ll see better results.

I recently read a nice article comparing EHR interoperability to the Transcontinental Railroad. They hit the key point when they said, “Just as standardizing the railroad gauge created a uniform distance between tracks so that track the came from the East and West would fit together, health care IT standards will create a seamless and interoperable IT infrastructure that will benefit the entire nation.”

I find the comparison incredibly intriguing and thought provoking.

The only problem I have with the comparison is that the transcontinental railroad was merging essentially 2 standards (east and west) and standardizing the gauge was the only standard needed. In health care IT we have far more stakeholders in the game and far more standards that need to be established (allergies, labs, RX, diagnosis, just to start).

This doesn’t diminish the value of the comparison since it’s often valuable to see a complicated challenge in a simplified way. I’m just saying that creating a standard in HIT is going to be much more difficult.

Today I came across the HHS Secretary Mike Leavitt’s blog. To be honest, I saw Mike Leavitt’s picture on the blog and I felt like I was meeting an old friend. No, I don’t really know Mike Leavitt from the next person on the street. We have never met before and the closest I’ve been to him is probably when I watched him pass by in numerous 24th of July parades in Utah. However, he was the governor of Utah for many of the years I lived in Utah and so I feel like I kind of know the man.

Reminiscing aside, I find Mike Leavitt’s blog completely captivating. He currently has been writing about his trip to China. For some reason I’ve always had an inner itch whenever I heard about China. I don’t know what it is, but I find the place completely fascinating. So, you can imagine my fascination with the HHS secretary’s interaction with the Chinese government. Plus, these posts about HHS and China give Mike a real personal quality that I find real and interesting.

Of course, I couldn’t begin to read the HHS Secretary’s blog without making sure to find some post about EHR or EMR. I quickly found a post entitled Value-Driven Health Care Interoperability which I think could more aptly be entitled “Electronic Health Records (EHR) Progress Report.” Of course, he is in government so that explains the title.

I’m grateful that the HHS Secretary is willing to engage the public in a discussion about EHR and EHR adoption, but unfortunately the post I found is so filled with political rhetoric. It sounds really good, but really has very little substance.

First, I’ll start with the good.

Three years ago, there were 200 vendors selling electronic health record systems but there was no assurance that the systems would ever be able to share privacy protected data in interoperable formats.

I think the concept of a certification for interoperability is good. It just makes sense that every EMR software vendor should be able to interact with another. Establishing a quality standard for this interoperability is valuable and even worth certifying.

Unfortunately, I think the HHS Secretary has been getting bad information when he says the following:

Since then, we have made remarkable progress.

An EHR standards process is now in place, and we are marching steadily towards interoperability. We created the CCHIT process to certify products using the national standards and it is functioning well. More than 75% of the products being sold today carry the certification.

Where to begin? First, Mike has suggested that there were 200 vendors selling EHR systems 3 years ago (It’s probably a few more than 200 EHR, but we’ll let this one slide). Mike asserts that “75% of the products being sold today carry the certification.” If that’s the case, then simple math tells us that there should be 150 certified EHR software, no?

If you look at the 2006 CCHIT Certified Ambulatory EHR list I count 92 EHR software products. Let’s see, that’s only 46% of EHR products that are certified. Plus, my count of 92 EHR counts some of the software multiple times since a number of the EHR software vendors certified multiple versions of their product. That sounds like less than 75% of EHR products sold to me.

Of course, Mike Leavitt certainly could say that 75% represents a percentage of actual products sold. Certainly the certified eMD’s has a lot more installs than any of the free open source EMR products out there. However, I think it’s a bit deceptive to say 200 EHR and then 75% of products sold if they aren’t the same thing.

I also love how it says 75% of products sold. I think we’re all aware of the outrageous failure rates of so many of the EHR products out there. It’s unfortunate that we don’t have a percentage of products installed. Then, you’d have a much better idea of how many doctor’s offices really have the possibility of interoperability.

Wait a minute! I was being extra generous above when I said that there were 92 Ambulatory EHR CCHIT certified. Why? Because it was 92 EHR certified with the 2006 CCHIT Certification. Correct me if I’m wrong, but I think that interoperability was taken out of the 2006 CCHIT Certification (along with the joke of the pediatric requirements). I’m pretty confident about this, because I work on one of the 2006 CCHIT Certified EHR and I have no way of sending a chart to another clinic other than manually going through the product and printing out the chart.

What does all this mean? That means that instead of 92 interoperable CCHIT certified EHR, there are only 31 EHR CCHIT certified in 2007. That represents 15.5% (not 75%) of the 200 EHR products on the market today are interoperable according to number of certified EHR.

I’m not really blaming Mike Leavitt for this. I’m sure him or his office was given a nice executive report with a bunch of data and they made it look as nice as possible. Reminds me a lot of what I call EMR sales miscommunications. Sometimes the data just gets lost in translation. Let’s just hope my trackback to Mike Leavitt’s blog gets read.

You thought I was done. Nope. Still plenty more to say and I’m just hitting the major points.

In addition, a National Health Information Network will start testing data exchange by the end of the year and go into production with real data transmission the year after.

This concept I really find intriguing. I look forward to seeing this go public and I’m glad it’s on the agenda. However, I fear that this isn’t more than political hyperbole. I’d love to see how they plan to address any of the following: unique identifier, the ultimate hacker’s health information paradise, economic model, motivational model and that’s just the list off the top of my head.

The primary reasons for low adoption rates among small practices are predictable: economics and the burden of change.

I’m glad you pointed out the obvious. If this was so obvious, then why did you support the implementation of a certification that costs so much money that EHR will inevitably raise the cost a small practice pays for an EHR? That doesn’t make much economic sense. Not to mention you missed what I think is the biggest factor in lack of implementation: fear. Not fear of change. Not fear of the expense. Certainly those are two major factors, but I believe that adoption rates by small practices are so low because most doctors have seen too many of their colleagues fail at implementing an EHR.

Let’s start waving the CCHIT certification flag again. Many will be willing to make the case that CCHIT certification helps supplant a doctor’s fear that their EHR implementation will fail. It may even supplant some fear, but what it doesn’t do is decrease the number of failed EHR implementations. It’s a problem I’ve discussed many times on this blog. Certifications don’t certify usability. They never have and never will.

I actually have a thought about what should have been done instead of CCHIT, but I think I’ll save that for a future post.

Thanks Mike for opening up the lines of communication with your blog. Now it will be interesting to see if Mike Leavitt and HHS have really embraced new social media and participate in the discussion they started. I’m certain that Mike’s blog is going to become one of my favorite reads.