December 2015
Gauging The Future

I come from a family of railroaders. My father was a locomotive engineer, and both my grandfathers worked for the railroad. My great uncle helped rebuild the Panama Canal Railway in the early 1900s. I attended college on a National Merit Scholarship funded by Southern Railway. Railroading is part of my DNA.

I grew up in Tuscumbia, Alabama, site of the first railway in the United States west of the Allegheny Mountains. The track gauge (the distance between the parallel rails) for this company was five feet, which would become common for early railroads in the South. Other railroads used different track widths; the New York and Erie Railroad was built about the same time with a six foot gauge. The Baltimore and Ohio Railroad used a four foot eight and a half inch gauge, common for railroads in England, thinking that British equipment could be used easily. The differences in track gauge made the use of equipment on different railroads impossible. Early railroads, which were only constructed to connect different bodies of water, where the real transportation occurred, didn't care about standardization. They didn't want other companies to use their equipment. Proprietary standards didn't really matter, as they custom-built their equipment to service their own railroad. It was only after a standard gauge was established in the United States that the power of the railroads could be harnessed, saving tremendous amounts of money because goods could be shipped across the country without having to unload and reload products from line to line. What does this have to do with medicine?

This has to do with medicine, though, because we are seeing the same disconnect with Electronic Health Records. Hospital systems use proprietary EHRs to handle their own information. Many don't seem to want other companies to use their information anyway. Some say that data is being held hostage. That's where this discussion is connected. We've come to a point where the need for a standard gauge, or EHR standard, is imperative.

Information has become a commodity itself. It has form and worth. If it didn't have worth, hospitals and other health entities wouldn't protect it so well. Hospitals treat information as their own property, which it is in most instances. As an emergency physician, every contract I've signed with hospitals states that they are the custodians of the medical record, not me, which is as it should be. I'd propose going one step further, though, and suggest that hospitals shouldn't own the record, either. It belongs to the patient.

My hospital system uses Epic, an EHR that has become one of the dominant players in the field. One benefit of Epic is a feature called MyChart, where patients have access to their own health information in electronic form. It is a great feature, because patients have online access to the electronic record themselves. If they visit another provider, they can access their information from the Internet. There's even an app for it.

Other hospital systems using Epic have the ability to share information through a feature called Care Everywhere. Some health systems in Northern Kentucky are on the Epic platform, and I can see their health records within my own EHR in Louisville. Another large health system in Louisville is adopting the Epic platform, and in a moment of perfect ethical clarity, leadership of both organizations agreed to share information. It is the right thing to do, and I applaud the leaders of these organizations for doing what is right for our patients. 

Epic is not alone in its endeavor to share information. Meditech, Cerner, McKesson, Seimens, Allscripts, CPSI, and Athena all have stated their desire to achieve true interoperability. But in many ways, we're talking about railroads again. Many EHRs think their system is the best. It's time to move beyond mere interoperability.

Health Information Exchanges (HIEs) offered great promise several years ago. They would function as a regional data hub where information could be shared among all providers. While some regional efforts were successful, they never took off.

The benefit of the EHR is in its ability to share data, not just capture it. Epic has taken the next step with another of its initiatives called Lucy (Where does Epic come up with these names?), which is a leap to the next iteration of EHRs, called a Personal Health Record, or PHR. These PHRs are data repositories of health information for an individual patient owned by individuals. Rather than depending on a collection of MyCharts at individual health systems, or a local HIE, the patient owns the data.

This is the ultimate solution to interoperability. Instead of EHR vendors vying for their own system, it's time to establish a uniform "track gauge" for health information, one that will allow ALL EHRs to have semantic interoperability, so that shared information will not only have syntax or a common language, but also meaning or semantics. Only then can EHRs reach their true potential and serve patients.The Meaningful Use language (required by the feds for EHRs) sets lofty goals. They won't be met until our patients control their own health information. Physicians must be their advocates in this fight, too.

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