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HL7 (Health Level 7)

The key developer of HL7 predicts what standards are on the horizonin healthcare.

Healthcare Technology: You developed the interchange protocol that became the first version of Health Level 7 (HL7), which today is the most widely used data interchange protocol in healthcare. In addition to HL7, what other standards do you see on the horizon?

Donald Simborg: In addition to HL7, there are not only other standards on the horizon, but many other standards already in place. HL7 is an important standard for data interchange, but there are other important standards in use. These include healthcare-specific standards like LOINC, which is the laboratory standard, and DICOM, which is the image standard. In addition, we have non-healthcare- specific standards that are very important in healthcare — the Internet (TCP/IP) being the most important. XML has become a very important message transfer type standard that is being incorporated into HL7. So fortunately, in healthcare we don’t always reinvent wheels, but we do benefit and use standards that are more general.

Getting to your answer of what is on the horizon, I think the major standard that is emerging has to do with the data content of clinical records and clinical care. The main standard there today, and I think emerging for the future, is SNOMED CT. I see that becoming much more widely used, and it’s very necessary. HL7 primarily deals with the messages, what kinds of messages and what things need to be in messages, but it doesn’t go down to the level of how you code all the various concepts that are used in healthcare records and healthcare communications. SNOMED CT takes it that next step. Another entirely new area of standards development in healthcare relates to interoperability in the emerging National Health Information Network and its component sub-networks.

HCT: How do EHRs apply to physician input systems?

DS: EHRs must deal with physician input — you don’t get anything into the record that comes from a physician unless the physician puts it in there directly or indirectly. Obviously everything in a health record doesn’t come from a physician; it comes from other professionals and it comes from laboratories and other places. A substantial part of what is in a health record, however, comes from a physician. There must be facile ways for physicians to enter their encounter notes and orders into an electronic format that can be understood by not only computers but also obviously communicated to other people in the healthcare system. So it’s essential that we have physician input systems. This has been the largest barrier to date to the adoption of EHRs.

HCT: What are some of the types of information captured?

DS: The main areas are ones I just mentioned: the encounter note itself; that is, the note that a physician records in a record during and after seeing a patient at a patient visit. That usually includes components defined by the acronym SOAP: subjective, objective, assessment and plan. Subjective is the history information — what the patient tells you about himself or herself. The objective part of a note contains the things that the physician observes or things that are determined by testing procedures. The assessment, which is a critical part of the input from a physician, is what the physician thinks about all this, what’s the physician’s impression of the patient’s problem and how bad the problem is — the severity of the problem. The fourth component, the P or the plan part, is what the physician is going to suggest or recommend. It contains the diagnostic and/or therapeutic next steps, which would include the orders, such as the prescriptions or orders for procedures.

HCT: What are some of the benefits and risks of electronic record capture, storage and transmission?

DS: Well, being someone who’s been working most of his career trying to get physicians and others to use electronic records — I have a strong bias that the benefits far outweigh the risks. But there are risks, so let me start on the risk side. I’d say the primary risk is the potential for loss of privacy or confidentiality of records and the potential for abuse of that information. So I would say that’s the biggest risk we need to guard against, and make sure there are appropriate safeguards to reduce that kind of a problem. On the benefit side, it’s a long list, a huge list, and they fall into two main categories: clinical benefits and financial benefits. Clinical benefits are almost self-explanatory. The fact that a physician or other health professional can have access to legible records is one main benefit. To have access to information virtually anywhere, any time, without having to find a chart is just an enormous clinical benefit. In addition to just the availability of the information, the more modern systems all engage in what people call decision support. These are methodologies that are available in computerized systems that will help alter or improve the decisions that are actually made by the physician. All physicians make errors — they can’t be expected to be perfect. In addition to reducing errors, decision support systems can suggest better ways to do things according to the latest published evidence. So decision support is a huge benefit of these systems.

On the financial side, there’s just no question that these systems are going to be important in reducing the costs, particularly the rising costs, of healthcare.

These decision support components have already been shown to reduce errors. Errors, in addition to being bad medicine, are also very costly. Someone has to take care of the complications from these errors that are made. Just having access to information widely between physicians, which isn’t available today, will prevent unnecessary care and unnecessary duplication in care. So there are many ways that these systems are going to reduce costs in addition to improving clinical care. The benefits are enormous. There are risks, though, and we can’t let the concern or the threat of the risks impede the benefits that we’re going to get.We just have to deal with the risks.

HCT: Do you think there will be widespread adoption?

DS: You know, I have a saying: “paper records are dangerous to your health.” They really are.

HCT: Do you think there will be widespread adoption in five years?

DS: I think we’re on a rising part of the curve, largely because of a lot of the stimulus going on at the federal level now, with things Dr. Brailer is doing and the things going through Congress now. So I think we’re going to have a lot of stimulus, a lot more adoption. Widespread in five years? It depends on what you mean by that. I’d say if we’re at about 5 to 10 percent adoption now, we’ll be in, perhaps, the 30 to 50 percent range in five years. I’d say that’s widespread compared to today. Not anywhere near 100 percent. The key will be changing the economic model, particularly with regard to the financial incentives to physicians to adopt these technologies. If Congress passes legislation requiring Medicare to provide the proper financial incentives, we will get much higher adoption in five years.

HCT: You’re way ahead of your time.

DS: Well, I am working on it.