EMR Standardization

January 19, 2013

As electronic medical records become more complex, the potential arises for systems to diverge based on their own specialization.  However, government agencies and health IT professionals have been working diligently to encourage standardization within the industry through Meaningful Use guidelines and the development of interoperability and health information exchange practices.  With the prospect of reimbursement fraud, diagnostic errors, technical failures, and more looming over EMRs, it is essential that standardization be a key goal as we move into the future.

There are many areas where standardization can be applied in the H.I.T. world.  Interoperability and health information exchange are perhaps the areas that receive the most attention.  A recent article by Dr. Doug Fridsma, Chief Science Officer and Director, Office of Science and Technology, reviewed both concepts. Simply put, health information exchange is the ability of one system to exchange information with another.  Interoperability takes this one step further and dictates that systems not only be able to exchange information with each other, but also that the respective information is able to be used.  For example, with health information exchange, a medical record from one EMR may be scanned and sent to another EMR system.  With true interoperability, the record is able to be scanned and sent and the information received can alert the provider automatically of a potential drug interaction.  Dr. Fridsma stresses that while health information exchange is important, interoperability should be the ultimate goal because of the benefits it offers the healthcare community.

The American Health Information Management Association (AHIMA) recently made a call for action regarding the standardization of data and how it is collected, stored, and used by EMR systems to enhance their capabilities.  AHIMA cites that guidelines are needed surrounding data integrity, patient safety, quality, and the prevention of billing errors. The organization calls for developing standards for EMR design that will produce better clinical documentation which ultimately leads to more accurate diagnosis and improved patient care.

In a separate article, Dr. Fridsma discusses additional areas where standards should be (and in some cases, are currently) applied, including meaning, structure, reporting, transport, and access.  Meaning encompasses vocabulary standards for medications within H.I.T.  Structure involves creating standards to support transitions of care and patient care summaries.  A substantial accomplishment was recently made in this area as a national standard has been established.  Reporting relates to developing standards for diagnoses and test results, primarily in the public health arena.  There is currently a national standard for this, referred to as HL7 2.5.1 standards.  This is the target all EMRs aim for and are able to use, bringing consistency across the board.  Looking to transport, this highlights health information exchange and involves identifying a way to consistently and securely send information from one EMR system to another.  Direct exchange is currently the protocol used to accomplish this task.  Finally, access incorporates making health information accessible by patients (patient health portals, etc.).

It is a certainty that EMR vendors will continue to compete with each other to offer exclusive features that make them more marketable.  In addition, H.I.T. professionals will have different ideas on what advancements need to be made within the industry.  However, a baseline level of standardization where systems can interact with each other, information can be used by providers and patients effectively, and intelligent reporting is routine is necessary so that health IT advances as a cohesive unit.

EMR Consulting and EMR Jobs
Excite is pleased to offer H.I.T. consulting services nationwide to those organizations needing assistance with EMR standardization.  Contact us online to learn more about our solutions or call us at 877-803-5804.  Looking for a position as an H.I.T. consultant?  We offer desirable positions across the country.  Contact us online or call us at 877-803-5804 to speak with a recruitment specialist.