Every few years, health care, like any other industry undergoing rapid changes, adopts a rallying cry. For some time now, it's been interoperability. The clamor is reaching a fever pitch, and with good reason. Our collective efforts to significantly improve health and health care through electronic health records, population health management and even the "empowered patient," will be largely unfulfilled without interoperability.
For health care to have a shared view on interoperability, and a shared commitment to it, industry leaders need a common definition. We'll use the elegant and simple definition used by the Office of the National Coordinator for Health Information and Technology (which follows the Institute for Electrical and Electronics Engineering definition): "the ability of systems to exchange and use electronic health information from other systems without special effort on the part of the user. "
While there are more sophisticated definitions delving into foundational, structural and semantic approaches, what it comes down to is this: Interoperability means that data can traverse organizations, groups and technology platforms. It allows the exchange of data among providers, public health agencies, patients and researchers. That means disparate EHRs — and other systems and devices — must share information both inside and outside the walls of any single institution.
The ONC has issued a draft report, "Connecting Health and Care for the Nation: A Shared Nationwide Interoperability Roadmap." (The ONC is now accepting public comment and will issue a final report around the time this article goes to print.)
In her introduction, Karen B. DeSalvo, M.D., national coordinator for health information technology, writes, "Achieving that better care system and better health for all will, through health IT interoperability, require work in three critical pathways: (1) requiring standards; (2) motivating the use of those standards through appropriate incentives; and (3) creating a trusted environment for the collecting, sharing and using of electronic health information." The ONC is so determined to make true interoperability a reality that it has hired its first chief health information officer, Michael James McCoy, M.D., who has extensive experience in standards development.
Why We Need Interoperability
Today's health care consumer may receive care in multiple settings from multiple providers. In addition, both payment and delivery models are changing rapidly. All of this activity leads to significant demands for data fluidity — data needed to coordinate care, manage quality and reduce costs. This information is important for the person at the center of health care: the patient. Everything we do in health care should be designed for the patient. The EHR is a wonderful thing, but if it's confined within the walls of a single institution, it falls far short of its intended value. If a clinician does not have access to a patient's complete record of care, he or she must make calculated guesses regarding what's appropriate, or begin the care process again.
A recent study found that 20 percent of patients who were transferred from one hospital to another underwent unnecessary, duplicative testing. It's a costly, flawed and avoidable route to patient care.
A patient who has multiple prescriptions from different physicians may run the risk of adverse drug interactions because the pharmacy and the physicians' systems don't "speak" with each other. Even more cause for concern is that patients dealing with a serious illness may find themselves carrying their own paper records and images from clinician to clinician during an already stressful time. Lack of interoperability is inefficient at best and, at worst, adds costs and harms patients. Without interoperability, we fail the patient.
If critical information is shared between providers and systems, it creates greater efficiency and speed in care, helps to ensure the right diagnosis and treatment, and eliminates redundancy. In addition, it makes all of that care more cost-effective. Interoperability ensures that the vast amounts of data generated by personal fitness and wearable monitoring devices is included in the patient's EHR. Such devices capture information about activity, heart rate, blood pressure and even medication adherence and stress levels. This technology expands the body of clinical knowledge a provider will have about the individual patient under his or her care — but only if it is available.
The Challenges of Interoperability
Over the last five years, EHRs have been adopted at an impressive rate, and HIT professionals and providers, myself included, might feel the need for a few high fives and pats on the back. Last year, under Stage 2 of the meaningful use program, there was an emphasis on interoperability, although in many ways it was relatively modest, requiring only the sharing of summary of care records. Even this limited use highlighted glaring obstacles to true interoperability.
The differences in how EHRs were developed and implemented, and the inconsistent use of standards, means that sharing data — and ensuring that it is usable — is complicated and burdensome. The lack of a nationwide patient identifier hinders providers from sharing patient data. A directed exchange (sending a specific set of information to a specific provider) may be relatively simple, but pulling together data from a wide array of sources using a mechanism such as a record locator service can be overwhelmingly complicated. A new health information exchange often requires that clinical processes be re-engineered or created, work that is always difficult.
The most personal of information about an individual makes sharing of information uniquely complex and sensitive. In a March 4 Health Affairs blog by five U.S. senators, "Where Is HITECH's $35 Billion Investment Going?" the authors point out the particular sensitivity of patient data: "Unlike a credit card number, the information contained in a patient's health record is impossible to reissue. Health records contain financial records, personal information, medical history, and family contacts — enough information to steal and build a full identity or use for valuable research purposes."
There are other major challenges. Despite the calls for interoperability, often there is insufficient motivation among providers or HIT developers to make it happen. Providers have been reluctant to share the information they have generated, and the sheer number of different systems that must communicate with each other is staggering. In addition, some vendors have had little incentive to play together, giving rise to a pattern of data blocking.
A Nationwide Effort to Advance Interoperability
There are several efforts underway to address these challenges. At the center is Health & Human Services, within which the ONC resides. The ONC has outlined five core components that it aims to achieve:
- core technical standards and functions;
- certification to support adoption and optimization of health IT products and services;
- privacy and security protections for health information;
- supportive business, clinical, cultural and regulatory environments;
- rules of engagement and governance.
Other Health & Human Services agencies, most notably CMS, also have critical roles to play in advancing interoperability, as do state governments. Such states
as Massachusetts, New York and Delaware are advancing care delivery through state-level health information exchanges.
Increasingly, the private sector is stepping up to the challenge. There are various collaborations in the works — even among traditional HIT competitors — to create standards and promote the sharing of data. The CommonWell Health Alliance has developed and implemented critical interoperability components such as a patient identification and linking and a record locator service. Carequality, another collaborative, is developing an interoperability standards and governance framework. The Argonaut Project is defining and testing the next generation of interoperability standards. The eHealth Initiative recently released its 2020 Roadmap, which outlines a path to broad interoperability. The Joint Interoperability Testing and Certification Program is working to facilitate the exchange of patient information across state lines.
All these collaborations bring together industry stakeholders to accelerate interoperability. No single organization, not even the federal government, can surmount the interoperability challenges without the collaboration of all stakeholders in health care.
Where Do We Go from Here?
A wide range of industries and sectors — banking, telecommunications, supply chain, transportation and emergency services — have achieved interoperability. Think about the remarkable ease of conducting transactions at an ATM not owned by your own bank. For a nominal fee, you have access to account assets anytime, anywhere. Granted, interoperability in health care is a much more significant challenge than in any other industry, but those industries have shown us that it can be done.
We have made progress. It's been slow and, at times, maddening. But the stakes are high, and it is crucial that we continue to hammer away at the obstacles.
Collectively, we must focus on several goals:
- advancing standards development and pursuing new technical approaches to effecting standards-based interoperability;
- strengthening sanctions, perhaps through the certification process, to minimize business practices that thwart interoperability;
- increasing transparency of vendor and provider progress in achieving interoperability;
- developing a trust framework that balances the need for efficient exchange with the privacy rights of patients;
- promoting collaborative multistakeholder efforts, such as CommonWell Health Alliance, Carequality and eHealth Initiative;
- encouraging provider-led activities within communities to broaden the range of interconnections — ensuring that stakeholders such as safety net providers are included;
- creating a governance mechanism that ensures an effective interchange across a wide range of health information exchanges;
- making reimbursement changes that emphasize care coordination and population health management, all of which must continue to evolve and be implemented.
As important as these goals are, the most important thing we need to do is to remind ourselves constantly that we are here for the patient, and we will have failed that obligation if we settle for anything less than widespread, efficient and secure interoperability.
John Glaser, Ph.D., is a senior vice president of Cerner Corp., headquartered in Kansas City, Mo. He is also a regular contributor to H&HN Daily.