Intermountain CMIO: How interoperability bridges gaps in knowledge, decision support to improve patient care

Stan Huff, MD, chief medical informatics officer at Intermountain Healthcare, discusses the Salt Lake City-based health system's approach to interoperability and how to apply it beyond data sharing.

With 25 years of experience in medical database architecture and medical vocabularies, Dr. Huff works primarily on interoperability, architecture and strategy initiatives at Intermountain. He also serves as a clinical professor of biomedical informatics at University of Utah in Salt Lake City.

A fellow of the American College of Medical Informatics, Dr. Huff is also co-chair of Health Level 7 Clinical Information Modeling Initiative and a former member of the ONC Health IT Standards Committee.

Here, Dr. Huff shares some of Intermountain's interoperability initiatives and programs they have developed to enhance clinical decision support within the EHR.

Editor's note: Responses have been lightly edited for clarity and length.

Question: What strategies has Intermountain implemented to support data interoperability?

Dr. Stan Huff: We've done a lot to try and assist physicians in taking better care of patients. One example is the program we implemented that helps clinicians choose the most cost-effective antibiotic when treating patients. Basically, how this works is the system knows the patient's white blood count, temperature, and suspected site of infection. Then, using historical data for people with similar sex, age, and signs and symptoms and having the knowledge of whether the infection was community-acquired or hospital-acquired, the EHR can determine which antibiotic would cover 80 percent of the known infections that are suspected or 99 percent of the infections, etc.

We also have programs that help physicians order the right blood products for what condition or disease they're trying to treat as well as programs that help ensure the right medications are prescribed after a patient has a myocardial infarction. That's just a short list. We have completed hundreds of initiatives where we've created these capabilities in our EHR systems both in the past as well as projects we're currently working on in our Cerner system.

Q: Have you rolled out any technologies, such as wearables or remote patient monitoring, to support data sharing between patients and physicians?

SH: We have an extensive telehealth network, which allows physicians in our tertiary care centers to interact with patients in our smaller hospitals as well as rural hospitals and clinics. This helps patients who have severe trauma or other kinds of difficulties by giving them the benefit of central expert and specialist clinicians providing their medical care.

We also have an online patient portal, where patients can log in and access any of their data that relates to their healthcare. They can view progress notes, lab tests, X-ray results and similar information. Intermountain is also one of the hospitals participating in Apple's health information exchange program, Apple Health Records. This allows our patients to receive real-time updates of their lab data, progress notes and medications directly through their iPhone.

Intermountain also has the Connect Care program that allows patients to directly consult electronically with care providers about acute signs and symptoms that they might be experiencing.

Q: Of all the initiatives Intermountain has implemented to improve EHR interoperability, does one stand out in particular?

SH: A lot of our focus recently has been on the HL7 Fast Healthcare Interoperability Resources standard, and the use of the FHIR standard to create interoperability. We imported a FHIR based program from Boston Children's Hospital. They developed a pediatric growth chart application that we then imported and connected to our Cerner EHR using the FHIR standard. It was a good demonstration that we were able to share an app between entirely different EHR systems using the FHIR standards.

We also have a lot of interoperability with the Utah Health Information Network, and we use HL7 standards within that environment. Some HL7 and FHIR standards versions make it possible for us to share data both ways; Intermountain contributing data that non-Intermountain clinicians can access when taking care of patients and vice versa. We also support interoperability between our health system and the Utah State Health Department. Between us, we share information relating to immunization histories and data for reportable, communicable diseases.

Q: What are the biggest obstacles you face when deploying new interoperability initiatives?

SH: Because the FHIR standard is relatively new, we're learning as we go with FHIR implementations. Given the flexibility of the FHIR standard, it has been imlemented a bit differently by different EHR systems. We learned a lot in the pediatric growth chart, figuring out what to name the data elements and how it should be used because there were differences in the way that people thought about it at Boston Children's Hospital versus how we needed to implement it at Intermountain. We had the same situation with the University of Utah, which uses an Epic EHR. Since we use Cerner, the implementation of the standards between the two EHR vendors are just a little bit different, so we have to work to understand at a very precise level what the data elements mean and how we retrieve them out of the system so that the software has the same behavior regardless of what system it is operating within.

Q: If you could eliminate one of the healthcare industry’s biggest technology struggles overnight, which would it be?

SH: Interoperability. The purpose of interoperability isn't just technology for technology's sake; it is so that we can take better care of patients. At Intermountain, we have improved the quality of care and decreased the cost of care we provide through our decision support initiatives. The challenge we have though is that without interoperability, every single one of those programs must be created at Intermountain using our own programmers and resources. We have done a lot, but literally, we could do one thousand times more than what we're currently doing if we were in an environment where we could share with other institutions.

This is why we're excited about activity like SMART on FHIR. In an environment where the systems are truly interoperable, it's not just about data sharing but about sharing apps, work flows, and knowledge as executable programs. You can't teach physicians to be perfect information processors; they cannot learn everything there is to be known about medicine at any given point in time. The only way we can start approaching higher quality of healthcare is if we have a way to share knowledge, not just through academic journal articles but through shareable programs and decision support modules. That sharing can only happen if we have interoperability at a platform level, so these programs and tools we create at Intermountain can be shared with other healthcare organizations, and in return we can use decision support apps that they develop.

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