A Physical Therapist's Guide to the National Health Information Network

Tapping Technology

by Daniel J Vreeman, PT, DPT

A Physical Therapist's Guide to the National Health Information Network

Imagine that you are onboard an airplane that's preparing for takeoff, and that your pilot suddenly announces that the navigational system is down but the flight will proceed anyway. Would you feel comfortable with this news? Probably not. Yet, often health care providers and consumers must fly blind, in a sense, making decisions without the benefit of sufficient health information.

The National Health Information Network (NHIN) aims to solve this problem by ensuring that complete and accurate health information is available to consumers and providers. Achieving this ambitious goal, however, will require a radical transformation of our current health care system. Only the active and strategic participation of physical therapists (PTs) will ensure that the NHIN will meet the unique needs of the physical therapy profession and those it serves.

Where we are. The US Department of Health and Human Services (HHS) has cast a vision of delivering "consumer-centric and information-rich care,"¹ but health care today is falling short of this goal as it faces a confluence of information demands. Clinicians are expected to make effective and efficient care decisions despite having to use health information that often is incomplete, ambiguous, and poorly organized. Health care organizations are confronted with a plethora of expanded uses for health information in quality initiatives, claims support, public health reporting, and clinical research. Consumers, meanwhile, have become accustomed to the ease and empowerment of electronic banking and commerce, and are beginning to expect the same accessibility in health care. Regrettably, health care, and physical therapy in particular, has lagged behind as other industries have successfully transformed their business processes with information technology.

Where we are going. The national initiative to develop the NHIN is rooted in the belief that improving health information technology can improve care and save more than $140 billion annually.² How? By improving information sharing and care coordination while simultaneously reducing redundancies and medical errors.

On April 27, 2004, President Bush signed Executive Order 13335,³ designed to "provide leadership for the development and nationwide implementation of an interoperable health information technology infrastructure to improve the quality and efficiency of health care." Subsequently, the president set the ambitious goal of having electronic health records (EHRs) for most Americans within 10 years. To lead this transformation and coordinate efforts among federal agencies, the president established the Office of the National Coordinator for Health Information Technology within HHS. Not long after its inception, this office announced HHS's vision for the "The Decade of Health Information Technology"¹ and a strategic framework with four primary goals:

1. Inform clinical practice with use of EHRs.
2. Interconnect clinicians with an infrastructure that supports electronic exchange of health information.
3. Personalize care with personal health records, informed consumer choice, and use of telehealth systems.
4. Improve population health through unified public health architectures, streamlined data collection for quality monitoring, and accelerated research and dissemination of evidence.

The NHIN is a cornerstone of HHS's broader efforts. Within HHS, the Office of the National Coordinator for Health Information Technology, the Agency for Healthcare Research and Quality, the Centers for Disease Control and Prevention, the Centers for Medicare and Medicaid Services, and the National Library of Medicine all operate specific, large-scale initiatives under this framework to promote the adoption of information technology. Recognizing the importance of these initiatives, the APTA Board of Directors identified electronic medical records/information technology as a Priority Level 2 issue for 2006.⁴

How It Will Work

In describing what the NHIN will be, it is helpful to consider what it will not be.

The NHIN is not the government's master plan to develop a central database of all health information. Rather, it is meant to function as a set of many networks that will communicate with one another via a shared set of technical and policy requirements. Some networks will be geographically based to link institutions and practices within a community, whereas others will be "affinity" based-for example, exchanges among business partners or research centers. This approach will leverage the existing infrastructure and pools of information.

The NHIN is not a law mandating specific hardware or software use, but instead will develop through a progressive series of initiatives and incentives. HHS established a public-private collaboration called the American Health Information Community to provide recommendations on creating interoperable EHRs that ensure privacy and security. With input from a variety of stakeholders, the NHIN is primed to unfold in a smooth, market-led way.

EHRs. The EHR systems used by providers are primary building blocks of the NHIN. These systems are the vehicle for delivering information within the NHIN to individual providers, whenever and wherever they need it. Additionally, EHRs are interfaces for collecting information directly from providers and instruments (such as vital sign devices or EKG charts), and are the repositories where these data are stored. Many PT clinicians and managers think of electronic documentation systems when they hear the term EHR, but the kind of record system that will enable the NHIN has many capabilities beyond capturing clinical documentation. The Institute of Medicine has described the "core functionalities" of EHRs⁵ as including the set of features listed in Appendix 1. This list reflects the fact that the EHR is far more than a "word-processed" version of a traditional paper chart, and illustrates the interwoven themes of integrating information resources and using electronic tools to help clinicians and patients make care decisions.

Key challenges. To be successful, any strategy for building the NHIN must address a number of critical barriers.

Limited adoption of EHRs. Although the technology for creating EHRs has existed since the late 1960s, adoption and penetration has been limited. Expanding the adoption of EHRs will require concerted efforts to improve incentives, as well as close attention to socio-technical challenges to implementing such systems.

Financial risk. Purchasing or developing in-house EHRs presents a financial risk because of the uncertain return on investment and the unequal accumulation of benefits-providers and institutions invest in the systems, but much of the savings is reaped by payers. Some risks for physical therapy clinics may be alleviated by pay-for-performance initiatives being developed by CMS and by HHS's plan to develop a certification process for EHRs to ensure that products meet minimal functionality requirements.

Lack of standards. The current state of health care information systems is similar to that of the US railroad system in the 1850s. At that time, several companies began laying tracks, but track widths varied so that trains could not switch between rail networks. Similarly, the limited amount of electronic health information that currently exists is stored in an assortment of isolated, incompatible computer systems that cannot communicate with one another. This often happens even within a single institution.

Smooth exchange of health information requires vocabulary standards for identifying the content of clinical information, messaging standards for forming the electronic "envelopes" to be sent between computer systems, and transmission standards for moving those envelopes from one system to another. Although health care has a core set of generally accepted data standards for exchanging information (see Appendix 2) and there is agreement on using the Internet to carry NHIN data, the standards are not implemented consistently enough to allow widespread data exchange.

An additional challenge for physical therapy is that much of the language we use to describe our unique body of knowledge still is under development. Moreover, many of the profession's commonly used clinical tests and measures are not widely represented in nationally recognized vocabulary standards, and often computer systems used in physical therapy do not employ messaging standards.

Threats to privacy and security. Exchanging health information requires trust between patients and all involved entities, including providers, payers, researchers, and others. The NHIN will require mechanisms to protect health information and allow patients to restrict access where desired.

What the NHIN Will Look Like

The NHIN aims to solve the problem of interoperability while simultaneously promoting widespread adoption of EHRs. The idea is to ensure that we do not build electronic "islands" of data that would prevent us from leveraging the computer's processing capabilities on aggregate data. The goal is to allow clinicians to view a complete record that includes all of the patient information they are authorized to see, regardless of where the data originated. In the envisioned environment, clinicians will access NHIN data through computer systems that link patient information with other clinical resources, such as practice guidelines and the scientific literature, and that contain automated tools to assist clinical decision-making.

A hypothetical example. To illustrate what this environment might look like for a PT, consider this example. Suppose a family who recently moved to your area visits you as a primary contact because their daughter, who has cerebral palsy, is having difficulty walking. You collect information and administer specific tests and measures during your examination, storing the data in an EHR.

Informed by the electronic data, the EHR uses automated guidelines and locally designed clinical best practice rules to suggest specific care options to discuss with the couple. Based on the patient's clinical profile and these guidelines, the EHR suggests referral to a specialized gait analysis laboratory. During your evaluation, you consider the computer's suggestion, the family's priorities, and the examination results, and decide that such a referral would help determine the most appropriate interventions. You then initiate an electronic gait analysis consult that includes a summary of your evaluation and the components of your examination that justify the request. The computer collates and prints for the family, based on their demographics and the patient's clinical status, relevant educational materials and a list of community resources.

As soon as the results of the gait analysis (performed at a nearby academic center) are available, they are sent electronically to your office. They include both discrete data elements from the instruments used and a narrative summary with recommendations. You review the results and recommendations in light of your examination findings and establish with the family an appropriate plan of care. The plan includes your chosen interventions and an electronically processed referral to an orthopedic surgeon for consultation on possible surgical interventions.

Is this type of system complete fantasy? Hardly. This level of connectivity and automation is exactly what the NHIN aims to establish. While much work remains, it is not a pipedream. In fact, I work at an institution, the Regenstrief Institute Inc, that has pioneered information exchange.

A real-world example. The Indiana Network for Patient Care (INPC)⁶ is a working example of a community-wide health information exchange that has been in operation for more than 7 years. The INPC includes information from all five of the major hospital systems in Indianapolis (15 separate hospitals), several large physician groups, the county and state health departments, homeless clinics, and reference laboratories. The electronic infrastructure fostered by the Regenstrief Institute provides physicians in hospitals and emergency rooms with access to a cross-institutional "virtual patient record" assembled from INPC constituents and viewed through a Web browser-based program. The network also delivers laboratory, radiology, and other clinical documents to physicians' offices throughout the community through a program called DOCS4DOCS.

Clinicians interact with the INPC using these general tools, as well as institution- or site-specific programs that vary in sophistication. At Wishard Memorial Hospital, for example, clinicians use a suite of programs called the Medical Gopher for entering orders, writing clinical notes, generating clinical reports, and much more. The Medical Gopher has many features to support decision making, such as reminders for preventive care.

Although the INPC features much data that is useful to practicing PTs, the amount of physical therapy-specific content is rather limited. The information that does exist is stored as free text narratives, which does not allow clinical information systems such as  Medical Gopher to tap into their contents. A primary reason for the limited content is that PTs played little role in the system's development.

Implications for Physical Therapists

As we enter "The Decade of Health Information Technology," the vision and momentum of the NHIN offers a unique opportunity to improve our health care system. PTs not only should be aware of this initiative, but also should be playing active roles in making it a reality. Guided by my own experience with an operational, community-wide information exchange, I'll conclude with some suggestions about how we best can move forward.

Adopt EHRs, but be mindful of the complexity involved. PTs must use EHRs more widely if our profession is to participate in health care information exchange. Implementing EHRs involves complex socio-technical interactions, so we must carefully consider how EHRs alter workflow, and how we best can stimulate clinicians to actually use them. PTs must recognize the importance of institutional decisions about EHRs and ensure that they are involved in the process.

Make EHR purchase decisions with the vision of the NHIN in mind. Many EHRs in physical therapy may not have the features necessary for interoperable information exchange. Vendors design products to meet their customers' needs. If we do not express a desire for interoperability, the products we purchase likely will not support it. Instead of asking questions about relatively trivial matters such as "How much RAM do I need?" or "Will this run on the latest Tablet PC?", we should focus on issues relevant to interoperability, data reuse, and improved care delivery.

Good questions, for example, might be "Can this system send and receive health level 7 messages from other clinical systems? What vocabulary standards does this system support for sending information to other providers? What features of this system will help me make better clinical decisions?"

Participate in developing vocabulary standards that represent the clinical concepts of interest to PTs. Without universal identifiers for clinical observations, tests, and measures, each institution is free to invent its own labels for local data. This situation impedes the exchange of data. Where they are absent, we must create universal identifiers for common data elements. The language PTs use to describe clinical concepts and classification schemes still are evolving, but we should consider, as we develop them, how the terminology supports electronic exchange.


Achieving the goal of "consumer-centric and information-rich" care will require a complete transformation of our current health care system, but the challenges must not dissuade us from moving forward. Given the far-reaching implications of the NHIN's  potential benefits, physical therapy has much to gain from participating in its development. By taking an active role in adopting EHRs and developing vocabulary standards, PTs can help ensure that the NHIN meets physical therapy's specific needs.


Daniel J Vreeman, PT, DPT, is visiting assistant research professor of physical therapy at Indiana University and research scientist at Regenstrief Institute Inc. He can be reached at dvreeman@regenstrief.org.

Appendices

Appendix 1. Core Functions of an Electronic Health Record System

1. Health information and data.
2. Results management.
3. Order entry and management.
4. Decision support.
5. Electronic communication and connectivity.
6. Patient support.
7. Administrative processes.
8. Reporting and population health management.

(Source: Key Capabilities of an Electronic Health Record System, Institute of Medicine of the National Academies, 2003.)

Appendix 2. Data Standards for Health Information Exchange

Messaging:

• Health Level 7 (HL7): Exchange of clinical information.
• X12N: Exchange of insurance and administrative information.
• Digital Imaging and Communications in Medicine (DICOM): Exchange of clinical images (eg, radiologic studies).

Vocabulary:

• Health Care Common Procedure Coding System (HCPCS): Clinical procedures, products, supplies, and services.
• Current Procedural Terminology (CPT): Clinical procedures.
• International Classification of Diseases (ICD): Clinical diagnoses and procedures.
• Logical Observation Identifier Names and Codes (LOINC): Laboratory and other clinical observations.
• Systematized Nomenclature of Medicine-Clinical Terms (SNOMED): Clinical reference terminology, particularly for clinical findings.
• RxNorm: Clinical drug names (active ingredient plus strength plus dose form).

References

1. Thompson TG, Brailer DJ. The decade of health information technology: delivering consumer-centric and information-rich health care. Available at www.os.dhhs.gov/healthit/documents/hitframework.pdf. Accessed November 17, 2005.
2. Hillestad R, Bigelow J, Bower A, et al. Can electronic medical record systems transform health care? Potential health benefits, savings and costs. Health Affairs. 2005;24(5):1103-1117.
3. The White House. Executive Order 1335: Incentives for the Use of Health Information Technology and Establishing the Position of the National Health Information Technology Coordinator. Available at www.whitehouse.gov/news/releases/2004/04/print/20040427-4.html. Accessed November 17, 2005.
4.  American Physical Therapy Association. 2006 Critical Issues in Federal Government Affairs. Available at www.apta.org/AM/Template.cfm?Section=APTA_Policies_and_Priorities&Template=/MembersOnly.cfm&ContentID=26949. Accessed November 17, 2005.
5. Institute of Medicine of the National Academies, Committee on Data Standards for Patient Safety, Board on Health Care services. Key capabilities of an electronic health record system. Washington, DC: National Academy Press; 2003.
6. McDonald CJ, Overhage JM, Barnes M, et al. The Indiana Network for Patient Care: a working local health information infrastructure. Health Affairs. 2005;24(5):1214-1220.