A patient visits a hospital for a routine procedure. Regardless of his provider, the hospital can retrieve electronic copies of everything from family history and known allergies to detailed notes on previous hospital visits and prescriptions.
The information in the patient's EHR is well-organized, standardized, accessible and interfaces seamlessly with the hardware and software used by patient, clinician and provider.
This is the interoperable future the healthcare industry is working toward, but the path between here and there is riddled with stumbling blocks and complications.
Ultimately, making healthcare management systems interoperable means creating an environment where clinicians, organizations and providers can share data on patients and access medical information quickly and easily, which in turn should have a positive impact on patient outcomes.
Once the significant logistical, legislative and technological hurdles are conquered, that is. Here are 25 things to know about interoperability.
Terminology
There are 3 levels of healthcare information technology interoperability. It may be useful to think of these levels in terms of language interpretation.
1. Foundational interoperability can be compared to the one-to-one translation of a word from one language into another. Little context is provided beyond the basic transfer of the hard data. A system that receives the information won't necessarily be able to interpret or readily incorporate it, although it will be able to successfully retrieve it.
2. Structural interoperability provides that one-to-one translation with additional information — enough to allow for proper syntax or for the proper integration of the data into the new system. A thorough understanding of the information is not necessarily a component of structural IO, but technology systems can exchange hard data.
3. Semantic interoperability is the gold standard, the type of synergistic compatibility that allows for information to not only be shared seamlessly, but for systems to understand the information they send and receive and to use it effectively. This is the equivalent of having a fluent conversation in another language, without barrier. Semantic IO allows systems to parse information, categorize, organize and incorporate it as if the data had been generated within the system itself, rather than received from a completely different source.
4. Information blocking is the purposeful interference with the exchange of electronic health information. Healthcare information systems, organizations or providers may take steps to make their software or data collection systems purposefully incompatible with other systems, the same way a device manufacturer might develop a product that only interacts with other products from the same manufacturer, to encourage consumer loyalty. Information blocking does not serve to protect patient safety or maintain the security of a patient's health information.
Key statistics
5. With proper integrations of EHR, medical devices and interoperable standards, healthcare costs could be reduced by as much as $30 billion per year, on top of improved patient care and hospital safety, according to an analysis by the West Health Institute. The primary cost benefits of efficient EHR adoption and interoperability are an anticipated reduction in unnecessary procedures, malpractice lawsuits, hospital stays and patient visits.
6. In 2013, 71 percent of physicians reported having adopted some type of EHR system and 10 percent were planning to adopt an EHR system In the same year, 59 percent of hospitals reported using some kind of EHR.
7. Here are some key findings from the ONC's National Health Information Exchange and Interoperability Landscape Report for 2013.
a. Thirty-eight percent of providers said electronically exchanging data decreases their ability to separate sensitive health information from other data being exchanged.
b. However, 80 percent of providers reported electronic data exchanges increase their practice's efficiency.
c. Furthermore, 89 percent of providers said electronic data exchanges improve the patient's quality of care.
Interoperability advocates and efforts
8. CommonWell Health Alliance, whose members include athenahealth, Cerner, Meditech and OmniSYS, is an organization devoted to making health data available to patients, clinicians and providers regardless of where care is sought or given. Additionally, CommonWell believes provider access to this data must be built-in health IT at a reasonable cost for use by a broad range of healthcare providers and the people they serve.
9. Health Level Seven International, founded in 1987, created standards for data exchange in healthcare and is now an authority on standards for interoperability. In December 2014, HL7I launched the Argonaut Project, an initiative to accelerate the development and adoption of interoperability resources. Here are three things to know about the Argonaut Project initiative:
• HL7 launched the Argonaut Project in response to the JASON Task Force's recommendations to improve interoperability. JASON is an independent group of scientists and researchers that advise the federal government on issues of science and technology. The task force released a report in April 2015 urging the government to form a national, standardized health IT architecture to encourage interoperability. This, in essence, is the goal of the Argonaut Project: to support interoperability through HL7's Fast Healthcare Interoperability Resources and develop a first-generation FHIR-based application programming interface.
• Eleven organizations are involved in the Argonaut Project: athenahealth, Beth Israel Deaconess Medical Center in Boston, Cerner, Epic, Salt Lake City-based Intermountain Healthcare, Rochester, Minn.-based Mayo Clinic, MEDITECH, McKesson, Boston-based Partners HealthCare System, SMART at the Boston Children's Hospital Informatics Program and The Advisory Board Company. In April, Accenture and Surescripts joined the project.
• In its mission to boost interoperability, the Argonaut Project suggests replacing healthcare-specific standards with universal, Internet-based standards. This is where FHIR comes in. FHIR data exchange standards are universal, whereas the Consolidated Clinical Document Architecture the healthcare industry currently uses to meet stage 2 meaningful use requirements is XML-based and a more healthcare-specific set of complex document standards.
10. IHE USA is a 501.c.3 not for profit organization founded in 2010 that operates as a national deployment committee of IHE International. IHE USA serves as a voice representing U.S. health IT interests and key partners in national health IT efforts for fostering the national adoption of a consistent set of information standards to enable interoperability of health IT systems. IHE USA partnered with HIMSS to create ConCert, a comprehensive interoperability testing and certification program governed by HIMSS that determines whether or not EHR and HIE vendors meet the standards of advancing interoperability and enabling the secure, reliable transfer of data.
11. The Center for Medical Interoperability focuses on improving the safety and quality of care as well as removing risk and cost from the healthcare system by solving the shared technical challenges the industry faces today. CMI promotes progress toward interoperability through the improvement and integration of medical devices, EHR and technical infrastructure. CMI's board includes CEOs from Nashville, Tenn.-based Hospital Corporation of America, Brentwood, Tenn.-based LifePoint Health, Franklin, Tenn.-based Community Health Systems and several other nonprofit and academic health systems.
Government involvement
12. The Office of the National Coordinator was created in 2004 with an executive order from President George Bush and was legislatively mandated by the 2009 Health Information Technology for Economic and Clinical Health, or HITECH, Act. The ONC was created and designated as the main federal entity charged with coordination of nationwide efforts to implement/use health IT and the electronic exchange of health information to improve patient care.
13. As part of the HITECH Act, the federal government put aside $27 billion for an incentive program to encourage providers to adopt EHRs. To earn these incentives, providers must demonstrate that the certified technology must improve quality, safety, efficiency and reduce health disparities. It must also improve care coordination and maintain privacy and security of patient health information. As of April 2015, Medicare payments to eligible professionals under the EHR Incentive Program total approximately $20.6 billion. Medicaid EHR Incentive payments total roughly $5.9 billion.
14. Despite the incentives created to encourage EHR adoption, there has been little progress in terms of how easily the government can counter information blocking, which severely weakens the effectiveness of EHRs. An April 2015 report from the ONIC to Congress stated that many types of information blocking are beyond the current reach of federal law and programs to address. While many stakeholders are committed to interoperability, the ONC said current economic and market conditions create business incentives for some to exercise control over electronic health information that unreasonably limits its availability and use.
15. There are four important factors to consider when developing EHRs to maximize interoperability, according to the government:
• How applications interact with users, such as e-prescribing
• How systems communicate with each other, such as messaging standards
• How information is processed and managed, such as health information exchange
• How consumer devices integrate with other systems and applications, such as tablet PCs
16. President Bush recently described his vision for EHR interoperability by painting a specific scene, according to Politico: "There's a car wreck and the EMT takes a tag off the victim, plugs it into the computer and uses his records to make medical decisions."
17. As an effort to try to bring about this reality and set standards for coordinating the implementation of health IT systems that communicate well with one another, in September 2014 the ONC published the five elements it deems necessary to achieve interoperability:
a. Adoption and optimization of EHRs and health information exchange including increased adoption across all providers and settings of care including long term and post-acute care providers, behavioral healthcare providers and laboratories
b. Standards to support implementation and certification, including standardized vocabularies and transport mechanisms that enable exchange across different EHR systems and setting of care
c. Financial and clinical incentives to support adoption and implementation of EHRS across all settings of care
d. Privacy and security, including principles to support the privacy and security of patient information
e. Rules of engagement or governance, including an infrastructure to support health information exchange
18. Following this, the ONC published its A Shared Nation Interoperability Roadmap in January 2015, which included 10 guiding principles and checkpoints on a 10-year timescale within which interoperability could be achieved. Here are those ten principles.
a. Build upon the existing health IT infrastructure: To the extent possible, the ONC will encourage stakeholders to build from existing health IT infrastructure, increasing interoperability and functionality as needed.
b. One size does not fit all: The ONC will strive for baseline interoperability across health IT infrastructure while allowing innovators and technologists to vary the usability in order to best meet the user's needs based on the scenario at hand, technology available, workflow design, personal preferences and other factors.
c. Empower individuals: Electronic healthcare information from the care delivery system should be easily accessible to individuals and empower them to become more active partners and participants in their health and care.
d. Leverage the market: Demand for interoperability from health IT users is a powerful driver to advance ONC's vision. The market should encourage innovation to meet evolving demands for interoperability.
e. Simplify: Where possible, simpler solutions should be implemented first, with allowance for more complex methods in the future.
f. Maintain modularity: A large, nationwide set of complex systems that need to scale are more resilient to change when they are divided into dependent components that can be connected. Modularity creates flexibility that allows innovation and adoption of new, more efficient approaches over time without overhauling entire systems.
g. Consider the current environment and support multiple levels of advancement: Not every individual or clinical practice will incorporate health IT into their work in the next 3-10 years and not every practice will adopt health IT at the same level of sophistication. Therefore, the system should account for a range of capabilities.
h. Focus on value: The ONC will strive to make sure its interoperability efforts yield the greatest value to individuals and care providers; improved health, health care and lower costs should be measurable over time and at a minimum, offset resource investment.
i. Protect privacy and security in all aspects of interoperability: To better establish and maintain public trust that health information is safe and secure, the ONC will strive to ensure that appropriate, strong and effective safeguards for electronic health information are in place as interoperability increases across the industry.
j. Scalability and universal access: Standards and methods for achieving interoperability must be accessible nationwide and capable of handling significant and growing volumes of electronic health information.
19. Another component of the ONC's Interoperability Roadmap was a 10-year time frame with checkpoints along the way, broken down into three segments with individual agendas.
a. Three-year agenda: Send, receive, find and use health information to improve health care quality.
• Fine-tune and use the health IT infrastructure enabled through information of the HITECH Act to support transformation of healthcare to a more patient-centered, less wasteful and higher quality system.
• Improve the interoperability of existing healthcare information networks and scale existing approaches for fluidly exchanging health information across vendor platforms to support a broad array of transitions of care.
• Focusing on query-based health information exchange, or the ability to search for and retrieve health information in addition to point-to-point information sharing.
• Address critical issues such as data provenance, data quality and reliability and patient matching to improve the quality of interoperability.
• Operationalize a common framework to enhance trust by addressing key privacy, security and business policy and practice challenges.
• Advancing payment, policy and programmatic levers that encourage use of this information in a manner that supports care delivery reform, improves quality and lowers costs.
b. Six-year agenda: Use information to improve health care quality and lower cost.
• Over the next six years, the care delivery system will realize enhanced interoperability.
• Care providers, such as those in schools, ambulances and prisons will be able to appropriately exchange and use relevant health information.
• Multi-payer claims databases, clinical data registries and other data aggregators will incrementally become more integrated as part of an interoperable technology ecosystem.
• Healthcare providers will also be able to aggregate and trend information within and across groups of patients based on information from multiple data sources to monitor health disparities and quality improvement opportunities.
• As value-based payment gains traction across Medicare, Medicaid and commercials payers and purchasers, there will be new methods of measuring clinical quality that represent the most important aspects of care delivery and health outcomes.
• The ONC will work with stakeholders to refine standards, policies and services to automate the continuous quality improvement process and deliver targeted clinical decision support that fits into a clinician's workflow to close care gaps and improve the quality and efficiency of care.
c. 10-year agenda: The learning health system.
• The nation's health IT infrastructure will support better health for all through a more connected healthcare system and active individual health management.
• Information sharing will be improved at all levels of public health and research will better generate evidence that is delivered to the point of care.
• Advanced, more functional technical tools will enable innovation and broader uses of health information to further support health research and public health.
• Continuous learning and improvement will be feasible through analysis of aggregated data from a variety of sources. Health IT systems will enable both analysis of aggregated data and use of local data at the point of care through targeted clinical decision support.
• The process of clinical trial recruitment, data collection and analysis will be accelerated and automated. Retrospective analyses will allow for rapid inquiry around many aspects of public health, healthcare quality, outcomes and efficiency.
• Public health surveillance will be dramatically improved through better outbreak detection and disease incidence and prevalence monitoring.
• Interoperable health IT will also help contain outbreaks and manage public health threats and disasters.
20. Aside from the ONC's efforts, there are other federal and legislative initiatives intended to support and progress interoperability, such as the 21st Century Cures Initiative, pending legislation aimed at modernizing and personalizing healthcare by encouraging innovation and research. The bill was unanimously approved by the House Energy and Commerce Health Subcommittee in May, and it calls for new criteria for interoperability and the compilation of a list of vendors labeled as either compliant or non-compliant. This list would be published by 2018 and non-compliant vendors will risk being decertified, in which case they could face penalties under meaningful use by 2019.
Pushback to the ONC's plan and goal
The ONC published commentary and criticisms it received about the Roadmap in the 60-day period following its publication. Here are some of the key criticisms.
21. The AHA expressed concern that the 10-year timescale — with benchmarks at three, six and ten years for the completion of different measures — laid out by the ONC to reach overall success for interoperability may be unrealistic. Concerns were raised especially over the three-year benchmark, which includes measures regarding data encryption accessibility, the implementation of new cybersecurity infrastructures.
22. The ONC has proposed the introduction of "granular choice" as opposed to "basic choice," which is the current standard. Rather than allowing for patients to decide across the board if their personal information will be shared, "granular choice" or allows patients to have much more finely tuned control over which parts of their medical data are shared. HIMSS, among others, have stated that such a change would add confusion to the process and complicate regulation.
23. The AHA does not believe it is necessary to make significant changes to preexisting legislation to ensure the proper protection of data. They cite standards like the National Institute for Standards and Technology framework as being adequate insulation from unauthorized access for the time being.
24. The creation of a central portal for providers to readily access information regarding cybersecurity threats across critical sectors should be a priority, according to the AHA.
25. The ONC should issue further guidance on the organization model of a full holistic risk management plan that can be broadly followed, according to the AHA.