This presentation discussing interoperability was given at the European Society of Cardiology in 2009.This remains an important topic for healthcare worldwide. Addendum: All names shown are fictitious and not real patients.

1. Data Exchange
Between Electronic Medical Systems
David L. Scher, MD, FACC, FHRS
Clinical Associate Professor of Medicine
Pennsylvania State University College of
Medicine
2009

2. Data Exchange
Between Electronic Medical Systems
• Overview
• Fundamental Issues
– Who owns the data?
– Cost and other obstacles.
• Examples

3. Health Information Exchange
Point-to-point transactions using
varied and incompatible medium

4. Health Information Exchange – The Regional Model?
Standards-based communication;
regionally and beyond

5. Health Information Exchange – The National Model?

6. Overview: Why Data Exchange?
• Fast organized delivery of results: streamlines
business (insurance) and clinical care processes.
– No EMR needed (integration)
– Interacting with existing EMR (interoperability)
• Access new and important historical records
anywhere at anytime as soon as available.
– Compare labs, reports, progress notes and ECGs

7. Overview: Why Data Exchange?
• Streamline the interaction of referring and consulting
practices.
– Attending physicians and consulting physicians can
see records at the same time.
– Eliminate paper records or Fax transfers for consults
and referrals.
– Eliminate the need for duplicate testing.
– Coordinate care, medications, allergies.
– Improve patient outcome and eliminate system waste.

8. Who Owns the Data?: Issues
• Differs in USA among individual states.
• Traditionally in most states: information is physical
property of physicians and hospitals, allowing insurers
and patients access.
• Recently, this has changed: 2009 Federal law: any
specific encounter information may not be released
except to insurance personnel unless granted permission
by the patient , if provider has been fully compensated
for the service provided.

9. Who Owns the Data?: Issues
• Commercial entities use data for business purposes.
• Ownership of data from clinical trials.
• Should data be private or public?

10. Cost and Other Obstacles
• Until present, cost in the USA was borne solely by
the physician and hospital.
– Incentives: organization of data, potential patient
safety
– Disincentive: cost, no interoperability.
• 2009: $19 billion US federal government subsidies
for EMRs. Must use Health Information Exchanges!
• Hidden costs: fees for licensing, interoperability
interfacing , system maintenance.

11. Cost and Other Obstacles
• Missing Links – Standardizing nomenclature among
proprietary systems: e.g. common definition for Allergies;
subjective measures, such as patient/presenting problem even
more difficult to codify
• Standards were and continue to be developed that facilitate
accelerated deployment of HIEs
– HL7
– CCHIT Certifications
– ELINCS (simplifies and normalizes laboratory results)
– NDC (National Drug Codes)

12. Electronic Record
System Adoption and Growth: USA and EU
Key Points:
2015
Sweden
Sweden 99%2
93%2,3
• US - HITECH ACT
• CBO forecasts
penetration rate to
increase to 90% by
20194
• EU – Avg. 40-50%
aaaaaadoption rate2,3
• Avg. CAGR of
~3.1% per year2
UK
Germany
France
Italy
Spain
Sweden
UK
2015
2,3
UK 58% 2
71%
2019
US
17%1,34
US 90%
2015
France
France 7%2
6%2,3
2015
Spain
Spain 31%2
25%2,3
CAGR (2009-2015)
3.5%
3.1%
3.2%
4.0%
3.9%
1.1%
Germany
2015
Germany 2,3 2
39% 45%
Italy
2015
23%2,3
Italy 29%2

13. Variability of Logistics of Implanting and Follow-up
Centers in Europe
300
Implants/
Center
Netherlands
217
Canada
192
Denmark
159
Germany
80
France
78
Belgium
73
Switzerland
62
Sweden
59
Australia
42
Portugal
37
Austria
36
Italy
35
Spain
34
Penetration: Implants/Million
Country
GER
250
200
ITA 80 km2
NED
AUS 8500 km2
AUT
150
2
BEL 178 km
100
50
DEN
SUI
CAN 36500 km2
FRA
ESP
SWE
POR
0
Density: Km2 Covered By Each Center
• EUCOMED ‘07
• Internal Analysis ‘07

14. Wireless Substitution: Implications for Remote
Follow-up of ICDs and pacemakers
USA
% population w/o POTS
% >55 yrs w/o POTS
2009
21.50
6.54
2010
24.80
7.72
2011
28.10
8.90
2012
31.40
10.08
2013
34.70
11.26
2014
38.00
12.44
International
% population w/o POTS
% >55 yrs w/o POTS
2009
39
12
2010
44
14
2011
48
15
2012
53
17
2013
58
19
2014
63
21
POTS = Plain Old Telephone System
Analysis based on Wireless Substitution: Early Release of Estimates From the National Health Interview Survey, January 2005June 2008 by Stephen J. Blumberg, Ph.D., and Julian V. Luke Division of Health Interview Statistics, National Center for Health
Statistics

15. Future of EMR Adoption
Obstacles
- EMR systems
- Large investments
- Recurring annual maintenance
costs of 12-18%
-
-
Opportunities
- National programs set up to
encourage adoption (i.e. HITECH ACT)
-
EMR vendors do not have desirable
head count
- increasing implementation time
and cost of systems
National Registries
- Database housing implanted
device information i.e.
complications
-
Fragmented Market –difficult and
costly for 3rd party data companies to
create turn key solution
National Databases
- Multiple EMR vendors that have
concrete standards that will feed
into the database
-
Integration will become an asset to
workflow management
- Need for data integrity will
increase

16. Examples of Interoperability

17. Interoperability of EMR with Remote
Monitoring of ICDs
•16 physician single specialty cardiology private
practice group with 3 EP physicians, 2 EP nurses,
and 3 EP technicians.
•Following over 1100 ICDs and 3000 pacemakers in
an outpatient setting.
•GEMMS dedicated cardiology web-based EMR
system with servers in our office.
•Medtronic Carelink® and Boston Scientific
Latitude® RMS.

18. Development Issues
•Uniformity of display features of different companies’ device
parameters and data collection. Need for clinical input for
definition, organization, and display of data.
•Interface software development by both the EMR company
and device companies.
•Cost.

28. Interoperability With Outside
Systems
• Holter monitoring system.
• Hospital electronic medical record system.

32. PHS-Connect powered by PinnacleHealth
Practice with
EMR
Laboratory
Results
Practice w/ EMR-lite
Results,
Documents,
Registrations
Radiology
Reports
Cardiology
EKG & Reports
Health Information Exchange
Therapies
Transcribed
Reports
Long-Term Care
Facilities
Reports
Independently Administered
Longitudinal Medical Records
Labor &
Delivery
Patients from External
Locations (Web Patient
Portal)
Outpatient
Surgery
Dialysis Unit
Insurance Payers
Emergency
Department
Registration
Current Medication
List Service
32

35. SUMMARY
• 1. Adoption of an electronic health record
system necessitates interoperability.
• 2. Non-technical challenges: cost
• 3. Technical challenges: Diversity of EMR
systems and interfaces, Internet vs. land phone
lines vs. cellular-based technologies.
• 4. This will happen. How and when depends
upon cooperation among private companies
and governments (local and national).