Mar 01 2018

A Lack of Interoperability Limits Telehealth's Potential

Duplicate and fragmented documentation makes treating patients a challenge. An interoperable EMR exchange could help, argues Kevin Jones of the Ohio State University Wexner Medical Center.

Telehealth holds incredible potential with the noble goals of allowing patients to stay close to home and enabling access to highly specialized care many miles away. The clinical benefits are well-documented. Much of the focus around improving telehealth surrounds reimbursement structures.

However, significant technological barriers beyond just connectivity remain to complicate the process.

Limited EMR Interoperability Inhibits Telehealth

The most significant issue for providers at the moment appears to be with interoperability.

Regardless of whether the local and consulting hospital use the same electronic medical record vendor or different vendors, one underlying problem still exists: There are at least two clinicians trying to document on the same patient in two different systems simultaneously.

To remedy this, if a telehealth visit is planned, such as a specialty visit for psychiatry or dermatology, providers can exchange the Consolidated Clinical Document Architecture (CCDA) record prior to the visit. This can help reconcile the documentation of the patient's allergies, medications and problems. While it offers some advantages, multiple providers are still capturing vitals and documenting medication administration records and a host of other clinical data in two systems. In the end, there are two distinct sets of notes created by different providers, which wastes time for providers and virtual storage space, and introduces inefficiencies into the healthcare system.

More than other telehealth scenarios, telestroke illustrates the most complicated case. With stroke cases, there is little to no advanced notice of an incident, which means there is almost no time to exchange the CCDA records to at least allow providers at each hospital to reconcile patient history.

Generally, the CCDA exchange is not available until after the visit has been completed, which makes timing very difficult while the patient is in transport. Potential stroke victims have a very pronounced time element so the ability to manually fax or exchange data in any other manner is limited at best. Moreover, clinicians must manually exchange data or else tap an agnostic third-party system to facilitate the exchange between hospital EMR vendors involved.

Third-Party Solutions Can Eliminate Duplicate Documentation

In this way, third-party vendors can offer one potential solution to the interoperability problem. In this case, providers at both hospitals log into a single web-based application and can document on the same patient simultaneously. This virtually eliminates double documentation as both providers build upon the same note.

The downside, however, is that using a Software as a Service solution limits some interaction with devices, such as patient monitors. Overcoming this challenge requires the local hospital seeing the patient to tap (relatively expensive) equipment that can connect with local devices to capture vitals and other data elements to send to the third-party application via a web service or something similar.

Documentation is then sent to both hospitals as a single note, not as discrete data elements. If the patient is critical enough to warrant being transported to the consulting hospital, this data is not able to be sent in a format that can be consumed in a discrete format. Upon arrival, vital signs, medication administration and other clinical data is only available in report format.

EMR vendors have offered a similar function by acting as the third-party vendor. With these solutions, the consulting hospital allows access for providers from the local hospital to document on the same chart. The benefit of these solutions is that both healthcare organizations can use native EMR tools, such as discrete data entry and Medication Administration Record (MAR). If the consulting hospital EMR is used, patients being transported have a huge benefit in the fact that the data is available from time of original admission to the local hospital, painting a much greater picture for the stay. In this case, the original hospital, however, is still left with the report format for documentation.

This is probably the best-case scenario for transported patients thus far, but it fails when the patient isn't critical enough or can remain in the original hospital. In this case, the single-patient stay in the same hospital is broken into two different charts.

A Universal EMR Exchange Can Solve Telehealth Woes

Regardless of a third-party vendor or remote access to the consulting hospital, many patients will still have their care compromised by disparate data spread across multiple patient charts. The ultimate solution resides in an interoperable data exchange that can take data from one system, be it the EMR or third-party solution, and send the data to one or multiple EMRs in a standardized, discrete format that can be consumed for inclusion in the patient charts.

More importantly, this needs to be done at a minimum when the patient is leaving their original facility to be transported to the consulting facility. This could potentially be an expanded CCDA record or a different protocol entirely.

If this is done, it could help to eliminate the woes of a fragmented telehealth documentation system and streamline care for patients everywhere, simultaneously saving time for clinicians and valuable server space for healthcare organizations.

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