Table 2.

Key obstacles to PFT–EHR interoperability by stakeholder group

Stakeholder Group	Identified Obstacles
The patient	• Evolving technologies require evolving integration
	• Limited approaches to address home data collection and desire for an app
	• Lack of seamless information connectivity across time and geography
The clinician or researcher	• Complex steps to extract data from EHR into clinical notes
	• Heterogeneous PFT data types and sites of data storage preclude monitoring trends over time for an individual patient from childhood through adult life
	• Limitations of EHRs in primary care and limited information exchange between primary care providers and specialists impairs continuity of care
	• PFT data are often sequestered. For example, PFT data obtained on a person as part of their workplace screening is not incorporated into their health record and is therefore unavailable when they develop a health problem later in life
	• Inability to integrate images into the EHR limits ability to assess flow-volume loops and other quality metrics
	• Lack of metadata to indicate quality of testing
	• Interfacing costs and lack of clear value to reimbursement and healthcare outcomes
	• Clinically generated PFT data lacks uniform, discrete, structured data elements
	• Inability to retrofit existing PFT data because of cost and person-hour limitations
	• Inability to integrate PFT data with data regarding underlying disease type and severity
	• Raw data underlying flow-volume curves needed to assess technical errors with greater precision are generally not provided
The device manufacturers	• Lack of IT resources from purchasers
	• Lack of open application-programming interfaces for clinical data
	• Lack of consensus on which discrete variables should be sent to the EHR. Decisions on variables sent from vendors to EHRs are usually left up to the lead physician, with high variation between interfaces
	• Electronic PFT forms represent a streamlined version of a full report, potentially losing crucial data if certain variables are selected. However, more data fields (particularly if manual entry or curation is required) can lead to more errors
	• Poor interoperability at the health system level
	• Need for adequate connectivity to support data transfer from devices to EHRs
	• Lack of incentives by customer to link PFT data to the EHR (i.e., lack of incorporation of interoperability into laboratory certification)
	• Lack of variable-naming conventions, including multiple LOINC depending on the context of data acquisition
	• Lack of subject-matter expertise among clients. PFT directors often do not possess the IT knowledge needed for pre–interoperability-assessment needs, and IT departments do not possess the intimate knowledge needed to understand the needs of the PFT laboratory and/or healthcare stakeholders
	• Lack of common data model and interoperability standard by societies
The EHR companies	• Data-output formats and fields vary across devices inputting into the EHR
	• Compatibility with the EHR varies across devices
	• Variation in PFT orders linked to testing
	• Multiple PFT devices/vendors within single customer base
	• Lack of willingness of PFT vendors to interface discrete data with EHRs
	• Lack of variable-naming conventions and incomplete or duplicate LOINC
	• PFT data not prioritized for standardization by organizational bodies (FHIR)
	• Lack of common data model and interoperability standard by societies

Definition of abbreviations: EHR = electronic health record; FHIR = Fast Healthcare Interoperability Resources; IT = information technology; LOINC = Logical Observation Identifiers Names and Codes; PFT = pulmonary function test.