Interoperability: Why You Should

Introduction
The transition to electronic medical records (EMR) software in physician office practices presents the attendant opportunity to implement interoperable or connected diagnostic devices. Adopting diagnostic devices capable of being interoperable with your EMR yields benefits in the areas of workflow efficiencies, medical record error reduction, and enhanced data access. Major connected product categories include automatic vital signs collection devices and a full suite of diagnostic cardiopulmonary equipment. In the cardiopulmonary category, it is essential that the solution be one that is truly interoperable, or bi-directional in nature, for the full benefits to be realized. The latter can only be accomplished with a custom-programmed interface between the diagnostic devices and each one of the many EMR programs available in the market today. Finally, a demonstrable return or payback on the incremental investment of converting to connected devices has been shown to be compelling.

Why Connect Devices?
Figure 1 depicts the three major areas that motivate device connectivity. In a truly interoperable EMR-diagnostic device solution, appreciable improvements in practice efficiency can be realized. Such improvements include the elimination of manual and paper recording of diagnostic test results, a streamlining of the workflow required to order, administer, review, store & retrieve the diagnostic test and its results, and the elimination of duplicate data entry. The latter applies especially to the redundant entry of patient demographic information into diagnostic devices. When such information, which is already contained in the patient’s EMR, is automatically transferred to the diagnostic device, the time needed to redundantly enter this information into the diagnostic device is saved.

A further benefit of eliminating such redundant steps is a commensurate reduction in the potential for errors in data entry and in the association of the results with the incorrect patient’s record. Other opportunities for error are also reduced, including transcription errors which have been shown to occur in more than 10% of cases, patient ID errors in the test results, and lost results due to misplaced, misfiled, or unintentionally discarded paper records.

Another important reason to adopt diagnostic devices which are interoperable with your EMR is the greatly improved access to the information gained in doing the testing. A connected solution enables immediate, practice-wide access to results information from any computer on the network. Further, in the case of a web-based solution access can be had from any computer with an internet connection. This enhanced access has as its benefits more efficient communication to the physician of a completed test, faster and more convenient review, interpretation, and confirmation of the results by the physician, and streamlined progress notes and billing documentation for reimbursement.

What Can be Connected to the EMR?
In addition to diagnostic devices, opportunities exist for an interoperable solution in the areas of patient check-in and self-input of history, electronic prescribing, laboratory testing, and connectivity to hospital and affiliated practices. The focus of this article is on EMR-connected medical diagnostic devices and their associated benefits.

Major diagnostic device categories capable of EMR-connectivity include:

Automatic Vital Signs (Spot check and continuous monitors)

Electrocardiographs (ECG)

Exercise Stress ECG

Holter ECG Monitor

Spirometer

Ambulatory Blood Pressure Monitor

Automatic or electronic vital signs collection devices are perhaps the most prevalent interoperable diagnostic test in use today. Given their relatively simple yet essential data set, the workflow is highly streamlined and integrated into the EMR program itself. In the optimum solution, vital signs results including blood pressure (BP), temperature, heart rate, and pulse oximetry are collected and automatically stored in the patient’s EMR in less than 1 minute. The newest generation of these devices performs the testing even faster, taking BP during inflation of the cuff as opposed to during deflation, and allowing for a hook-up to an electronic scale for simultaneous collection and storage of weight and body mass index, and producing results including the other parameters mentioned above in only 30-45 seconds total.

The PC-based resting ECG is another diagnostic device quickly gaining in popularity and interoperable use. In an interoperable EMR-connected solution, the PC-based version of the ECG is far preferred over the traditional or standalone “box” ECG for many reasons. Chief among them is the streamlined workflow or reduction of work steps needed to order, collect, store, and review the ECG. Further, the PC-based ECG can run seamlessly in conjunction with, and on the same PC as, the EMR program. This has as its benefits a lower up-front investment owing to the common hardware platform, simplified test administration right at the point-of-care, and elimination of redundant patient demographic data entry as this information is automatically passed from the EMR program to the diagnostic device.

The benefits of PC-based testing are not limited to the ECG. Presently in the market there are also PC-based versions of Exercise Stress ECG, Holter ECG, Spirometer, and Ambulatory Blood Pressure Monitor (ABPM). Figure 2 depicts the full suite of connected vital signs and cardiopulmonary diagnostic devices, including the PC-based versions which deliver the optimum in interoperable benefits.

What to Look for
At the top of your list should be the question of which (if any) of the EMR programs the diagnostic device manufacturer has a relationship with and vice versa. The acid test of a connected diagnostic device is its quality and quantity of custom-programmed interfaces with each individual EMR program. Quality gets at how “tight” or complete the interface is and thus how efficiently information is exchanged between the device and EMR, and how streamlined the workflow is for you and your staff. Quantity gets at the fact that no two EMR programs are exactly alike, hence the need for individually programmed interfaces between each EMR and diagnostic device. Absent such a relationship, it is highly unlikely that a truly interoperable or bi-directional interface exists between that diagnostic device and EMR.

The considerable benefits in the areas of time savings, efficiency gains, and error reduction will be compromised, if not completely lacking, in the absence of a truly interoperable interface. This two-way exchange of information is the essential key to streamlining workflow and reducing opportunities for errors. The aforementioned example of patient demographic information readily conveys the importance of this capability. Without the bi-directional interface there can be no automatic passing of the patient demographic data into the diagnostic device and, correspondingly, no return passing of the test results and this patient data back into the correct EMR. Figure 3 depicts the features and benefits of true two-way data exchange.

Manual substitutes for this optimized functionality abound, and often a device manufacturer’s claim of connectivity is a disguise for an inefficient, burdensome, and time consuming process. Examples include the need to still manually enter the patient information into the device, manually move data files around including between the device and the computer and the computer hard drive and the EMR, and in the worst case the scanning of new (as opposed to legacy) paper test results and subsequent shredding of the hard copies. Such approaches not only fail to achieve the potential benefits of interoperability but in essence may actually be worse than the traditional paper-based workflow and record keeping.

Dollars and Sense
The benefits of interoperability are quantified most readily in time savings and error reduction, the former of which can be applied to anything from using increased productivity to see more patients or spend more time with existing patients, to doing more tests or procedures to improve patient care and practice income, or freeing up more time to spend with the family. Of course, time is also money and these time savings can be converted to labor dollar savings as well. A simple example for automatic vital signs collection with EMR-connectivity in a 5-MD Practice seeing an average of 100 patients per day follows.
Manual Vitals Capture
2,000 patients/mo x 2.5 min/patient =
5,000 min/mo

Integrated-Digital Vitals Capture
2,000 patients/mo x 45sec/patient =
1,500 min/mo

Time Savings Estimate = (5,000 – 1,500) = 3,500 min/mo; or 700 man-hrs/yr
Opportunity Cost Savings: 700 man-hrs/yr x $25.00* = $15,000/yr
* Hourly salary estimate for clinical assistant

Given the investment cost of approximately $1,500 for the connected automatic vital signs collection device, it becomes clear that a speedy return on investment could be realized.

A similar cost/benefit exercise can be applied to the connected cardiopulmonary devices. In the case of the PC-based ECG for example, the time savings entails even more variables than in the above, such as eliminating the need to manually enter patient data into the device, saving the time to print and scan the ECG (in the case of digital storage without connectivity), saving the cost of the paper, saving the time of shredding the hard copy, and so on. A calculation similar to the above that captures all of these savings opportunities could thus be constructed as follows:

Calculation: (#) of diagnostic tests per year (x) total amount time saved by eliminating manual test processes above (x) technician and/or RN hourly rate (+) cost of ECG tracing paper

Conclusion

The advent of EMR software in physician office practices also presents the opportunity to implement interoperable or connected diagnostic devices. Devices capable of connectivity with your EMR result in benefits in the areas of workflow efficiency, error reduction, and enhanced data access. Connected product categories include automatic vital signs collection devices and diagnostic cardiopulmonary equipment. In the cardiopulmonary category, a fundamental requirement is that the system is truly interoperable, or bi-directional in nature, to optimize the benefits of the digital devices. Such a system requires a custom-programmed interface between the diagnostic devices and each one of the myriad EMR programs in the market today. Finally, the benefits of an interoperable system can yield a return on the incremental investment of converting to connected devices which can be measured in time savings, labor cost savings, or both.