Operation Electronic Integration: Connecting EHRs With Other Systems a Work in Progress
By Joey Berlin Texas Medicine July 2021


Even in medicine, today’s world is a connected one. But that doesn’t mean every conceivable connection is in place, nor does it mean the ones already in place are perfect.

According to Texas physicians, that sums up the situation with electronic health records (EHRs) and their integration with other databases that can securely transmit patient information back and forth between physicians, labs, other practitioners, hospitals, and state agencies.

Electronic integration has come a long way. TMA’s latest Survey of Texas Physicians shows 89% of doctors in the state now use an EHR.

But the survey’s polling on the use of health information exchanges (HIEs), for example, shows not nearly every physician is getting the most out of those shared repositories for patient information. Just 17% of respondents said they’re able to access all necessary data through an HIE while treating patients, and 35% said they don’t participate in an HIE at all. (See “EHR Survey Says ...,” pages 30-31.)

Meanwhile, integration with the state’s Prescription Monitoring Program (PMP) – a concerted, highly funded effort by the state following the 2019 legislative session – has progressed well, says Sugar Land family physician Troy Fiesinger, MD, but is dependent on what EHR vendor a physician is using.

“There are definitely still opportunities for improvement both on the PMP side and on the health information exchange side,” said Dr. Fiesinger, who gives the current state of integration a B grade. And lackluster two-way data-sharing between physician record systems and the state’s immunization registry, ImmTrac2, was a focus for the Texas Medical Association in the 2021 legislative session.

HIEs: The private practice factor

HIEs have become more centralized, says El Paso infectious disease specialist Ogechika Alozie, MD, chair of TMA’s Committee on Health Information Technology. But he gives the current state of integration with HIEs “a C to a B, at best. I’d give it those grades because it hasn’t historically been easy.”

There are three key forms of HIE, according to the federal Office of the National Coordinator for Health Information Technology:


  • Directed exchange, which allows practitioners to send and receive information between each other for coordinated care;
  • Query-based exchange, allowing practitioners to find and/or request information from other practitioners, often for unplanned care; and
  • Consumer-mediated exchange, which allows patients control of their health information among practitioners.


The success in getting physicians integrated, Dr. Alozie says, is just like picking a house: “It’s all about location, location, location. It just depends on which geography you’re in. Each major city in Texas has its own HIE. They all operate differently … and have different goals.”

Dr. Fiesinger says the HIE that Harris County uses, Greater Houston HealthConnect, “works far better now than it did when it was first launched 10-plus years ago. All the work that the HIE staff, the county medical society, and the hospitals put in is finally paying off now over the last couple of years.”

HealthConnect is “definitely very useful, definitely very helpful, and our [EHR] requires us to reconcile the HIE reports with our own internal documents, which is fine. That’s what we want. … Where it could be improved would be adding all hospital systems, adding more clinics,” Dr. Fiesinger said. “Some physician groups that are not hospital-affiliated are part of it, like a practice a mile down the road from us. But most aren’t, so that would be helpful.

“If more specialists outside the hospital system [were on it], that would be helpful, too. The biggest issue for us in primary care is, what medicines did the specialist change? That’s really important information for us.”

Dr. Alozie says the “last struggle” is to get more private-practice physicians on HIEs.

“Part of it is we haven’t proved the value proposition,” he said. “It’s not enough to just say, ‘Hey, join an HIE because ...’ A doc is going to say, ‘Well, what’s in it for me? Why do I need to do this?’”

Some of those physicians, he says, may not think they need to know what happens if one of their patients visits the hospital. But as payment begins to move toward at-risk contracts involving value-based care, he says, knowing what’s happening when your patient gets care elsewhere is taking on new significance. And payment isn’t the only consideration.

“The other piece, it just depends on how much information you need as a physician. Do you need to know your patient’s in the hospital? Irrespective of payment, maybe you do, maybe you don’t. And there’s a good argument to be made [either way]. Some will feel, ‘Well, I’m not getting paid for this, so why do I need to know? That’s the hospital’s job, to manage the patient in the hospital and then get them back to me.’

“Others will say, ‘Well, I want to know. Even if I’m not in the payment arrangement, I still want to understand what happened to my patient, and even if I don’t look at it real-time, have the ability to [know] what happened in the hospital.’ I’m one of those. I’m not in a payment arrangement. But as an HIV physician or infectious disease physician, I want to know what got changed, what happened when my patient was in the hospital that I maybe see [the effects of] in clinic.”  

Immunizations: A missing link?

For many physicians in Texas, the path between their EHRs and the state’s immunization registry,
ImmTrac2, is currently a one-way street. Fort Worth-area pediatrician Jason Terk, MD, is one of those physicians, and he says it’s not ideal.

“From a practical point of view, we’re better now than we were 10 years ago, in that we have the ability to share information from our system to ImmTrac pretty well,” Dr. Terk said. “But it’s still a process in which you don’t have the ability to click a button and query the registry at the point of care.

“I literally have such a button in my [EHR]. If we had a functional, integrated type of connection with ImmTrac, I could push this button, it would query the registry, and it would have data from the registry populate into my record. And anything that was in my record could be immediately populated to ImmTrac. The promise to that has been [just] a promise for quite some time. We’ve been told, ‘It’s coming, it’s coming, but it’s not here yet.’ And it’s still not here yet.”

A spokesman for the Texas Department of State Health Services (DSHS), which administers ImmTrac2, told Texas Medicine that while various stakeholders believe ImmTrac2 doesn’t have that “bidirectional” capability, it actually has had it for almost two years, according to the department’s “ImmTrac team.”

“They did declare readiness for bidirectionality beginning Jan. 1, 2021, but the team did have a number of stakeholders that piloted with them prior to that date,” DSHS Press Officer Douglas Loveday wrote by email. The department’s requirements for submitting consent for ImmTrac2 inclusion made it hard for some vendors to implement the bidirectionality into their EHR, he said. Also, the state’s “opt-in” law for patient consent to be included in the registry made it difficult for those EHRs to be customized to meet the department’s specifications, although for the time being, “the consent reporting requirement was relaxed since COVID reporting does not require consent submission by state law,” Mr. Loveday added. He says about 4,500 practitioners are submitting data successfully between their systems and ImmTrac2.      

Lacking that option himself, Dr. Terk says from a practical standpoint, if one of his patients comes into the office without a vaccination record, someone on his staff can log in to the registry and look up whether the patient has a record in ImmTrac2. But if the login information is missing or forgotten, or the person in the office who normally accesses the registry isn’t there that day, “it basically makes it a frivolous exercise to try to get that information at the point of care. Which therefore means a lost opportunity to provide immunizations if they need it.”

During this year’s legislative session, TMA backed House Bill 325 by Rep. Donna Howard (D-Austin) and its companion, Senate Bill 468 by Sen. Judith Zaffirini (R-Laredo), which would have introduced technological updates to ImmTrac2 to make it more interoperable with physicians’ EHRs. The bill also would have made ImmTrac2 an opt-out system, in which a person must request exclusion from the registry, rather than its current setup as an “opt-in.” Neither the House nor the Senate bill reached a committee hearing.

PMP: Your success may vary

Integrating EHRs with the prescription monitoring program, PMP Aware, became a priority for TMA and the state when legislators passed a mandate for prescribers to check the databank  before writing any prescription for opioids, benzodiazepines, barbiturates, or carisoprodol. That mandate went into effect on March 1, 2020.

Allison Benz, executive director of the Texas State Board of Pharmacy, which administers the PMP, provided data to Texas Medicine showing 71.4% of Texas physicians were registered to use the database between December 2020 and February 2021. Physicians accounted for 55% of the nearly 58 million database searches. Searches from an integrated EHR made up 81% of all searches, or 46.7 million.

Ms. Benz says integration has “really taken off.”

“We’ve done different things, trying to get the word out there that physicians do have that capability to be integrated, and that we’ve got the funding for it. They don’t have to pay any additional cost. [Integration has] really increased the number of people that are using the system.”

Dr. Fiesinger enjoys what he describes as “seamless integration” with his EHR. But he says colleagues have reported challenges.

Some EHRs, for example, charge for interfaces and add-ons to make it happen. For small practices, that expense is a barrier.

“To me, the onus is on the vendors to ... make it seamless, quick, easy, embedded in a logical, functional manner so it’s very easy for us to access it,” Dr. Fiesinger said.

Tex Med. 2021;117(7):32-34
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Last Updated On

May 02, 2022

Originally Published On

July 02, 2021

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