Issues of Integration and Interoperability in Healthcare IT



DL401 – American healthcare system fall 2010Issues of Integration and Interoperability in Healthcare ITSubrata BeheraRhona BanayatLisa SandersonDecember 5, 2010This paper will discuss issues with integration and interoperability in Healthcare IT, workflow automation challenges, current integration standards, and future opportunities in healthcare integration and interoperability.Contents TOC \o "1-3" \h \z \u Original Term Paper Outline PAGEREF _Toc279087435 \h 51. Introduction and Approach PAGEREF _Toc279087436 \h 72. Current Integration and Interoperability in Healthcare IT PAGEREF _Toc279087437 \h 8Scenario Process Flow and Description PAGEREF _Toc279087438 \h 8Definition of Integration and Interoperability PAGEREF _Toc279087439 \h 15Data Integration and Interoperability Benefits PAGEREF _Toc279087440 \h 18Barriers to Integration and Interoperability PAGEREF _Toc279087441 \h 183. Workflow Automation Challenges PAGEREF _Toc279087442 \h 21Standards & Best Practices PAGEREF _Toc279087443 \h 21Data Quality PAGEREF _Toc279087444 \h 22Workflow Complexity PAGEREF _Toc279087445 \h 25Privacy Concerns PAGEREF _Toc279087446 \h 26Productivity Concerns PAGEREF _Toc279087447 \h 28Risk of Adverse Outcomes PAGEREF _Toc279087448 \h 29Resistance to Change PAGEREF _Toc279087449 \h 30Cost PAGEREF _Toc279087450 \h 324. Health Care Systems Standards & Interoperability Landscape PAGEREF _Toc279087451 \h 34Current State of Standards PAGEREF _Toc279087452 \h 34Standards Development Organizations PAGEREF _Toc279087453 \h 37Standards Governance PAGEREF _Toc279087454 \h 40?Office of the National coordinator for Health Information Technology (ONCHIT) PAGEREF _Toc279087455 \h 41?Certification Commission on Health Information Technology (CCHIT) PAGEREF _Toc279087456 \h 41?Healthcare Information Technology Standards Panel (HITSP) PAGEREF _Toc279087457 \h 43?Nationwide Health Information Network (NHIN) PAGEREF _Toc279087458 \h 43Key Issues Related to Standards & Interoperability PAGEREF _Toc279087459 \h 44Lack of coordination of efforts and competing standards PAGEREF _Toc279087460 \h 44Lack of a single governing body PAGEREF _Toc279087461 \h 45Key Emerging Technologies for Healthcare Standards & Interoperability PAGEREF _Toc279087462 \h 46XML Standard PAGEREF _Toc279087463 \h 46Services Oriented Architecture (SOA) PAGEREF _Toc279087464 \h 475. Conclusion PAGEREF _Toc279087465 \h 496. References: PAGEREF _Toc279087466 \h 50Original Term Paper Outline Topic: Issues of Integration and Interoperability in Healthcare ITBy: Subrata Behera, Rhona Banayat, and Lisa SandersonIntroduction and Approach. Our objective is to use a scenario based approach to: Identify the points of integration and interoperability among patient, PCP, specialist, hospital, Pharmacy benefit manager and payor (insurance company). Identify how integration is enabled via health data exchange.Identify limitations and challenges with integration and interoperability. In-depth discussion about current integration and interoperability in healthcare IT. (written by Subrata Behera)Scenario process flow and detailed description. Define integration and interoperability generally and in the context of our scenario.Data Integration and Interoperability benefits.Barriers to Integration and Interoperability.Workflow Automation Challenges (written by Lisa Sanderson)Acknowledge need for centralized repositories to address fragmentation issues.Discussion of technical limitations and challenges in current environment.Discussion of human factors such as communication, culture, which impede automation.Discussion of future opportunities and/or potential of healthcare integration and interoperability. (written by Rhona Banayat)Emerging technologies (e.g. SOA)SecurityGovernanceStandardsConclusion / SummaryReferences 1. Introduction and Approach Healthcare reform and the mandates for electronic health records have pushed to the forefront of our political and business agendas the need for Healthcare to exploit information technology. Historically as an industry, Healthcare has lagged in adoption of technologies. From an IT perspective, the linchpins to achieving Healthcare reform mandates are the fundamental enablement of integration and interoperability. We used timely research (sources from 2003 to present), to define integration and interoperability, and then explore a broad range of issues limiting them. Among the limiting factors are financial and organizational barriers and issues which challenge workflow automation. We end our analysis with a summarization of existing and emerging standards which address some of the barriers and challenges discussed.We begin our discussion by defining the scenario which formed the basis of our analysis which identifies points of integration and interoperability among Patient, Primary Care Physician, Specialist, Hospitals, Pharmacy benefit manager and Insurance companies. The intent of the scenario is to identify how integration is enabled (or not) and to demonstrate the issues which limit them.Scenario: A 56 year old female breast cancer survivor is experiencing symptoms she fears may be indicative on a re-occurrence of the disease. Prior episode of disease was approximately 12 years ago. At time of prior illness, residence was in a different geographic region of the country. Upon relocation, patient established relationship with new primary care provider who is not affiliated w/ former PCP or hospital where she previously received cancer treatment. Patient is fully insured with private insurance from a national insurance provider under her husband’s employer. 2. Current Integration and Interoperability in Healthcare IT Scenario Process Flow and DescriptionBased on the scenario the following are the detailed process flow and detailed description of the integration effort that is required to make it all work and will also identify the integration and interoperability issues.Patient calls PCP to schedule appointment. Office staff verifies eligibility.Patient calls into the physician office to schedule an appointment. This has been the standard way of scheduling office visits for a long time. The front office staff will schedule the patient for a certain date and provide the conformation to patient. With the advent of healthcare IT some of these tasks have been automated. The patient can log into a portal where she can search for an appointment online and confirm the appointment. This is much more efficient as the patient can book appointment at their convenience and don’t have to wait for the physician’s office to be open.The front office staff then checks if the patient in eligible based on the insurance information provided by the patient. The eligibility is checked using a Real Time Eligibility (RTE) application which will check with the insurance vendor regarding the benefits that patient is entitled to. Traditionally these had been separate applications running at a physician office that would check the patient’s eligibility. With the advent of the EMR the front office can enter all pertinent information about the patient in the EMR and click a button to check the eligibility of the patient. This brings the beauty of healthcare integration where an X12 message is sent out from the EMR to insurance companies and the response is got back real time in couple of seconds. This saves a phone call by the front office staff to the insurance companies.Patient consults PCP to discuss symptoms.PCP has recent medical history, but no medical records regarding prior illness. PCP requests that the patient obtain full medical history from former PCP.The patient comes for the appointment with the provider at the scheduled time. Since the patient does not have a copy of the previous medical records the provider would be sending in a request to the previous PCP to send across the copy of the medical records so that it would be helpful for him to ascertain the previous treatment and the treatment that needs to be done. This would result in loss of valuable time as the medical records would need to be sent across. This also increases the risk of data getting lost. It would be safe if all the providers are using some form of EMR and the EMR can talk to each other where a request for a medical record can be sent online and records can be shared online.PCP orders the following diagnostic procedures:Lab tests at local hospital. Results to be sent to PCP and oncologist.The PCP then places a laboratory order in the EMR and the order is sent to the local hospital. The PCP being part of the hospital network the order can be performed at the hospital. The order is sent real time to the hospital laboratory system using HL7.Mammogram at local radiology center. Results to be sent to PCP and oncologist.Appt. is scheduled with oncology specialist from a difference group practicePatient contacts former PCP and hospital where she received treatment to request transfer of medical records to new PCP and oncologist.Patient must obtain form to request medical records transfer from hospital. Medical records from former PCP can be electronically transferred to current PCP and oncologist.Patient goes to hospital for lab tests. The patient goes to the laboratory for test. The tests are completed.Lab test results are sent to PCP and oncologist.The results are then sent across to the PCP and oncologists. Since the PCP is part of the hospital network there is s direct interface between the lab system and the EMR used by the PCP. The PCP will receive an inbox notification that there is a new result for the patient to review. Since the oncologist is not part of the network he would be receiving the lab results through the local health information exchange. Since the all the providers in the area where the patient resides participate in the health information exchange it is easier for sharing of data between the providers and the hospitals. In this scenario while ordering the lab test the provider had mentioned the oncologist as the cc’d provider the oncologist will receive a copy of the result.Patient goes to radiology center. The patient has to get the radiology test done at a radiology center as the radiology services of the hospital are outsourced. Radiology results are sent to PCP and oncologist.The radiology result is sent to the PCP and oncologist by the local health information exchange that is working in the area.Patient goes to oncology specialist who, upon review of diagnostic procedures, orders breast biopsy, to be performed as part of the office visit. The oncologist after reviewing the results from the laboratory and radiology tests performs a biopsy which is then to a laboratory to be tested.Biopsy is performed; patient goes home and awaits results.Specimen is taken from the patient and sent to the diagnostic vendor.Biopsy sample is scanned and tracked and sent to diagnostic vendor for processing.Diagnostic vendor sends results to oncologist and PCP.Since the diagnostic vendor is not connected to the EMR of the PCP and Oncologist the results are faxed and a copy is sent through post. The office staff at the PCP and oncologists office scans the copy of the result and attaches the same to the patient chart.Oncologist contacts patient via email informing her that results are positive and recommends mastectomy, followed by chemotherapy. The patient receives a secure email through the EMR portal that the results are in and that she needs a follow up visit with the oncologist.Oncology office staff schedule surgeryOncologist submits prescription for pain medication to local pharmacy. Oncologist sends the prescription for the drugs to the local pharmacy through online prescription management system Oncologist communicates Dx and treatment recommendations to PCP and sends paper copy of medical records to PCP.Patient is admitted to hosp where mastectomy is performed and 1st course of chemotherapy is administered. Patient is admitted to the hospital network that PCP belongs to. The mastectomy is performed and the chemotherapy is administered. Patient is discharged from hosp.Patient receives weekly chemotherapy for 6 weeks as outpatient service.Appointments are created by the PCP with the hospital so that the patient can receive chemotherapy for 6 weeks. Since the patient was seen at the hospital the same medical record will contain all the previous information about the patient’s admission at the hospital. So all the new information about the chemotherapy treatment will be updated on the patients chart. Since the PCP is part of the hospital system he will be able to pull the active medical record for the patient will be able to keep a track on the progress that the patient is making.Patient has follow up consult w/ oncologist. The patient will take a copy of the medical records will all the information to the oncologist as the oncologist is not part of the hospital system. Patient has follow up visit w/ PCP.The patient follows up with the PCP after 6 weeks of chemotherapy. The PCP is able to pull up the latest updates on the patients on the EMR.Definition of Integration and InteroperabilityThe healthcare applications today being used at various places are complex pieces of software which needs a lot a care and maintenance. Integration in healthcare IT has been identified as one of the major stumbling blocks for the implementation of electronic medical record. The stumbling blocks have been lack of data standards, transparency and missing data. In the end it all boils down to one issue which is integration.In earlier days of healthcare IT the systems were standalone applications and they were not required to be integrated with each other. These systems resided at the particular hospital and had connection with other systems. We still have these independent systems being used by various healthcare vendors. These applications were going at doing there defined set of tasks but are not capable of sharing information which is key for the success of the electronic medical records. There are many organizations which still have these legacy systems which don’t allow them to integrate to the newer systems and hence integration becomes a problem in healthcare. (Chester, 2007)Over a period of time systems were developed which were more user friendly and allowed relay of data from one system to other. Most of it was rekeying the data from one system to other system. We all know for the fact that the manual data entry has its own share of issue. As per the FDA estimate one out of every 50 data entered is wrong. That is a lot considering that these were dealing with patient data and critical information. Keeping aside the errors there were large overhead costs associated with the data entry process. Then came HL7 which provided a set of protocols for two disparate healthcare systems to communicate to each other. The integration model of today has been modeled mostly on the HL7 standards. The inherent issue with the HL7 model has been that the vendors generally don’t conform to the HL7 standards. This has created a lot pains for integration various medical systems even though the vendors mention that they support HL7 standards. With the advent of the middleware which we refer to in our daily lives as interface engine in integration world it was easy for routing of various HL7 and X12 messages to various downstream applications. This helped in doing away with the various point to point interfaces and helped in reducing costs and better operational performance. (Chester, 2007)Integration has moved from point to point interfaces between two systems to enterprise business process platforms embedded in the center of an enterprise. Modern platforms are able to manage and orchestrate high volumes of messages and enable organizations to create large enterprise wide composition applications, trade with external partners and mine real time business/medical data. More and more organizations are aware of the possibilities inherent in strong middleware strategy and vendor middleware engines continue to develop into mission critical platforms. (Chester,2007)There are advantages to use of integration with the healthcare domain. Use of integration can help in sharing of data across healthcare applications and making data available for use by the end users. Real time availability of data can save time and lots of effort on the end users part to get things completed. But there have been issues with sharing of data of between various healthcare applications as the standards on which they operate are different from each other. Then comes the term Interoperability in Healthcare IT. As per the IEEE dictionary Interoperability is defined as: "The ability of two or more systems or components to exchange information and to use the information that has been exchanged.”Interoperability is the exchange of patient related information with the various legacy systems to serve a greater good. We have seen as the Healthcare IT getting more diversified so has the need for interoperable solutions been in demand. Currently health information is proprietary is owned by the organization or health system where the patient visited. Interoperability will allow data to move away from proprietary silos and be shared among various systems and applications. The positive effects of interoperability in healthcare are tremendous. Through Interoperability we can have care providers accessing patient medical records and have all the information about the patient on their fingertips for treating the patients. Patients can easily change care provider or seek expert opinion without the fear of having their data lost. Consumers will be better informed about their health with the information at their fingertips. Interoperability is critical for the widespread use of Electronic Medical Records adoption and use. Without interoperability the information will still would have been in silos as in the paper medical record world. With interoperable solutions EMR adoption will be for increased consumer choice, portability and control. (Brailer,2006)We have seen systems on various data standards (various versions of HL7) trying to talk to each other. We have developed standards that allow disparate healthcare applications to talk to each other but we have not developed systems that are interoperable. We need systems that can process data coming from foreign systems running on a different standard. Currently most of the healthcare application supports a single standard and hence integration becomes a difficult proposition. There are a few EMR’s in the market that can support multiple standards at the same time. Until that happens we cannot say that we support interoperable solutions.Data Integration and Interoperability Benefits The integration and interoperability of clinical data allows the following benefits (Advisors, Healthcare Data Integration Market Overview, 2008):Improves communication and information sharing among sites of care Offers a richer picture of the patients overall health and health history Can reduce redundant tests, procedures, etc. Reduces costs for resources (staff labor, interfaces, paper information relay) Provides for the timely consumption of patient data for physicians May tighten the strategic bonds between hospitals and community physicians Barriers to Integration and InteroperabilityWe have seen in working that integration and interoperability benefits the care providers. In this section we would discuss the various barriers to integration and interoperability.Barriers to Integration:First and foremost is the technical consideration that needed to be taken into consideration for integration of various standalone/integrated EMR’s. A few of the technical barriers in integration are quality of data, compliance with various interchange standards, various level of support and uptime for various set of care providers(Ambulatory setting as compare with hospital setting) CITATION Placeholder1 \l 1033 (Advisors, Healthcare Data Integration Market Overview, 2008). Since these are highly complex technical activities involved in the process we are seeing resource crunch in this particular area. There is need of more trained and qualified individuals and dedicated resources to manage the technically complex work of integration. Organizations are focusing more resources and manpower towards creating such a team which would help them in the longer run with the various integration efforts that the organization might undertake.Secondly, there are issues from the organizational front which brings on more challenges. Integration of data from multiple systems and sources can be expensive, especially for the provider organizations which might want data integration with multiple community physicians. Depending on funding arrangements, physician groups may face similar cost concerns if they are seeking to share data with multiple hospitals and other organizations in the service area. CITATION Placeholder1 \l 1033 (Advisors, Healthcare Data Integration Market Overview, 2008). We are seeing more and more vendor companies hosting the EMR for the provider organization. In the particular model the provider organization pays a set amount of fees every month/year basis to have access to the EMR. This has its own advantages as the provider organization doesn’t have to invest on the cost and maintenance of EMR installation and hence can focus on their core motto “to serve the patient”.Barriers to Interoperability:Firstly, interoperability benefits are highly dispersed across many stakeholders. Some could lose from disruption of longstanding industry practices, particularly vendors who rely on custom integration of their products for revenue and who use the lack of interoperability as a customer retention strategy. (Brailer,2006)Secondly, the negative network externalities and first-mover disadvantage that penalize early adopters make it difficult to synchronize the behavior of the market so that interoperability can gain a foothold. Just like the fax machine, the last to install an interoperable EMR benefits from everyone else’s prior investment, and the first to install bears most of the cost. (Brailer, 2006)Third, interoperability first movers have faced many barriers and challenges that have resulted in partial success, slow progress, and outright failure. Interoperability may be beneficial, but it is certainly not easy. (Brailer, 2006)3. Workflow Automation ChallengesTechnology is the means to an end to improving overall health care quality and effectiveness. There are many challenges to achieving healthcare workflow automation across a broad spectrum from lacking standards, technical constraints, and organizational barriers. This section will describe the following challenges impacting workflow automation:Standards, Best PracticesData QualityWorkflow ComplexityPrivacy ConcernsProductivity ConcernsRisk of Adverse OutcomesResistance to ChangeCostStandards & Best PracticesTo a large degree, standards for healthcare data exchange are still evolving. Where robust standards are defined, they are typically applied to administrative or financial functions such as registration, scheduling, billing and reimbursement. Clinical information systems do not communicate with each other seamlessly since standards are lacking or not broadly implemented.Standards need to be developed for specific specialties and / or diseases. Clinical systems are often designed to support a single application and do not easily interoperate at enterprise scale. Data base structures are difficult to modify and extend to meet specific needs of an organization or specialty. Disparate systems implemented within an enterprise are inconsistent in user interface design and often do not fully automate and integrate a broad clinical workflow. “Poor user interface and system design hinders clinical workflow and can result in wasted time, poor data collection, misleading data analysis, and potentially negative clinical outcomes. “ (Sanderson, Kadry B. and Macario A., April 2010)Most Healthcare organizations have implemented 3rd party vendor software products and integrated them internally. Organizations are dependent on vendors and have little recourse if a vendor fails to deliver on requirements. Decisions on technology acquisitions and implementations are often made by individuals or groups who lack clinical expertise. As such, the best interests of the clinical end users and overall usability of the systems are compromised.Aging legacy applications cannot keep pace with growing demand and the complexity of heterogeneous computing environments. Systems created and integrated via mergers and acquisitions have also been inconsistently integrated using custom or proprietary interfaces.Data QualityHealthcare workflows utilize data from disparate information systems to make decisions and manage treatment. One of the greatest impediments to building workflow-based healthcare information systems is lack of access to all relevant data or the quality of data itself. Without access to timely, accurate and relevant data, it is virtually impossible to fully manage the state of a patient’s care. Data quality can compromised for many reasons as described below. Access: Several data access problems may exist which limit the data necessary to automate workflows. An organization may not have technical infrastructure in place to inter-operate with external vendors or to exchange data with providers who practice outside the bounds of their organization. Data from legacy applications may not be accessible due to system constraints. Consistency: Consistency is the degree to which data is standardized in format, meaning and understanding. A variety of coding standards exist for consistent identification of discrete data attributes. What is lacking is consistency in the meaning and interpretation of data in a broader workflow context as well as broader definitions of healthcare terms and vocabularies. Also an issue is different systems and organizations use different terms to mean the same thing, which makes the interpretation of information ambiguous. Much healthcare data is unstructured or in narrative form and therefore cannot be interpreted systemically without complex algorithms to parse, tokenize and infer its meaning.Timeliness: In the clinical workflow, timeliness of data is essential. Data may not be timely where lags exist in data collection or exchange. Lags are common when data is manually entered not at the point of care, but later in the clinicians work day. System lags are common. Many interfaces among systems are still batch based. Lags in data collection or exchange limits the data available to support clinical workflow processes at the point in time when they are needed. Completeness: Data may be incomplete when systems are upgraded or replaced, and when data from older platforms is not converted to the new applications. Data which resides only paper form is excluded from the automated workflow, if not accessed manually through existing business processes. Automated data collection is also not bullet proof. There are no guarantees that designs for automated workflow have the checks and balances in place to define and enforce data completeness.Relevance: Relevance is the degree to which the right data is used in the right context in workflow automation. Given the volume and complexity of healthcare data, identification of the data relevant to the diagnosis and treatment at hand is inherently complex. The appropriate amount of data and its timeframe relevant to the course of treatment are also factors in the correct use of data in automating workflows.Accuracy: Data may be inaccurate due to mistakes in transcription, data entry, inconsistent automated data exchange formats or software defects. Obviously inaccurate data will have a serious adverse affect in automating workflows. As with data completeness, there are no guarantees that designs for automated workflow have the checks and balances in place to define and enforce data accuracy.Security: Security also limits the data available to support clinical workflows. Data access may be restricted due to patient privacy or organizational policies determining which users are authorized to access what data. Workflow ComplexityThe healthcare industry has been slow to adopt business process management (BPM) practices and workflow tools. BPM technologies are capable of automating workflows and handle the complexities which exist in healthcare environments from physical resource constraints, to utilizing technology for clinical decision making, and care management which considers variations in patient conditions and treatments. Only recently has there been an increased use of SOA-based healthcare information systems or electronic medical records which can collect the data necessary to leverage the possibilities of business process management. Even with growing data availability and BPM IT development tools, there is still the “perception that healthcare is a much more complex environment than other industries that employ BPM, and that BPM is simply not ready for that level of complexity.” (Emanuele, Jonathan and Koetter, Laura, Siemens Medical Solutions, 2007).Designing an automated system to account for variability in clinical decision making is inherently complex. Physicians make different decisions when treating patients with similar conditions. Historically, physicians have had discretion in determining the care their patients need. While adoption of evidence based medicine and standard treatment protocols will provide some consistency in decision making and treatment, “healthcare [is] unique; it is unrealistic to force a single standard when developing clinical treatment processes.” (Emanuele, Jonathan and Koetter, Laura, Siemens Medical Solution, 2007).Given the large number and variety of practices, the need for inexpensive, mass retail systems is at odds with the ability to customize IT systems to meet the needs of individual practices. Customized solutions are expensive either in the software cost itself, the cost of IT staff to implement custom features, or both. Adding fuel to the fire of complexity, opinions differ widely regarding systems implementation strategies: “whether HIT should be implemented in small practices all at once or piecemeal, whether clinicians should be allowed to participate on their own schedules or financial incentives should be used to encourage timely adoption, whether training should be on or off site, and whether dedicated technologists are necessary for success.” (LeTourneau, Barbara, September 2004). Complex workflows are poorly addressed by standardized HIT systems. Classifications of practices by clinical specialization or size may need to be expanded to include such factors as the patient population served, dynamic reimbursement models, whether the practice belongs to a managed care plan, and staffing. These sources of heterogeneity highlight workflow differences and have important implications for the widespread integration of HIT systems. Heterogeneity also renders it difficult to make standardized recommendations about optimal system design of HIT products and services.Privacy ConcernsOur privacy policies and their enforcement are complex and often ambiguous. Concerns regarding the risks of privacy breaches and how checks and balances can be ensured systemically also impede adoption of workflow automation and EMRs. Health IT programs and applications need to address key privacy principles such as right of access and need to know. “Implementing a standardized approach to protection of personal privacy that encourage public acceptance of health IT is needed to achieve the high degree of public confidence and trust needed to encourage widespread adoption of health IT and EMRs.” (Melvin, Valerie, January 2009).The complexity of our distributed healthcare delivery system further complicates privacy enforcement. “Confusion about the HIPAA laws themselves and how they need to be implemented is rampant throughout doctors' offices and healthcare facilities across the country…One other privacy concern for EMRs is the fact that most of the applications being used by health systems, doctor's offices, hospitals and other facilities, don't fall under HIPAA constraints themselves. A patient's records are kept in a format on computer servers that are owned by another company, and not by that hospital or doctor's office itself. That third party does not have the same restrictions as the healthcare professionals themselves have. Unless there is some other contractual reason for them not to share patient information, there is no law that says they can't do what they want to with it.” (Torrey, Trisha February 19, 2009).With access to distributed health data, or of health data from multiple sites, the potential of loss of information privacy is greater than in isolated EMR systems, or in systems with paper medical records without proper procedures and controls. In contrast, some industry experts believe that with proper enforcement and technical controls, EMRs may actually be more secure than traditional paper-based systems which are prone to security breaches due to human error and / or mishandling of paper records. Applicable security technologies exist and have proven effective in the banking and military sectors, but experience is lacking to ascertain whether these technologies will meet the needs of health care. The study referenced below notes that states that have enacted medical privacy laws restricting the ability of hospitals to disclose patient information have seen a reduction in EMR adoption by 11 percent over a three-year period or 24 percent overall. States with no such regulations, on the other hand, experienced a 21 percent gain in hospital EMR adoption. Source: privacy principles and challenges are fully and adequately addressed, there is reduced assurance that privacy protection measures will be consistently built into health IT programs and applications and will impede adoption.Productivity ConcernsMany physicians are concerned that process modifications needed to improve workflow and efficiency will actually decrease productivity. In a study comparing EMR adoption between physicians in a paper based practice vs. physicians whose practices are already utilizing a rudimentary EMR, the perception of productivity impacts were varied. “Leaders of paper-based systems were more apprehensive. For example, a respondent at a paper-based practice said he expected ‘2–3?weeks of disastrous inefficiency followed by 4–6?months of relative inefficiency.’ However, a leader from an EHR-based system reported ‘since the practice has already gone through an EHR implementation process...staff productivity will not go down drastically with the [new EHR system].’ A respondent at a paper-based practice was unable to respond to questions about the impact an EHR would have on workflow. Instead, the respondent began answering questions further questions: ‘What will happen when the system is down during office hours? How will the visit details be recorded? Will the physicians have to convert back to note-taking, instead of entering information directly into the EHR?’ This uncertainty was echoed several times by other leaders of paper-based systems. In contrast, a respondent from an EHR-based practice calmly stated, ‘Disruption is expected; however, all our [staff] are already used to working with computers.’ Source: the extreme differences between the paper based on EHR based physicians, it is likely the truth regarding negative impacts to EMRs lies somewhere in between. Many physicians are not computer savvy and may be lacking simple skills like typing necessary for effective EMR implementation. Physicians fear the EMR will interfere with them getting their work done and add administrative burden to their workflow, creating inefficiencies. These factors are also indicative of change resistance which is further discussed below. Risk of Adverse OutcomesAnother factor limiting the adoption of workflow automation and EMRs is the risk, real and perceived, of adverse outcomes due to system and user errors. This risk was realized with the implementation of a computerized physician order entry (CPOE) system at Cedars-Sinai hospital in 2003. Cedars-Sinai introduced the customized system in response to California state law requiring hospitals to adopt plans to reduce medical errors. Hundreds of doctors complained the CPOE was difficult to use and compromised patient safety. “Physicians voted "nearly unanimously" to suspend the CPOE system until system flaws could be corrected, including problems completing routine clinical tasks, such as ordering medication, tests and supplies... Physicians said the system caused errors and delays but none which resulted in patient deaths and injuries. Hospital officials, however, maintain that physicians' opposition to the system stemmed from difficulties using the system and time constraints, not patient safety.” (Archive , January 2003).A similar study by Institute of Medicine and safety initiatives promoted by the Leapfrog Group was performed evaluating a commercially sold CPOE system in an effort to reduce medical errors and mortality. The study sought to test the hypothesis that CPOE implementation would result in reduced mortality among children receiving specialized care. The reverse occurred. The mortality rate significantly increased from 2.80% before CPOE implementation to 6.57% after CPOE implementation. The study “observed an unexpected increase in mortality coincident with CPOE implementation. Although CPOE technology holds great promise as a tool to reduce human error during health care delivery, our unanticipated finding suggests that when implementing CPOE systems, institutions should continue to evaluate mortality effects, in addition to medication error rates, for children who are dependent on time-sensitive therapies”. Source: studies emphasize 2 points regarding the risk of adverse outcomes resulting from implementation of new technology. First, the importance of clinician training and education and an implementation strategy aimed at mitigating the risks cannot be underscored when implementing a large scale clinical system or EMR. Second, it cannot be assumed that the advent technology in and of itself will improve quality.Resistance to ChangeManaging resistance to change is always critical to the success of any innovation. Often resistance decreases once transition to a new system is complete. Physician resistance is a challenge in the implementation of workflow automation and EMRs. Clinicians may be reluctant to adopt new ways of doing things that interfere with their workflow, taking time away from patient care. “During the early stages of transition, a cooperative environment, which was conducive to minimizing initial resistance later, became an impediment: “At times [it] exacerbated implementation challenges or encouraged passive resistance.” Building a cooperative culture is important, especially when selecting an EHR product; however, during the implementation process, a directive leadership style may be necessary for success.” (Lee, Jason, Cain, Carol, Young, Scott, Chockley, Nancy and Burstin, 2005).Change in the form of business partnerships is also a factor in integration and data exchange. “Discussions regarding data integration may surface stickier relationship issues between providers and the physician community. The data integration opportunity may give rise to improved and stronger relationships – or the discussions and planning may further fracture tenuous relationships if one party senses an imbalance of power. In addition, competing IT initiatives may be the focus of attention at provider and/or physician group sites and result in one party feeling the other is not fully at the table.” (Impact Advisors, LLC, September 30, 2008).Physician resistance to change is further complicated in small group practices where physicians are not hospital employees and therefore lack the resources available to larger organizations. Even if medical staff leaders are employees of a hospital, they still walk a fine line between the needs of the organization and the needs and desires of physicians to retain their autonomy. Physicians are accustomed to being the expert. When they feel uninformed or uninvolved, they tend to perceive incompetence on their part, as a defensive mechanism. When threatened by change, “physicians may ask themselves whether they possess the skills necessary to make the transition. If their skills turn out to be inadequate, they may feel embarrassed and fearful that it could result in bad information about them.” (LeTourneau, Barbara, September 2004).Automating workflows and implementing EMRs cause disruptions and requires changes at all levels within our distributed healthcare delivery system. Re-engineering workflow processes and redesigning common practice patterns requires significant planning, training, education and communication. It is important for senior leadership to provide the support structure and guidance necessary for success, including defining appropriate engagement models with physicians necessary to managing their resistance to change in a constructive way. CostCost is also a barrier. “Despite the improvements in charge capture and better access to health information the realized savings and impact on patient throughput is not enough to cover the cost of the technology, maintenance, and support. HIT is necessary for improved quality of care but it increases the cost of doing business.” (Sanderson, Kadry B. and Macario A., April 2010). Many studies have found that costs are an important challenge to overcome. The high costs of implementing an EHR system are often prohibitive. Costs are often an adoption challenge to office practices and an implementation challenge to individual physicians whose salaries are dependent on productivity. Physicians in office or individual practices do not have the advantage of financial and IT infrastructure resources available to staff physicians employed by hospitals or other large healthcare delivery organizationsIntegration of data from multiple systems and sources can be expensive, especially for the provider organizations which might want data integration with multiple community physicians. Depending on funding arrangements, physician groups may face similar cost concerns if they are seeking to share data with multiple hospitals and other organizations in the service area. 4. Health Care Systems Standards & Interoperability LandscapeCurrent State of Standards Standards are important because they facilitate the ability of different applications built by different vendors to communicate and share data with each other. As discussed in the scenario walk-through covered in the earlier sections of this paper, the ability to share information between the primary care physician’s office and the hospital emergency department is central to improving health care delivery. There is no question that integration and interoperability is highly dependent on the development and use of standards across all participants in health care delivery. Nevertheless, the current information technology landscape in US health care is best described as fragmented and lacking in uniformity in terms of its use of standards. Several technical standards such as HL7 do exist but the key issue is that the utilization of these standards is for the most part voluntary and not mandated. For the exception of HIPAA, which is the only government mandated standard that exists today, there are no other standards being mandated. Many healthcare systems vendors will proclaim they support HL7 but the reality may be completely different. Per Kovner and Knickman, many systems “currently used by physicians and hospitals don’t use HL7, either because they were developed before the standard was written or the vendor chose not to use it.” (pg 376) To help describe the various standards in existence in healthcare today, below is a table that outlines some of the key ones currently in use and/or being promoted. The table includes the name of the standard and type, what the standard is used for, and the organization(s) involved in developing and distributing them. Table 5.1: Key Health Care System Standards StandardsDescription & PurposeStandard TypeOrganizationICD-9 International Classification of Diseases 9th revision. Used for coding, these are alphanumeric designations given to every diagnosis, description of symptoms and cause of death. These codes are used for both reimbursement purposes as well as for clinical research and studies. ICD-9 is leveraged in Diagnosis Related Groups (DRGs) used by Medicare reimbursements for example.Coding & ClassificationWorld Health Org (WHO) --> Centers for Medicare & Medicaid Services (CMS) --> US National Center for Health Statistics (NCHS)CPTCurrent Procedural Terminology. Developed, published and copyrighted by AMA, these codes are used for describing medical and surgical procedures/services provided by physicians and other practitioners. These codes in turn are used by insurers to determine the level of reimbursement for a given procedure.Coding & ClassificationAmerican Medical Association (AMA)SNOMED CTSystemized Nomenclature of Medicine - Clinical Terms. A comprehensive clinical terminology developed specifically to facilitate the electronic exchange and retrieval of detailed clinical information. It is also used to organize the content of medical records.Vocabulary & Data StructureInt'l Health Terminology Standards Development Org (IHTSDO) --> National Library of Medicine (NLM)LOINCLogical Observation Identifiers Names & Codes. Developed to facilitate the electronic transmission of laboratory results to hospitals, physicians, third-party payers and other users of laboratory data. It also provides a standard set of universal names and codes for identifying individual lab and clinical results. Vocabulary & Data StructureRegenstrief Insitute at Indiana UniversityHL7Health Level 7. A messaging standard used to support the exchange, management, and integration of data that support clinical patient care. Sample messages include patient information (i.e. ADT) and billing information. HL7 interfaces are widely used for sharing data across a multiple systems within an organization. Data InterchangeHealth Level Seven InternationalDICOMDigital Imaging and Communications in Medicine. Developed for the electronic transfer of digital diagnostic imaging (i.e. CAT scans and MRIs) between devices manufactured by different vendors. It is a standard for handling, storing, printing, and transmitting these types of information.Data InterchangeNational Electrical Manufacturers AssociationNCPDP StandardsNational Council on Prescription Drug Programs. The standards developed by the NCPDP are used for the transfer of data between the various providers within the pharmacy services sector. The standards include the electronic submission of 3rd party drug claims, billing unit, SCRIPT for e-prescribing, etcData InterchangeNational Council on Prescription Drug ProgramsX12NANSI Accredited Standards Committee develops standards for electronic exchange of business information such as insurance eligibility, referrals and authorizations, claims, claim status, payment, and remittance advice, and provider directories.Data InterchangeAccredited Standards Committee X12GS1 StandardsGS1 standards are used for accurate identification and communication of information regarding products, assets, services and locations within the healthcare supply chain industry. GSI standards GLN, GTIN, and GDSN. Data Structure and InterchangeGS1HL7 EHR Functional ModelProvides a list of the various functions that may exist in an EHR system. It allows for a standardized description of functions by health care setting such as the emergency room, physicians office, etc. Health Record Content StandardsHealth Level Seven InternationalCCR Continuity of Care Record. Provides a standard health care data summary that’s aggregated from multiple data sources. Its main purpose is to provide an overall picture of a patient’s past and current health status. Health Record Content StandardsASTM Int’l, MA Medical Society, HIMMS, AAFP, and othersSource: Kovner & Knickman; Wager, Lee, & GlaserStandards Development OrganizationsThere are approximately 40 organizations that develop standards for the healthcare industry. In addition, there are about 50 other organizations that have “strong ties, interest in, and power to influence [these] SDOs”. (Hammond, Jaffe, and Kush, July 2009). Figure 5.1 below is a representation of what the US healthcare standards landscape looks like and includes only the more well-known SDOs and related organizations. Figure 5.1: US Healthcare Standards Landscape Source: Hammond, Jaffe, and Kush, July 2009The American National Standards Institute (ANSI) is one of the more prominent organizations responsible for formal standards development in the US. ANSI is the US based member of the International Standards Organization (ISO) who oversees standards from a global perspective. Within ANSI, two key organizations (also known as SDOs or Standards Development Organizations) responsible for the actual development of standards are HL7 and ASC X12. As shown in the table XX, HL7 and ASC X12 are the primary standards currently used in the US for health data and insurance claims data exchanges. A relatively new organization that’s also been active in healthcare standards in the US is the Integrating Healthcare Enterprise (IHE) organization. The IHE’s approach is focused at the grass roots level involving various healthcare organizations, private companies, and healthcare professionals. Each year, member groups meet at the annual Connect-athon where they are given the opportunity to test their application solutions and verify interoperability capabilities. The Connect-athon “offers vendors a unique opportunity for connectivity testing—removing barriers to integration that would otherwise have to be dealt with on site, at the customer's expense. Companies taking part have responded overwhelmingly that the IHE process addresses important issues in their product development plans.” () This industry-led working and hands-on approach has been valuable and allowing vendors and organizations to prove out their individual system implementation of the identified standards and its specific capabilities in interoperability and integration. The following is a summary of the breadth, scope and approach IHE is taking to define Health Care data exchange standards and best practices.IHE domains are responsible for the development and maintenance of IHE Technical Frameworks which define integration profiles for various healthcare domains. Integration Profiles define the roles, actors, standards and vocabulary necessary to support integration within a particular domain. The frameworks focus on the specific criteria and / or nuances of the domain. New Domains are added as more fields of healthcare adopt the IHE process. IHE Patient Care Coordination (PCC) domain was established in July 2005 to deal with integration issues that cross providers, patient problems or time. PCC addresses workflows that are common across multiple specialties or those which do not have a specific IHE domain. Below are the domains which have been finalized, are undergoing implementation trials, or have been retired (meaning no longer being maintained by IHE)CardiologyEye careIT infrastructureLaboratoryAnatomic PathologyPatient care CoordinationPatient Care DevicePharmacyQuality, Research and Public Health Radiation OncologyRadiologyIHE has broadly defined procedures and best practices necessary for technical framework development of the domains noted above. The procedures span both technical aspects of development as well as methodology considerations for organizations who wish to implement IHE profiles and include the following:Profile Proposal Process IHE Profile Design Principles and Conventions Writing Technical Frameworks and Supplements Guidelines for Profiles Incorporating HL7 Messaging Cookbook for Security Considerations Public Comment Process Cross-Domain Profile Review Cross-Domain Dependency Process Technical Framework Publication Process Standards GovernanceAs previously mentioned dissemination and utilization of standards in health care are inhibited by the fact that it is all voluntary and that there is no centralized governance or strict enforcement of the identified standards. The federal government’s HIPAA transaction standards and compliance requirements, mandated by the US Department of Health and Human Services (HHS), is the only one that is actually adhered to by the healthcare industry in general. HIPAA adopted certain standard transactions for Electronic Data Interchange (EDI) of health care data and they include the following: claims and encounter information, payment and remittance advice, claims status, eligibility, enrollment and disenrollment, referrals and authorizations, and premium payment. ?Also under HIPAA, any “covered entity” is required to use the adopted standard. These adopted standards are developed and set forth by the following HIPAA designated standard maintenance organizations (DSMOs): ANSI Accredited Standards Committee X12 (ASC X12)Health Level Seven (HL7)Dental Content Committee of the American Dental Association (ADA DCC)National Council of Prescription Drug Programs (NCPDP)National Uniform Billing Committee (NUBC)National Uniform Claim Committee (NUCC)?Source: Wager, Lee, & Glaser (pg. 245) Most of the HIPAA transaction standards come from the ASC X12N standard set. Aside from the HHS, there are several other federal organizations that have recently been established to support the effort of setting US health care IT standards. The key ones include CCHIT, ONCHIT, HITSP, and NHIN and are described below. Office of the National coordinator for Health Information Technology (ONCHIT) – Under the Department of US Health and Services (HHS), the ONC was established in 2004 by then President Bush to provide leadership in the development and implementation of interoperable health care systems. The ONC is the “principal Federal entity charged with coordination of nationwide efforts to implement and use the most advanced health information technology and the electronic exchange of health information.” () ONC’s mission also includes Health IT policy coordination, strategic planning for HIT adoption and health information exchange, and establishing governance for the Nationwide Health Information Network (discussed further below). Certification Commission on Health Information Technology (CCHIT) – CCHIT is a “nonprofit organization with the public mission of accelerating the adoption of robust, interoperable health information technology.” (). ?The Commission was established in 2004 and has been certifying electronic health records (EHRs) since 2006 utilizing the first ever comprehensive requirements for what features and functionality should be included in these systems. The federal government (ONCHIT) has officially recognized the Commission as a qualified certifying body and with the advent of ARRA it has come to the forefront as a leading body in setting EHR standards. “This commission wields immense power over the future of health information systems by deciding what features of EMR are vital and the standards for interoperability between health IT systems.? They will have a leading voice in what the CMS (Centers for Medicare & Medicaid Services) will deem to represent “meaningful use” and thus qualify physicians and hospitals for a piece of the large pot of stimulus money that is being dangled in front of providers to stimulate EHR adoption.” (Wodajo, 2010). Initially, the definition of “meaningful use” had a false start in that it was too vague to be actionable. CCHIT led the industry in defining the final rule which divides the meaningful use criteria into a core set and a menu set:The core set of criteria is mandatory and includes (but is not limited to) using a CPOE system, recording vital signs and demographic data, providing patients with electronic copies of health information and discharge instructions, and testing EHR systems for clinical data exchange. With the menu set, hospitals and eligible providers choose from five of 10 criteria. These include, but again are not limited to, performing medication reconciliation, submitting data to immunization registries, generating lists of patients based on specific conditions, and providing summary care records. Source: Information Technology Standards Panel (HITSP) – HITSP was established in 2005 by the ONC to “serve as a cooperative partnership between the public and private sectors for the purpose of achieving a widely accepted and useful set of standards”. HITSP’s membership and participation is open to anyone. Below is a table that identifies the make-up of the groups involved. Since its inception, HITSP has developed interoperability specifications that include existing standards such as HL7, NCPDP, and ASC X12N. Table 5.2: HITSP Membership ProfileMembership on the Panel is open to groups within any of four major categories. The current allocation of membership (data as of September 2009) is: ?Standards Developing Organizations (SDOs)4%??Non-SDOs85%??Government Bodies6%??Consumer Groups3%??Project Team Members (non-voting)2%??Total100%?There is no fee to participate in the HITSP or its committees. Registration is required. Source: Nationwide Health Information Network (NHIN) – Similar to HITSP, NHIN was established by the ONC as a key component to its strategic plan. NHIN is being built to “provide a secure, nationwide, interoperable health information infrastructure that will connect providers, consumers, and others involved in supporting health and healthcare. This critical part of the national health IT agenda will enable health information to follow the consumer, be available for clinical decision making, and support appropriate use of healthcare information beyond direct patient care so as to improve health.” () NHIN is being pushed by the ONC as the foundation that will connect the various health information exchanges (HIEs) that are being built across the country. Key Issues Related to Standards & InteroperabilityLack of coordination of efforts and competing standardsAs shown in Figure 5.1, the US healthcare standards landscape involves many parties each having its own focus area. These areas sometimes overlap with each other and sometimes they compete. Per Wager, Lee, and Glaser, “The relationships among the various standard-setting organizations can be confusing. Not only do many of the acronyms sound similar, but the organizations themselves, as voluntary, member-based organizations, can set their own missions and goals. Therefore, although there is a formally recognized relationship among ISO, ANSI, and the SDOs, there is also some overlap in activities.” (pg. 235) There are certainly benefits that can be gained by having these standards organizations working and collaborating with each other. Hammond, Jaffe, and Kush point to several of these successful collaborations in their 2009 article "Healthcare Standards Development: The Value of Nurturing Collaboration". On the same token, they also point out the continuing barriers to collaboration and the ongoing struggles resulting from the lack of a more global and formal standards setting. Lack of a single governing bodyAs mentioned throughout sections of this paper, the lack of a single standards governing body that has the ability to direct and mandate certain standards to be used globally, has resulted in a quite fragmented healthcare IT standards landscape. This environment in turn inhibits the integration and true interoperability of the systems being used by physicians, by hospitals and by the payers. From a technical standards perspective, organizations such as HITSP and the IHE are trying to fill the various roles left open by a missing “mandating” body and so far have been successful with their efforts. However, they can only go so far. From a terminology standards perspective, the story is the same. In a 2006 report jointly published by the American Informatics Medical Association (AMIA) and American Health Information Management Association (AHIMA), the formation of a “Centralized Terminology Authority” was strongly proposed. The report pointed out that without a single governing body that has the ability and power to mandate medical terminology and classification standards, the overall goal of full system integration and interoperability will be hampered. “Tighter integration between terminology and classification is needed to drive processes. There also needs to be ongoing investment by the federal government in mapping and maintenance.” (pg 3) Whether it be a single governing body filled by the federal government, by industry representatives, or perhaps both, the existence of a single governing body with the power to mandate global standards is needed. Key Emerging Technologies for Healthcare Standards & Interoperability In this section, two key emerging technologies in health care standards are discussed. Because of the lag in adoption specifically within the healthcare industry, the term “emerging” may be used lightly. Nevertheless, the following technology components are discussed for their potential contribution and impact to the health care standardization and interoperability: 1) XML Standard and 2) Services Oriented Architecture (SOA). Both of these components have their origins and foundation from the revolutionary internet technology whose use has grown exponentially within the past decade. XML Standard XML is an acronym for extensible markup language. Without getting too technical, XML is a “flexible text format for creating structured computer documents.” (en.wiki/xml) Another simple definition provided by the HHS is the following: eXtensible Markup Language (XML) is a flexible way to create common information formats and share both the format and the data on the World Wide Web, intranets, and elsewhere. XML describes the content in terms of what data is being described.” () So why is XML important? XML is important because it provides a “messaging standard” in health care applications. A big problem in health care systems right now is that there is no explicit structure used in health-care-related data or information (i.e. reports, publications, etc). A lot of the clinical information is captured in narrative format that lacks structure. XML can solve this problem in two ways: 1) by providing a standard means of describing the structure of the information within the clinical documentation and 2) by identifying meaningful elements contained within. “XML can provide a sort of “composition technology” for such a flexible bottom-up approach.” (Schweiger, Ralf PhD, Hoelzer, Simon MD, Altmann, et al, 2002)Services Oriented Architecture (SOA)By definition, SOA is a system functionality design principle that has “services” at its core. A service can be an entire process, a function supporting a process, or a step of a business process. (Juneja, Dournaee, Natoli, et al, 2008). The significance of SOA in health care is that it provides a true interoperable solution for an environment where there are many disparate systems that utilize the same set of information. Traditionally, health care organizations that have numerous systems (sometimes counting in the hundreds) rely heavily on interfaces to share data across these systems. Interoperability is defined via these interfaces. With SOA, the delivery of these data sets to multiple system databases is changed from multiple interfaces delivering the data to possibly only one single service. SOA allows for the reuse of services and standardization of shared data. Another potential benefit of SOA in the healthcare industry is its ability to connect health information networks or exchanges. Per Juneja, Dournaee, Natoli et al, “Although there are industry standards for data representation in healthcare, such as HL7, a fundamental problem with those standards is their varied interpretation in software. Therefore, the very first objective for a HIN should be to standardize the software interpretation and therefore implementation of representation and translation of healthcare data on the network. The most cost-effective way to do this is through a standardized set of core business services that represent healthcare data.” SOA is the solution that can provide these “services”. Figure 5.2 below represents how a single service can be utilized by the participants in an HIE/HIN. As Juneja, Dournaee, Natoli et al describe, “Instead of each participant in the HIN and the HIN data center having to create and sustain an system interface for each participant in the network, all a participant needs to do is transform their systems representation to the one specified by the service, which defines the canonical form for the specific data being exchanged (such as patient, provider, order, referral, and so on).” SOA not only reduces the number of system interface points but also the total cost of integration. Figure 5.2: SOA Integration ArchitectureSource: Juneja, Dournaee, Natoli, et al, 2008 5. ConclusionWith health reform the big push in healthcare is for the implementation of EMR systems and health information exchanges. We have highlighted in this paper the various barriers and stumbling blocks to the successful implementation of such. These include technical barriers, data quality issues, organizational structures and cultures, longstanding industry practices, and historically, as compared to other industries, the overall lack of focus on greater system integration and interoperability.These problems indeed are vast. However, they are not insurmountable. A key focus on the standards and best practices in HIT and taking steps towards a more regimented approach to the implementation and use of these standards is important. On the same token, cooperation and coordination amongst the key stakeholders in the healthcare industry will strengthen the efforts towards greater interoperability and allow for more meaningful exchanges of data. 6. References:Archive (Jan 22, 2003), , “Cedars-Sinai suspends CPOE use”. Retrieved from , Randolph C. Jr. MD, Clayton, Paul D. PhD, Journal of the American Medical Informatics Association, Volume 3, Number 2, Mar / Apr 1996, “Privacy, Confidentiality, and Electronic Medical Records”. Retrieved from , David J (January, 2006), , “Interoperability: The Key to the Future Health”. Retrieved from , Keith; Bakken, Suzanne; Bowman, Sue; Detmer, Don, et al. “Healthcare Terminologies and Classifications: An Action Agenda for the United States”. American Medical Informatics Association and American Health Information Management Association Terminology and Classification Policy Task Force Report (November 2006). Retrieved from Commission for Healthcare Information Technology website. Retrieved from , Simon (August 28,2007), , " Part One - A brief History of Healthcare Integration". Retrieved from , Lynne A., and Holland, Marc InterSystems (August 2008), “The Critical Need for Connected Healthcare: Meeting Today’s Integration Challenge”. Retrieved from , Jonathan and Koetter, Laura, Siemens Medical Solutions (2007), “Workflow Opportunities and Challenges in Healthcare”. Retrieved from , William Edward; Jaffe, Charles; Kush Rebecca Daniels. "Healthcare Standards Development: The Value of Nurturing Collaboration" Journal of AHIMA 80, no.7 (July 2009): 44-50. Retrieved from: YY, Carcillo JA, Venkataraman ST, Clark RS, Watson RS, Nguyen TC, Bayir H, Orr RA, University of Pittsburgh School of Medicine (Feb 206), , PMID: 16322178 , “Unexpected increased mortality after implementation of a commercially sold computerized physician order entry system”. Retrieved from , Timothy (June 23, 2010), , “Dissecting Physician Resistance to CPOE”. Retrieved from Advisors. (September 30, 2008), impact-, "Healthcare Data Integration Market Overview". Retrieved from , Girish, Dournaee, Blake, Natoli, Joe, and Birkel, Steve (March 7, 2008). InfoQ. “Improving Performance of Healthcare Systems with Service Oriented Architecture”. Retrieved from Lee, Jason, Cain, Carol, Young, Scott, Chockley, Nancy and Burstin, Helen, Health Affairs (2005), “The Adoption Gap: Health Information Technology In Small Physician Practices”. Retrieved from , Barbara (September 2004), Journal of Healthcare Management, “Managing Physician Resistance to Change”. Retrieved from , Diana (September 2009), Healthcare IT News, “CCHIT maps out path to certification with meaningful use focus”. Retrieved from , Valerie, Director Human Capital and Management Information Systems, U.S. Government Accountability Office (January 2009), “Health Information Technology: Federal Agencies’ Experiences Demonstrate Challenges to Successful Implementation”. Retrieved from , Molly (July 14, 2009), Healthcare IT News, “Study: Privacy laws deter hospitals from EMR adoption”. Retrieved from , Kadry B. and Macario A., University of South Carolina (April 2010), , PMID: 20084001, “Challenges that limit meaningful use of health information technology”. Retrieved from , Ralf PhD, Hoelzer, Simon MD, Altmann, Udo MD, Rieger, Joerg and Dudeck, Joachim MD (2002 Jan-Feb, pg 37-48), “Plug-and-play XML: a health care perspective”, Journal of American Medical Informatics. Retrieved from Torrey, Trisha (February 19, 2009), : Patient Empowerment, “Limitations of Electronic Patient Record Keeping: Privacy and Security Issues. Retrieved from , Felasfa MD (March 2, 2010), iMedicalApps, “What is CCHIT and how this group will affect physicians by defining meaningful use of Electronic Medical Records”. Retrieved from Zandieh, Stephanie O. MD, MS, Yoon-Flannery, Kahyun MPH, Kuperman, Gilad J. MD, PhD, Langsam, Daniel J. BA, Hyman, Daniel MD, MMM and Kaushal, Rainu MD, MPH (March 2008), , PMCID: PMC2517887, “Challenges to HER Implementation in Electronic – Versus Paper-based Office Practices”. Retrieved from ................
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