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The Evolution of Health Care Information: Shifting From Documents to Data
By Viet Nguyen, MD

Thanks to advances in technology and the evolution of information exchange, industries such as education and banking have altered how they document, process, and share information, making data exchange more convenient, efficient, and effective in these markets.

In education, for instance, all students once handwrote assignments, submitting them in person and on paper and waiting for feedback. Now, many educators and students alike benefit from Web-based information exchanges that streamline how classwork is completed, submitted, and evaluated. This electronic exchange also expedites the grading process for educators and ensures timely feedback for students. Creating efficiencies such as these through technology allows educators to spend less time on administrative tasks and more time directly teaching students.

A similar evolution is emerging in health care, where information exchange is stepping beyond paper-based documents into the realm of codified, structured data. Projects such as the Centers for Medicare & Medicaid Services’ (CMS) Electronic Submission of Medical Documentation (esMD) are ushering in a new stage of information exchange that will streamline and expedite the document review process for health care.

Evolving Document Review
In an effort to reduce the billions of dollars spent annually on improper payments, the CMS launched the first pilot demonstration of esMD in 2011, enabling participants to scan and electronically submit documents to the CMS’ review contractors via health information handlers. When participating organizations eventually enter phase 2, providers will not only send documents electronically, they also will receive requests from CMS contractors electronically—a process that currently is paper based—further speeding up document review.

Under this initiative, the Author of Record and the Electronic Determination of Coverage workgroups are developing and piloting procedures to further promote efficient electronic information exchange. For instance, digital signatures will soon enable providers to “sign” documents to ensure their authenticity and provenance.

Shifting From Documents to Data
Another industry that has seen information exchange evolve is banking. Two decades ago, most banking transactions were paper based and manual. Now most occur securely via ATMs, online, or through mobile apps, and information exchanges are composed of data rather than paper-based documents.

Unlike banking, information exchange in health care still is in its infancy, commonly relying on a scanned PDF format, which has limited benefits. The ultimate aim is to introduce technologies that eventually will capture and process highly structured, codified data, which then can be used to improve workflow efficiencies, maximize resources, and manage patients at the population health level.

In the early stages of this evolution, health care organizations can begin developing a framework for capturing, exchanging, and processing valuable patient data—all electronically—by adopting the following key strategies:

• Identify software and application suppliers with which to partner. Organizations should engage software and application suppliers who are committed to supporting and applying health information exchange (HIE), interoperability, and data standards to lay the groundwork for future data exchange.

• Participate in regional HIEs. By participating in regional HIEs as both data providers and consumers, organizations can gain experience actually applying health information standards now.

• Educate providers to accurately collect and share information. Organizations should work to shift the traditional physician mindset that patient information is “owned” by the physician. Instead, physicians must embrace their role as stewards of patient information and understand the importance of accurately collecting and sharing it to support quality patient care. They also must understand how patient data might be used for secondary purposes such as population health.

Shifting from documents to data is not going to happen overnight. Similar to the evolution seen in education, it will evolve over time as advances in technology, interoperability, and standards adoption continue to mature. While health care is at the beginning of this journey, the ultimate destination is within reach.

— Viet Nguyen, MD, is chief medical information officer for Systems Made Simple, a provider of IT systems and services to support critical architecture, data, and application challenges in the health care industry. He works as a terminologist with the VA in supporting its terminology and interoperability efforts, trained as a medical informatics fellow, and remains a practicing internist and pediatrician.