大多数医疗都是地方性的：将 Epic 与区域健康信息交换连接起来
Most Healthcare Is Local: Connecting Epic with Regional Health Information Exchanges
Steve Hess，UCHealth 的 CIO
想象一位患者来到医院进行移植评估。过去两年里，她在三个不同的卫生系统接受过治疗，看过该地区的专科医生，并在两个州的药房开过处方。她的肿瘤导航员需要在明天早上的预约之前获得她完整的病史。其中一些数据存在于我们的 EHR 中。很多数据则不在。
这就是三级和四级转诊中心的现实。患者从科罗拉多州及周边各州来到这里，因为他们的病情需要专科治疗。能够随时掌握他们的完整健康史，是发现并发症与漏掉并发症之间的差别。
每家医院都在努力解决这个问题，而全国大多数医院都在用同一款软件解决它。这一事实影响了行业讨论互操作性的方式，也影响了对话中被忽略的内容。
根据最近的 KLAS 报告，近一半的美国医院运行在 Epic 上，而且由于它们包括了许多美国最大的卫生系统，它们占据了大多数住院床位。UCHealth 就是其中之一。Epic 是一款出色的 EHR，而 Epic 到 Epic 的互操作性工具是我们在不同卫生系统之间移动数据战略的基本组成部分。
但美国一半的医院并不使用 Epic。许多门诊诊所、专业护理机构、家庭健康机构，以及患者在康复过程中接触的社区提供者也不使用。如果我们无法将数据移入和移出这些场所，我们就不能以应有的方式为患者服务。这就是互操作性的最后一英里，而地方健康信息交换（HIE）正是在这里完成任何 EHR 网络都无法完成的工作。
一些 CIO 持不同观点。理由大致是这样的：我们已经在 EHR 上进行了重大投资，它有自己的互操作性工具，而且国家交换框架正在成熟。我们真的需要在此基础上再建立一个地方 HIE 吗？这是一个合理的问题，我理解 CIO 们在证明每一项支出合理性方面所承受的压力。但是，一旦你看到在没有地方 HIE 的情况下地方层面会发生什么，答案就变得清晰了。
没有 HIE，医院就会退回到传真、与每个门诊合作伙伴的一次性点对点接口，以及要求临床医生走出工作流程才能找到信息的门户网站。这些变通方法在你最需要的时候会失效，而且它们无法扩展，以应对在小诊所、护理机构和家庭健康机构之间流动的大量数据。
正确做到这一点的临床影响是可衡量的。去年，提供者使用来自 Epic 和我们当地 HIE Contexture 的外部数据，避免了 13,000 例不必要的手术，通过利用外部数据的临床决策支持更改了 580,000 条用药医嘱，并填补了 280 万个护理缺口。这些数字反映了两个系统协同工作。它们是互补的，而不是竞争的。
临床医生也用点击来投票。我们的用户每年登录 HIE 数百万次。移植协调员、烧伤科护士和肿瘤导航员——那些照顾我们最危重患者的人——用它来填补他们手头没有的信息。如果他们不能从中获得价值，就不会有这些登录。
这一案例也超越了患者护理，延伸到公共卫生领域。我们依靠 HIE 与 Colorado Department of Public Health and Environment 共享免疫接种数据、实验室结果和容量信息。没有 EHR 能够大规模做到这一点，而且这不是可选工作。这是我们对我们所服务社区的责任的一部分。
这种社区责任也是为什么当我听到“将强大的 EHR 与新兴的国家网络结合起来就足够了”这一论点时，我会提出反对。像 Carequality 和 TEFCA 这样的框架做着重要的工作，并且正在变得更好，但大多数医疗都是地方性的。明天走进我们大门的患者是由路边的诊所治疗的，而不是全国各地的卫生系统。对她的护理最重要的数据是本地数据，而移动这些数据的基础设施就是地方 HIE。
对于权衡这一决定的 CIO 来说，成本是错误的框架。真正的问题是，你是否在为你社区中的每一位患者和提供者服务，包括那些不在你的 EHR 上的人。我们已经做出了选择，而且每年都会再次做出这个选择。我们社区的健康取决于此。
关于 Steve Hess
Steve Hess 是 UCHealth 的 CIO，UCHealth 是科罗拉多州最大的卫生系统。UCHealth 在科罗拉多州拥有 15 家医院，并在科罗拉多州、怀俄明州南部和内布拉斯加州西部拥有数百个诊所地点。他是 Contexture 的董事会成员。
Steve Hess, CIO at UCHealth
Imagine a patient who arrives at the hospital for a transplant evaluation. She’s been treated at three different health systems over the past two years, seen specialists across the region, and filled prescriptions at pharmacies in two states. Her oncology navigator needs a complete picture of her care history before tomorrow morning’s appointment. Some of that data lives in our EHR. A lot of it doesn’t.
This is the reality at a tertiary and quaternary referral center. Patients arrive from across Colorado and surrounding states because their conditions demand specialized care. Getting their full health history at our fingertips is the difference between catching a complication and missing one.
Every hospital is working on this problem, and most of the country is working on it with the same software. That fact shapes how the industry talks about interoperability, and what gets missed in the conversation.
Nearly half of U.S. hospitals run on Epic, according to a recent KLAS report, and because they include many of the country’s largest health systems, they account for the majority of inpatient beds. UCHealth is one of them. Epic is an excellent EHR, and the Epic-to-Epic interoperability tools are a fundamental part of our strategy for moving data between health systems.
But half of America’s hospitals aren’t on Epic. Neither are many ambulatory clinics, skilled nursing facilities, home health agencies, or the community-based providers a patient touches in the course of getting well. If we can’t move data to and from those settings, we aren’t serving our patients the way we should. That’s the last mile of interoperability, and it’s where local health information exchanges (HIEs) do the work no EHR network is built to do.
Some CIOs take a different view. The reasoning goes something like this: we’ve made a significant investment in our EHR, it has its own interoperability tools, and the national exchange frameworks are maturing. Do we really need a local HIE on top of that? It’s a fair question, and I understand the pressure CIOs are under to justify every line item. But the answer becomes clear once you watch what happens at the local level without one.
Without an HIE, hospitals fall back on fax, on one-off point-to-point interfaces with each ambulatory partner, on portals that require clinicians to step outside their workflows to find information. These workarounds fail when you need them most, and they don’t scale across the volume of data flowing to and from the small clinics, nursing facilities, and home health agencies.
The clinical impact of getting this right is measurable. Last year, providers used external data from Epic and Contexture, our local HIE, to avoid 13,000 unnecessary procedures, change 580,000 medication orders through clinical decision support that drew on outside data, and close 2.8 million gaps in care. Those numbers reflect both systems working together. They’re complementary, not competing.
Clinicians also vote with their clicks. Our users log into the HIE millions of times a year. Transplant coordinators, burn nurses, and oncology navigators- the people caring for our sickest patients- use it to fill in what they don’t have at their fingertips. If they weren’t getting value from it, the logins wouldn’t be there.
The case extends past patient care into public health, too. We rely on the HIE to share immunization data, lab results, and capacity information with the Colorado Department of Public Health and Environment. No EHR is set up to do that at scale, and it isn’t optional work. It’s part of our responsibility to the community we serve.
That community responsibility is also why I push back when I hear the argument that combining a strong EHR with the emerging national networks is enough. Frameworks like Carequality and TEFCA do important work and are getting better, but most healthcare is local. The patient walking through our doors tomorrow was treated by a clinic down the road, not a health system across the country. The data that matters most to her care is local data, and the infrastructure that moves it is the local HIE.
For CIOs weighing this decision, cost is the wrong frame. The real question is whether you’re serving every patient and provider in your community, including those who aren’t on your EHR. We’ve made our choice, and we make it again every year. The health of our communities depends on it.
About Steve Hess Steve Hess is CIO for UCHealth, the largest health system in Colorado. UCHealth encompasses 15 hospitals in Colorado and hundreds of clinic locations across Colorado, southern Wyoming, and western Nebraska. He serves on the board of Contexture Reader Interactions