EHR Integration: Achieving this Digital Health Imperative

The adoption of digital health technology will be on an upward trajectory over the next decade, with a forecasted market exceeding $379 billion by 2024. This projected growth makes the need to integrate these tools into the EHR increasingly critical for health systems. EHR integration brings forward and leverages data and insights from digital health tools to provide relevant information, alerts to threats and opportunities, and financial and operational guidance at the point of care.

Given that the encounter-based EHR is the principal electronic interface most clinicians use today, the path to improved data-driven outcomes is likely to be, at least for the foreseeable future, through the EHR. However, most of the rich array of data analytics, data analytics, predictive analytics, and wellness applications that can drive the target outcomes won’t exist within the EHR. As an encounter-based transactional system, the EHR has not been designed to support real-time, point-of-care clinical decision support and analysis from a range of sources; to do so, health systems must integrate the EHR with many other digital resources. Given the limitations of traditional EHRs, interoperability is top of mind for both health system executives and policy makers.

To Achieve EHR Integration, Health Systems Must Have Interoperability

At its core interoperability is about aggregating the rich data that health plans, health systems, vendors, and patients generate through EHRs, analytic systems, biometric monitoring, and other digital systems, and leveraging that data to improve patient diagnosis and treatment. The focus of interoperability is the point of care, where clinicians can maximize these technologies’ impact.

The Office of the National Coordinator for Health Information Technology (ONC) defines interoperability as, “the ability of a system to exchange electronic health information with and use electronic health information from other systems without special effort on the part of the user.” Users must be able to easily find and use the information on both ends, whether sending or receiving, as well as send to, and receive information from, third-party systems (independent IT vendors). In practical terms, integration is having automatic access (versus manual entry) in the EHR to clinical information from sources within and outside the health systems and using that information when treating a patient.

Healthcare Has Work to Do Towards Interoperability

A recent Health Affairs study found growing evidence of substantial treatment and efficiency gains through interoperability; the authors stated that interoperability “is expected to be a key enabler of population-based alternative payment models, delivery reforms, and improved performance measurement.” However, the study also found that as of 2014, only about one-fifth of U.S. hospitals were engaged in all four elements of interoperability (finding, sending, receiving, and integrating information).

According to the study, fewer than 50 percent of health systems report that they are integrating information. Among the barriers, health systems most commonly cite difficulty for clinicians in viewing third-party information (e.g., worklists or alerts) in the EHR workflow. The study also found that integrating third-party information is more complex than finding, sending, and receiving, and only the more advanced EHR systems support integration. This may explain the slower progress toward integration. Without strong demand and proven use cases (discussed later in this article), integration might continue to make slow progress.

EHR Integration Faces Technical and Administrative Challenges

There are currently two main categories of challenges facing EHR integration:

#1. Technical Challenges

The prerequisite for healthcare digital integration is getting providers to adopt EHRs; this is similar to the way high-speed broadband internet connectivity was a prerequisite to many internet-based services. EHR systems are now largely in place, and data shows that finding, sending, and receiving electronic health information is occurring at significant rates. Integration, however, involves specific technical challenges that may be more difficult than sending and receiving information.

For integration, systems must be able to call up, at the right time and place, the relevant third-party information within the EHR user interface. This requires a technical infrastructure that makes relevant information available in the user interface. The technical infrastructure might involve APIs, which pull in relevant information when certain screens are accessed or provide tabs to link to third-party content for worklists with relevant information. At the very least, integration requires the health system to configure software to share information.

Fortunately, healthcare IT regulators are increasingly encouraging the use of standard protocols to enable the free exchange of health information among digital health tools and EHR systems. Technical challenges should soon become a less significant barrier to integration, as long as parties are willing to enable the right infrastructure and exchange standards.

#2. Administrative Challenges

Many healthcare integration challenges involve a lack of willingness among the key players (health systems, insurers, and vendors) to do the work to make integration happen. Some of this resistance stems from specific objections:

• Difficulty integrating third-party sources: Some vendors cite difficulty integrating multiple third-party sources into the EHR as an objection to integration. Health systems don’t want an EHR interface that is so cluttered with data, worklists, and alerts that clinicians can’t effectively use it for an encounter. Many business and consumer platforms address this availability problem by enabling the user to configure the interface to see, and provide alerts for, information that is most relevant to them. Health systems can use the same tools to optimize a user experience to their practice needs and still be able to leverage the EHR’s rich functionality, information sources, and analytic capabilities for integration.
• Contractual limitations: Some industry participants will restrict integration with contractual limitations on integration. While limitations may be legal in name, they’re more accurately characterized as administrative barriers. Under the 21^st Century Cures Act  and HIPAA, interoperability laws do not impose barriers on integration; the laws instead promote interoperability. Any restrictions on integrating and sharing data tend to come from the vendor or provider.
• Privacy and security challenges:
  • HIPAA and state privacy and security rules impose limitations to ensure that health systems appropriately use and disclose protected health information (PHI). Organizations must take steps to ensure HIPAA compliance; however, these requirements shouldn’t pose a significant barrier to EHR integration in appropriate use cases. Health systems may need to put in place valid HIPAA business associate agreements (BAAs) to enable the integration with third parties.
  • For health systems to adopt and use electronic health systems, they must trust them. The Office of National Coordinator for Health Information Technology (ONC) included promoting trust as a guiding principle in its Nationwide Interoperability Roadmap, stating that public trust that health information is safe and secure is essential. To better establish and maintain that trust as interoperability increases across the industry, healthcare industry participants must ensure that appropriate, strong, and effective safeguards for electronic health information are in place. Stakeholders must also support greater transparency for individuals regarding the business practices of entities that use their data, particularly those not covered by the HIPAA Privacy and Security Rules. Addressing privacy and security in a platform-wide format that enables third-party sources will be critical to scaling the use of third-party systems, as well as integration within EHR systems.

Three Keys to Successful EHR Integration

To achieve EHR integration, the healthcare industry must establish standards, prioritize functional integration, develop use cases.

#1. Standards

For decades, healthcare IT leaders have promoted the use of common exchange standards to facilitate the exchange of electronic health information. HIPAA put this concept into law and developed it further in the HIPAA transactions standards. The transaction rule adopted the use of the ANSI X12 standards as well as the NCPDP exchange standards for pharmacy-related transactions. This rule, combined with the healthcare exchange requirements in the HITECH Act, have supported significant progress in the sending and receiving objectives of interoperability. Initiatives such as the Direct Project and Blue Button have also advanced the exchange of electronic health information.

Organizations behind recent standards development efforts are attempting to push the boundaries of interoperability further; their focus includes more real-time, or near real-time, exchange of health information and analytics and provisioning the relevant health information for providers at the point of care. APIs are integral to many of these efforts, as they allow third parties to access the data and data models within other software applications and apply their own tools to the data, as well as deliver their outputs or data analysis back into the primary user’s EHR.

APIs can enable platforms that aggregate data across multiple providers or vendors that could ultimately help facilitate a widely adopted, fully integrated digital healthcare ecosystem. As publicly available APIs that allow users to access data with few restrictions, open APIs can support further integration. The U.S. Department of Health and Human Services will likely create a definition of open APIs in healthcare that will include openly published specifications.

From a software vendor perspective, the definition of open API would include critical concepts:

• Another software vendor can use APIs solely with the permission of a healthcare provider without requiring permission from the originating vendor; the healthcare provider should not have to make a special effort to access the API.
• The API should allow both a bulk extract of historical data and a real-time update of new data. The software vendor should not put limits on the data extracted or the frequency of data requests. The software vendor may not charge more than a nominal fee for using the API and may not restrict healthcare providers in any manner, whether verbal or written, from providing access to the API to any software vendor they choose.

Health systems are widely adopting the FHIR standard, which builds on the HL7 standard, for the exchange of health information. In addition, the SMART on FHIR platform and the CDS hooks specification have made significant advances in providing a framework for the real-time exchange of health information. These standards and specifications provide the framework for rapid advances in EHR integration.

#2. Achieve Functional Integration 

In addition to standards that facilitate the exchange of electronic health information, to achieve true integration, health systems need the will to address the technical and administrative challenges. Even with wide adoption of SMART on FHIR, health systems and vendors must enable and configure their systems for integration; standards alone won’t enable integration.

For example, if a health system wants to include information on social determinants of health affecting a patient’s care that’s available from third party data sources, it must configure its EHR system so that these factors appear in a window within the encounter or use another method that makes the information available to the EHR user. The fact that both the source systems and the EHR are using FHIR does not automatically make the information appear. Health systems must take steps to use the tools and standards to make them a regular feature of the encounter screen in the EHR.

#3. Develop Use Cases

There are many potential use case examples of information that integration would make available in the EHR and that would prompt clinical action:

1. A priority list of patients who may be at risk for pneumonia or sepsis.
2. A prioritization of patients, based on healthcare and other data, of who would benefit from referral to a social worker.
3. Information on a patient’s medication adherence and medications that have worked in the past to help the patient to maintain compliance with medications.

When clinicians find themselves wondering how they prioritized ICU cases or manage the discharge of patients before they had this integrated information, they’ll be more likely to push for the continued and expanded use of data integration tools.

Healthcare Must Meet the Challenges of Integration

For the healthcare industry to meet its desired goals of full integration, it must navigate the current technical and administrative challenges. The industry is making significant progress as it unites around standards, administrative processes, and regulatory principles. Health systems can ensure continued progress with optimal industry coordination around standards, administrative processes, functional integration, and the development of compelling integration use cases to drive demand. As the digital trajectory of healthcare continues to rise, full EHR integration that brings real-time, data-driven insight to the point of care is an industry imperative.

Additional Reading

Would you like to learn more about this topic? Here is an article we suggest:

Turning Data from Five Different EHR Vendors into Actionable Insights

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