The full potential of electronic medical records (EMRs) cannot be realized until all healthcare facilities have adopted them, and utilize them to exchange health information. National standards for EMR system integration and interoperability have not yet been determined or adopted. Until then, we are not realizing the full advantage of medical technology and health informatics.  

Incompatibility between user interfaces, functionality and system architecture varies significantly between manufacturers’ products, and many forces are underway to improve the integration and interoperability of systems, and thus improve the status of healthcare data exchange and EMRs. 

Integrating data among and from various healthcare systems is a key component, or capability, of an EMR. The integration of patient data also has the potential for streamlining, automating and structuring clinical workflow. Integration will also provide support for many different care activities, such as electronic prescribing of medications, electronic referrals, ordering laboratory and radiology tests, patient monitoring, and displaying test results. Integration and interoperability among applications will also enable healthcare providers and researchers to maintain an information and data trail for purposes of quality assurance, medical auditing, disease surveillance and epidemiological monitoring.  

Interoperability will support data transfer and sharing among and beyond network systems to other networks and enterprises; image transfers; integration with non-clinical as well as clinical applications; knowledge integration and transfer; and medical terminology integration, mapping and transfer. 

Data interchange is the process required for a system to read information from another, including word processing, database tables, and statistical analysis data sets. The XML format is one that is known to offer cross-platform standardization and acceptance. XML provides both machine- and human-readable format and is self-documenting. It also is capable of representing basic computer science data structures of trees, lists and records. Application integration is a process that allows the automatic execution of application-specific business logic, or commands. Application interoperability is the capability of actions in one application to drive behavior in other systems in a logical sequence. The Health Level 7 (HL7) Clinical Document Architecture is one data interface solution. Many web services also enable application interoperability because they use standards that allow applications to request information from each other.  

Organizations such as community health information networks (CHINs) or regional health information organizations (RHIOs) must be in place in order to support data sharing. Two examples of RHIOs are the Massachusetts Health Data Consortium and the Santa Barbara County Data Exchange. RHIOs may have different focuses, such as disease surveillance, exchange of clinical data or administrative data. Their system architectures may vary as well, from a centralized model with a data warehouse, or a peer-to-peer model, where data remains on site but the model provides secure links to records in other locations.  

An integrated health information system would be similar to electronic banking and its worldwide network, according to David Brailer, past national health information technology coordinator. A clinician could access information about a patient anytime, anywhere, even if that patient lived in Chicago and was vacationing in Thailand when he/she sought medical care. His or her medical record could be accessed at the point of care. Without integration, the health care information that has been collected and made part of each patient’s record is fragmented and not as valuable as it could be. Integration and interoperability can help eliminate test redundancy and medication errors. They can also ensure better preparedness and access to medical and public health data in times of disaster. 

Many argue that interoperability should precede the use of an EMR – that it should be designed into EMRs and that the infrastructure and capacity for networking this information securely has to exist first. Others counter that interoperability will be a natural result of widespread EMR adoption.   

The Healthcare Information and Management Systems Society’s (HIMSS) Systemic Interoperability Commission has recommended an interoperable medication record for all Americans by 2010.  The Commission has called for product certification, data standards, standard product identifiers and vocabulary, and drug records in order to advance progress of health information technology interoperability.  

Product certification calls for the Department of Health and Human Services (HHS) to support a single process to certify that healthcare information technology products meet minimum standards. HHS should also ensure acceptance, implementation and ongoing maintenance of a complete set of interoperable data standards that function to ensure that data in one part of the health system is (when authorized) available across the complete range of administrative, clinical, research and public health settings. The Commission also called for HHS to work with drug, device, and test kit manufacturers to achieve standardized identifiers and vocabulary in labels and packaging. Interoperability will also ensure that all providers have access (when authorized) to patients’ medication records. 

Single-vendor solutions are not always possible in health care because of the specificity and complexity of health care’s needs. Often, a health care system will have to depend on several different vendors to provide their software needs, from pharmacy to imaging to medical records to emergency departments, and these vendors’ applications must be interoperable and capable of sharing information and data; sadly, many are not. 

A fully-standardized electronic health care information exchange and interoperability (HIEI) could yield a net value of $77.8 billion per year once fully implemented, which is about five percent of the $1.661 trillion spent on health care in the U.S. in 2003, according to Jan Walker, et al (The Value of Health Care Information Exchange and Interoperability, Health Affairs, Jan. 19, 2005). Walker and her colleagues also noted that the clinical payoff from improved quality of care and patient safety could exceed the financial benefits of HIEI. 

Health care providers and payers, patients, public health departments, laboratories, pharmacies and radiology centers would all benefit from system integration and interoperability in terms of knowledge shared, instant access to information, disease tracking, patient safety and security. Despite the arguments about standards, quality, cost and safety of sharing health care information nationwide and even worldwide, we must continue to work toward this goal of system integration and interoperability in order to improve our healthcare system. 

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