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Getting the Complete Medical Record #NHITWeek

Viewing electronic health record

During National Health IT Week, champions from across the industry are uniting to share their voices on how health IT is catalyzing change in U.S. healthcare. The following post from a National Health IT Week Partner is one of the many perspectives of how information and technology is transforming health in America.

Ken Rosenfeld

“Hello, this is Major Big Medical Center, how can we help you? You would like a referral? Please tell us all about yourself and your medical history….Great, now you will need to collect this long list of medical records and imaging, get them to us, and then we can set up an appointment for you.”

Sound familiar? How much stress is added to patients every day when they hear this after receiving an initial diagnosis like cancer?

There are important efforts to ensure patients can have access and control their medical records, including those being proposed in the Trusted Exchange Framework and Common Agreement (TEFCA) from the Office of the National Coordinator for Health Information Technology. However, if we rely solely on patients to ensure the full medical record is accessible at the moment they are diagnosed with a life-threatening illness, how will that help the patient?

Unfortunately, there is still no interoperable access to significant aspects of a patient’s medical history – pathology, images, radiology reports, consult notes, pre- and post-operative notes and much more. Often this information is siloed in electronic medical records (EMRs) and is often not available in health information exchanges. These broad and informative elements of a patient’s medical history are not part of the “least-common-denominator” clinical care summary record, but this information is still critical for evaluating patient care, particularly for specialty referrals.

The “full medical record” – from all locations the patient has received care – made easily and quickly available inside a clinicians’ EMR and PACS imaging systems is the goal. Today, unfortunately, it can take many days to get that information.

While the industry is taking important, but relatively small steps towards further interoperability, these efforts must turn, at some point, to gaining access to the full record. Unfortunately, this broader access is still not being pursued, except for some efforts.

Access to broader data such as radiology reports, consult notes, pre- and post-operative notes, etc. requires a greater degree of interoperability that we are still many years away from. The TEFCA draft proposal points out that “a recent survey of about 70 hospitals found that few hospitals used only one method to be interoperable. A majority of surveyed hospitals required three or more methods and about three in 10 hospitals used five or more methods.” But what data is even being shared at this point? The big issue is access to all relevant health history, not just medications, allergies, problem lists and care plans.

A useful Common Agreement (the “CA” part of TEFCA) can help enable the sharing of broader medical information, but the agreement must not be restricted to the limited data found in a clinical care summary or through a FHIR® application programming interface. It will take time to expand the semantics and data sets that enable the full medical-record to be shared in a fully interoperability format. In the meantime, the Common Agreement should be made broad enough to help with the effective and rapid exchange of important medical information that may not yet be fully standardized.

The industry needs to continue to work to fill the gaps that exist in sharing a full medical record, but we believe there needs to be more conversation in the industry regarding not just the sharing of information, but also the completeness of the information being shared.

The views and opinions expressed in this blog or by commenters are those of the author and do not necessarily reflect the official policy or position of HIMSS or its affiliates.

National Health IT Week | October 8-12

Healthcare Transformation | Access to Care | Economic Opportunity | Healthy Communities

Share your story, provide insights and help develop healthcare policy during NHIT Week – focused on catalyzing actionable change within the U.S. health system through the effective use of health IT.

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