Interoperability, patient identifiers and standards: A conversation on 'rules of the road' with SSM Health's CMIO

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When a patient walks into a hospital, there's no guarantee that patient's medical records will be accessible to providers, or that the medical records are indeed the correct ones for that particular individual. St. Louis-based SSM Health is tackling that issue head on.

In May, SSM Health became the first system to implement Surescripts' National Record Locator Service across its enterprise, allowing providers to search for and access a patient's EHR, regardless of hospital or EHR vendor. The Surescripts network is comprised of physician offices, hospitals, pharmacists and health plans and holds information on 140 million patients and close to 2 billion interactions between those patients and their care providers.

While this tool helps identify patients, the implications of accurate patient matching run much deeper. It opens the door to discussions regarding interoperability, standards surrounding data sharing and patient privacy.

These ideas are all interrelated, and in a recent interview with Becker's Hospital Review, Richard Vaughn, MD, CMIO of SSM Health, spoke about the system's efforts to address all of these concerns.

Note: Interview has been edited for length and clarity.

Question: SSM Health is the first health system to adopt Surescripts' National Record Locator Service. What prompted SSM to consider and eventually adopt the service?

Dr. Richard Vaughn: We've been working with Surescripts for a while, and we knew this was coming online with them. We were excited because it was another way for us to find out where our patients have been and be able to get the information from that location. It's just another puzzle piece that drops in to build out the lifetime record of the patient.

Surescripts has a unique look at the marketplace. We really saw an advantage that we would get information we wouldn't normally get through our other connections like health information exchanges. If a patient goes somewhere where we don't have a connection through an HIE or don't have a direct connection to the organization, this is another way to make sure we get that information.

Q: What has changed in terms of your connectivity or access to patient information since adopting the NRLS?

RV: We are seeing places we haven't seen before, places we did not have a connection with. We're in four states, so in Missouri we're connected to the HIE, but everybody may not be connected to it. We're starting to see already information where patients have been that we would not normally get from querying the HIE or querying other Epic customers through Care Everywhere.

Q: How is SSM Health harnessing interoperability to advance patient care and produce the best outcomes?

RV: Our most complex patients are on a lot of different medications, they might see multiple different providers at different locations, and not all of them are at SSM Health. We'd love it if that were true, but it's not always possible. We don't do everything. Our patients often have long-term relationships with other organizations. That being said, we want to make sure we see all this information, and when we have the information, we make faster, better decisions. Sometimes we don't know where the patient has been. Knowing the specialists involved and the name and location of that specialist is very important for us to make sure we are sending information back to that individual and we're communicating effectively with the entire care team that includes not only SSM providers but also includes sources outside of SSM.

Q: When thinking of HIEs or other networks, I'm curious to hear your insight on why we need third-party platforms to exchange data. Isn't data exchange the goal of EHRs, where IT systems should just be able to send the information back and forth without having to overlay anything else on top of it?

RV: That's where we want to be. But look at something like Carequality. Carequality is an agreement among people, especially vendors, to use a set of standards and approaches to describe and communicate data, and to all agree on how that [sharing] will work. How can we get Cerner to talk to eClinicalWorks to talk to athenaCare and all these other EHRs that are out there that may have developed a different approach to describing data or storing data in their systems?

I look at Carequality more as a set of rules than a third party that's overlaying or interfering or somehow interposing themselves between two EHRs. They're setting the rules of the road and making sure all these networks that currently exist as well as the different vendors who have data in their systems are agreeing to how that information should be exchanged. They're paving the road. We all agree the road is going to be a certain dimension and a certain width so a certain size vehicle can go down that road.

It's great for the government to require that we exchange information, but we really like the idea that the private sector is coming together to figure out how to make that happen.

Note: Carequality is a collaborative of public and private organizations including vendors, health systems, payers and more that agree to common standards and specifications to support data sharing and interoperability SSM Health has access to the Carequality service and connections as an Epic customer, as Epic is a member of the collaborative..

Q: Would you say Carequality has been successful? Where is the group on its journey?

RV: It's still early on its journey, but we're very excited to see folks beginning to join. I think we'll see that continue to expand, partially because there's a lot of focus on interoperability today and people want to demonstrate that they're trying to cooperate and they are not in the business of holding onto patient data and making it difficult to exchange. Carequality is looking for a way to do it in a very efficient manner and not have to come up with five or six different ways to do it.

Q: What are the barriers preventing us from reaching that type of interoperability?

RV: We have lots of standards but not everyone implements the standards in the same exact way, which seems to be kind of an oxymoron. We have in healthcare some of the most extraordinarily complex data that you would ever want to look at. We unfairly get compared to more simple industries. When you think about banking, you're moving decimal points, and it's a pretty well-defined knowledge area. When you talk about healthcare and 500,000 different diagnoses and millions of different terms to describe things and seemingly endless numbers of lab tests and other types of testing, there are a lot of details around how you normalize the data.

We lack a single patient identifier, and there are people who are very vigorous in this debate on both sides on whether we should have one. I think it makes a lot of sense [to have a single patient identifier] as we have an aging population with lots of healthcare problems. We need an effective way to identify and be very confident that we're handling data from that patient.

If you don't have a national patient identifier, you have to rely on five or six pieces of data. We need standards, strong standards. Complicated data is always going to be with us.

Q: Has the issue of identifying patients increased with the proliferation of digital health? Or has it always been a problem and now we're just now trying to figure out a way to solve it?

RV: Maybe in the past we didn't have electronic exchange of data to a large extent. Folks had separate records that never needed to be mixed or never could be mixed. Now you can electronically collect all the information of where the patient has been in 10 different hospitals. It's more of an issue now because you are mixing more data from more locations. For the most part, that should be a good thing. But it does put a challenge on making sure each place identifies that patient in the exact same way.

Q: People float the idea of using Social Security numbers as patient identifiers, which is interesting given the concern of data breaches and privacy. A single patient identifier seems somewhat equivalent to SSNs, but customers give [SSNs] out fairly frequently.

RV: People are learning not to give out their SSNs. People are much more reluctant to share SSNs, or you're seeing websites just asking for a part of your SSN instead of the whole thing. This whole ID theft issue has made people think twice about sharing more details. However, as we've looked at our approach in the state of Missouri of having people opt into participating in an HIE, we've had an overwhelmingly high opt-in rate. People really do think carefully about the importance of sharing their medical information. They're like, "Yes, I want my doctor to see this information." There is a good level of trust based on that. We need strong advocacy, and it's going to take a good campaign for a while to turn the corner on the national patient identifier.

Q: What is your ideal vision of interoperability, and how close are we to that vision?

RV: I would love to see the term "interoperability" disappear from the lexicon because it's ubiquitous and nobody thinks about it anymore because it just happens.

How close are we? I've been more encouraged in the past couple years than I have been in the last 10. I see it as the constant pressure that we've seen from folks that are advocating for patients as well as the government saying it sees this as an issue and we really want you to share data. The willingness of the government to step back and let the private sector figure out how to get it done is a great approach. They're not trying to force a particular system or enforce a single EHR vendor on us, but they are looking to say you need to be able to exchange information, the information needs to be meaningful, and we're willing to let you show us that you can do this.

More articles on interoperability:

Small, rural hospitals lag in interoperability: 7 findings from the ONC 
Out to create health IT's nervous system: Mana Health CEO Chris Bradley on the future of interoperability 
ONC launches challenge seeking input on using blockchain in health IT 

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