Interoperability: How Semantic Interoperability Improves Safety and Quality


July / August 2007


How Semantic Interoperability Improves Safety and Quality

Last fall, the University of Pittsburgh Medical Center (UPMC) embarked on the next phase of a plan aimed at continuing to improve the patient safety and quality of care across its network of 19 hospitals and more than 400 outpatient sites, physician practices, and other care facilities.

Like a growing number of healthcare organizations, UPMC has recognized the benefits that clinical information systems can deliver for both medical staff and patients. To this end, the organization has adopted electronic medical records systems (EMRs), computerized physician order entry (CPOE) systems, and other technologies that aid physicians.

This has earned UPMC industry-wide recognition for its efforts. But it wasn’t until last fall, through UPMC’s alliance with dbMotion — a provider of healthcare information integration software that facilitates interoperability and health information exchange (HIE) — that the organization found a solution to the often vexing problem of getting its disparate systems to truly “talk” to one another.

In healthcare IT parlance, UPMC and dbMotion have begun working to achieve “semantic interoperability.” That is, the ability for individual clinical systems to seamlessly share patient information and allow physicians, no matter where they practice in the network, to have full access to all the information they need at the moment they need it. Because the dbMotion Solution is based on a service-oriented architecture (SOA), it enables existing EMR systems and the supporting vendors to easily access patient data without complex point-to-point interfaces and the additional expense these connections require.

Most importantly, UPMC believes the alliance will allow it to build upon gains the organization has made in improving patient care and safety across its entire network of hospitals and care facilities.

Tracking Patient Data Across Care Settings
With UPMC’s adoption of EMRs in various clinical settings, the organization has already seen improvements in the areas of patient safety and quality of care. For example, UPMC’s Children’s Hospital of Pittsburgh implemented a CPOE system in 2002. This system captures all orders, including lab tests, medications, therapies, consultations, and communications between physicians.

An outcomes study, updated in 2005, shows the system has enabled the hospital to achieve a dramatic reduction in transcription errors, from an average of five per month to zero per month. In turn, the rate of medication errors has declined from .03 per 1,000 doses dispensed to .004 per 1,000.

UPMC saw similar improvements at UPMC St. Margaret Hospital following the implementation of a CPOE system in April 2004. Outcomes studies show that medication errors have dropped significantly, with a 77% decrease in medication administration omissions, an 86% drop in improper dosages administered, and a 79% decline in the number of clarifications needed by nurses and other physicians to process a medication order.

It should be noted that implementation of these systems also brought improvements in staff satisfaction. At Children’s Hospital of Pittsburgh, for example, it takes 50% less time for nurses and physicians to administer medications. In addition, one unit at Children’s reports the inflow of daily faxes has diminished from 49 to just 2.

But while these gains are noteworthy, they do not address the patient safety and quality of care challenges that arise when patients move between disparate hospitals and care settings in the UPMC network.

There is no question that the management of a patient’s longitudinal care remains a critical problem for many healthcare organizations. It’s not uncommon, for example, for patients to get discharged from an acute care setting with new medications. When this patient moves to an ambulatory care environment, however, physicians often do not have access to the records detailing those discharge medications. Similarly, it’s not uncommon for ambulatory care patients to arrive in ER settings where physicians also lack access to the patient’s medication regimen and history.

These gaps in the flow of patient data often result from the so-called “silos” of information created by disparate clinical systems adopted over the years. In some ways, this has been an inevitable outcome. Forward-thinking organizations have all sought best-in-class systems to address the individual needs of clinical departments and care settings. The problem arises when these organizations recognize the need to link these systems and realize that it’s often an expensive proposition and one prone to failure.

UPMC is no different. The organization has tried or considered several approaches to address these patient data gaps, from building its own interfaces and utilizing Clinical Context Object Workgroup (CCOW) standards to exploring options with other integration vendors.

CCOW has been very useful as an interim solution. It allows for applications to be traversed by a user with a single log-on, and provides access to multiple applications where data is stored. For example, if a user opens a CCOW-compliant ambulatory application and then jumps to a CCOW-compliant radiology application, he or she will automatically be transferred to the right patient in the radiology application — which corresponds with the patient being looked up in the ambulatory application. This allows the user to move from one application to another with no data transferred and the context preserved, thus minimizing keystrokes for locating patients in each application being used to view patient data.

However, it does not address the issues of semantic interoperability or a seamless, homogenized user interface between applications. Semantic interoperability, which is the ability of two or more information systems to exchange information and have the meaning of that information accurately and automatically interpreted by the receiving system, is the final objective.

The lessons learned from these efforts led to the dbMotion alliance. The dbMotion Solution will enable UPMC to create this connectivity, harmonizing the language and data between the disparate systems, without the need for expensive point-to-point interfaces and the challenge of getting vendors — who are often competitors — to cooperate with one another.

While the alliance is still in its early stages, UPMC’s physicians have already reported initial interoperability benefits for patient safety and quality of care. An ER physician, for example, reported that he prevented a possible latex allergy reaction because he had immediate access to a patient’s allergy history. Similarly, the real-time access to patient data enabled another ER physician to detect a more serious problem with a patient who was waiting to be seen for eye trouble. The physician recognized that if the patient’s condition was not treated immediately, it might result in a rupture and the loss of an eye. The physician ordered the patient to the front of the wait line to be seen immediately. This prompt attention saved the patient’s eyesight.

As the interoperability project continues, UPMC will be monitoring for similar patient safety and quality-of-care success.

Interoperability Aids: UPMC’s Economic Model
UPMC also believes the interoperability project will position the organization as a leader in the way healthcare networks are compensated for care delivery.

In the past, UPMC and other organizations have been paid based on utilization. That is, they provided a service and got paid for delivering it. With this model, the outcomes of patient care play only a limited role. This is not to suggest that organizations are not concerned with providing quality care to patients. But the reality is that the utilization model does not effectively support these goals.

That dynamic is changing, however, as pay-for-performance plans become the norm. UPMC has already seen some payers refuse to pay for care and treatment that results from patient infections that occur while they are receiving care in the network. With semantic interoperability, the organization will enable its physicians to better document efforts to control and check for such infections.

There is no question that such pay-for-performance plans will become ubiquitous. UPMC, however, is confident that its interoperability initiative will position the organization to meet these changing payer requirements and demonstrate shared goals for improved patient safety and quality of care.

Jay Srini serves as VP, Emerging Technologies for UPMC. She may be contacted at