Roundtable: The future of interoperability

The ability of electronic health record systems (EHRs) to communicate with one another, known as “interoperability,” has become a hot-button topic for physicians. One reason for this heightened interest is the requirement in meaningful use stage 2 (MU2) that eligible professionals exchange clinical summaries online in at least 10% of transitions of care, such as referrals to specialists and hospitals. In addition, accountable care organizations (ACOs) and patient-centered medical homes require physicians and other providers to exchange information more routinely than they do now to improve care coordination.

In this roundtable discussion, three panelists from different parts of the health IT arena discuss key barriers to interoperability and what the realities are for overcoming them. The panelists are: Doug Fridsma, MD, PhD, chief scientist of the Office of the National Coordinator for Health IT (ONC); Dan Haley, vice president of government and regulatory affairs for athenahealth, an EHR vendor; and Keith Hepp, senior vice president of business development at HealthBridge, a health information exchange (HIE) in Cincinnati. The exchange was moderated by Ken Terry, contributing editor for Medical Economics.

Interoperability progress

“To start, how much progress do you think we’ve made so far on interoperability and what has been the impact of meaningful use on that?” asked Terry.

“First, we need to make sure that we are all talking about the same thing,” said Fridsma. “There are clearly two components of interoperability: the ability to exchange information and then the ability to use the information that has been exchanged. So whenever someone says, are these systems interoperable or complains that they are not, I always ask what is it that they are trying to accomplish and to what degree does the technology help?”

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“It’s the distinction between interoperability and interoperation,” agreed Haley. “It’s not just a semantic distinction. Interoperability describes a capability and interoperation describes an activity.” 

“With that as a background, I think we have made some progress,” noted Fridsma. “Largely because of the meaningful use incentive program, the majority of providers are now using EHRs. Without that, online exchange of health information would be impossible. Meaningful use stage 2 raises the bar for interoperability among these systems.”

Haley countered that the Meaningful Use program has made the situation worse by subsidizing the purchase of non-interoperable EHRs. “Right now we have an awful lot of systems out there that are capable of interoperability but don’t interoperate due to structural, technological, or financial reasons,” he said. 

“As you know, there are two parts to the meaningful use program,” said Fridsma. “One is the certification criteria that are established though the ONC, and then there are the incentives and attestation that occurs through a separate process through CMS [the Centers for Medicare and Medicaid Services]. I think people have had technical challenges with attestation and meeting the requirements.”

Next: Continuity of Care Documents

Hepp criticized the Continuity of Care Document (CCD) that is used as the standard format for the required summaries of care. (ONC mandates a variant of the CCD called the Consolidated Clinical Data Architecture, or C-CDA, but some providers are still using CCDs).

“There is too much variability in the specified elements of the CCD, making it difficult to extract usable data from the document,” Hepp said. “Part of the challenge is getting everybody to agree on ‘semantic normalization,’ or the mapping of medical terms to a common nomenclature.”

Fridsma agreed on the need for a more uniform CDA to promote interoperability. “However, this is not something the government can do on its own,” he stressed. “It requires what I call open consensus-based, industry-engaged, standard development processes. The standard that comes out of those processes, however, is the starting point, not the end, because I don’t believe that we can truly achieve interoperability in a committee.”

“Committees in Washington, D.C. cannot establish interoperability,” emphasized Haley. “Mandates won’t do it. Federal dollars won’t do it.  We live in a world where we carry around a little supercomputer in our pocket that we use to interoperate, to share, and receive incredibly complex information with people all over the world. Providers and patients need to start demanding of health information technology the same level of functionality that we demand from information technology everywhere else.”

“In one sense, this is a chicken and egg problem,” responded Fridsma, “because you need both the policies to drive adoption and the technology to support those policies. ONC can devise policy drivers for interoperability, but it’s up to the industry to develop the technology and the standards to implement those policies.”

Fridsma believes that meaningful use has been able to “prime the pump” by helping to define technical specifications. He hopes that the industry, in conjunction with the ONC and the standards development organizations, can help to overcome the challenges within the consolidated CDA.

Haley agreed that meaningful use has helped this collaborative process to an extent. “If you prime the pump too long, you will flood the engine,” he said, “and what we are seeing now, in a sense, is the Meaningful Use program consuming itself.”

Haley believes the government program has distorted the health IT market in ways that have impeded interoperability. For example, he said, the delays in the MU2 deadline, including the hardship exception for providers who lack 2014-certified EHRs, have locked many providers into 2011-certified products that the more advanced products can’t communicate with.

“So the federal government is now defining as a hardship the very technologies they subsidized on behalf of those providers,” Haley said. “You also get a chain of events where vendors tell their clients that they cannot meet their compliance deadlines and these care providers turn to the government and say it’s not fair to punish them for the failing of their vendors. The government responds the only way they can by delaying the next stage, which has the effect of locking thousands and thousands and thousands of providers into the use of systems that do not interoperate.” Moreover, he said, this policy has given vendors of non-interoperable EHRs another year to sell their systems.

Haley admitted, however, that the interoperability requirements of MU2 have encouraged many providers to start exchanging data with each other.

Next: Direct messaging

Direct messaging

An important branch of policy-driven interoperability is secure messaging, using the Direct protocol that the public and private sectors agreed on recently. Direct messaging allows physicians and other providers to exchange secure messages using a protocol similar to e-mail. These messages may have attachments, such as CCDAs containing care summaries.

Like faxes, Direct can be used to “push” data from one point to another, but not to search for and “pull” data from disparate EHRs.

About half of the nation’s physicians have Direct addresses supplied by three dozen “health information service providers,” or HISPs. But that doesn’t mean that all of those doctors are using Direct. DirectTrust, a trade association that accredits HISPs, says about 7.7 million Direct messages were exchanged from January through July of this year.

“Do you believe Direct messaging is becoming a major mode of communication among providers and will it help meaningful use?” asked Terry. The panelists lauded the Direct trend, but pointed out that it is a very limited form of interoperability.

“Direct is only part of the portfolio of solutions required to provide interoperability in all situations,” Fridsma responded. “If you think about how we communicate with people in our family, we use our cellphone, text messages, email, or postings on Facebook. So Direct is an important part of the portfolio that will serve the needs of some specific kinds of information exchange, but we shouldn’t expect it to be the end-all and be-all.”

Haley agreed, but added that Direct is just one technological step up from fax. “We need to be careful not to lock ourselves into the use of inferior technologies in perpetuity in the name of making progress over the sad state of affairs we find ourselves in now, where doctors are still communicating by fax,” he cautioned.

“I believe Direct will become a permanent part of the interoperability ecosystem,” noted Hepp. “At HealthBridge we use different technologies based on what the problem is. For instance, we have hundreds of EHRs connected to our health systems, and we use HL7 and SSL [secure socket layer] technology. We don’t see any reason to rip that out with Direct.”  Hepp emphasized that it depends upon the business problem being solved. “Direct is not the best, most efficient way to solve every problem,” he added.

Next: Health information exchanges

Health information exchanges

Health information exchanges (HIEs), which can be used for both “push” and “pull” functions, enable providers to exchange data in some areas of the country. These organizations include public HIEs, and private HIEs that healthcare organizations use for communications among their affiliated hospitals, physicians, and ancillary providers.

Private exchanges have grown faster than public HIEs, partly because the latter have had difficulty finding a viable business model. In 2012, there were 119 operational public HIEs, with just 30% of hospitals and 10% of physicians participating in them.

Haley took a dim view of HIEs, saying he’d like to cut out “the middleman” entirely in data exchanges between EHRs. “When I communicate with a retail outlet electronically,” he said, “I don’t have to send my financial information to a government intermediary to translate it to the retailer, who then pushes information back through the intermediary to me.”

“The financial industry isn’t the best analogy,” responded Fridsma. “Certainly I interact with a retailer, but when I swipe my credit card, it goes to a clearinghouse that manages that transaction on behalf of that retailer. So there are intermediaries we currently use to help provide seamless transactions.” He believes that HIEs can be useful and noted that successful HIEs don’t just move information around, but also provide analytics and integrate data for their customers.

HealthBridge has been a great success story among HIEs. According to Hepp, it has been profitable for 10 years. “The basic value proposition for our hospital customers is cost savings,” Hepp noted. It costs them $1.12 to mail a lab result to a physician, versus 12 cents to send it electronically via HealthBridge. We also provide the data that our participants need as they move into ACOs and other value-based payment models.”

Next: Data liquidity

Data liquidity

With most providers still in a very early stage of interoperability, the current emphasis is on exchanging documents, such as the CCDA care summaries attached to Direct messages. However, the data in these documents cannot flow automatically into the appropriate fields of receiving EHRs if those fields are different from the EHR that generated that data.

It’s also difficult to search for data in disparate EHR databases. Both ONC and private organizations such as CommonWell, Healtheway, and the EHR/HIE Interoperability Workgroup are trying to solve these problems.

“ONC’s long-term goal is to move from a document-centric to a data-centric HIE,” Fridsma said. “We are seeking APIs, or plug-ins, that can help move this process along, and working on a structured data capture initiative to devise a syntax to describe granular data.”  He noted the ONC is continuing its work to standardize the meaning of medical terms, database structures, and the mechanisms of data transport and exchange.

Haley noted that CommonWell, an initiative started by several health IT vendors, including athenahealth, has been making progress. CommonWell is still focused on document exchange and accurate patient matching. Haley said the group is “excited” about a new HL7 specification, Fast Healthcare Interoperability Resources (FHIR), which defines a set of resources that represent granular clinical concepts.

Fridsma confirmed that FHIR has generated a lot of industry excitement. “Using modern standards like JSON and XML, FHIR is modular, data-centric, and developer- friendly,” said Fridsma. “I think there is tremendous interest in this as an evolving standard that might support interoperability.”

Although Haley expressed admiration for the FHIR approach, he cautioned the government against mandating it. “The reason we worry about that is precisely because FHIR is so cool and so promising,” he said. “We know full well, as people who work in technology, that right around the corner there will be something that makes FHIR look like a fax machine. So we want government to resist the impulse to mandate use of a standard or some set of standards that could very well be obsolete before they are even universally adopted.”

Hepp reiterated that semantic normalization must be accomplished before there can be true, data-centric interoperability. On the other hand, he noted, “We want to make sure we don’t make the perfect the enemy of the good. If the results of the 250 most common tests can be exchanged accurately between disparate EHRs, that would provide 95% of the results that physicians need, even if the results of many other tests cannot be easily exchanged.”

Next: Conclusion

Conclusion

Terry asked each panelist for their final take-away messages. “The industry needs to be patient while the pieces fall into place,” said Hepp. Looking back over the 15 years of HealthBridge’s experience, he noted there have been many changes in health IT, business models and expectations in that period. “While healthcare has not moved as fast as other industries, I think the technology standards will get there. Healthcare as a whole is being transformed right now and interoperability is one piece in that major transformation.”

“We will achieve interoperation when the consumers of health information technology demand interoperation, particularly care providers,” said Haley. “There is no reason that care providers in this country should not expect of health information technology every bit of the capability and functionality that they expect of information technology everywhere else in their lives. And there is no reason that care providers should count on vendors who tell them they cannot prepare them to meet reasonable requirements that are intended to improve the sorry state of health information technology in this country. If a doctor’s vendor is telling them that they can’t meet the meaningful use deadlines, then they have to get a new vendor.”

Fridsma re-emphasized the need to find multiple solutions to meet the interoperability challenge. “I think what we’ll have in the future is not going to be a singular architecture, but a portfolio of different capabilities that will be applied to solving the problems and helping to incentivize things. Just as the analogy was made to how we manage the rest of our information needs, success in getting to an interoperable healthcare system is when we stop talking about interoperability; it actually works, and people aren’t worried because the information is flowing at the right level of granularity and supporting the right usage,” he said.