Making the Case for Interoperability Standards

Republished with permission by author: Jeff Byers. This article first appeared in HealthcareDIVE on March 14, 2017

As hospitals plug into more networks with partnerships, mergers and new consumer health devices, interoperability is needed more than ever.

It's buzzy. It's the fly in the ointment for many and vendors swear it's seriously. just. about. to. gain. traction.

Interoperability. Thinking about the topic is daunting itself but for those on the frontlines of care delivery and for patients, its increasingly becoming necessary as the healthcare industry enters into a more networked era. 

When we last checked in on interoperability, the industry was touting the massive adoption of EHRs. Industry thought leaders such as former National Coordinator for Health IT Dr. Vindell Washington noted that once adoption hits a tipping point then data sharing can actually occur. That data sharing is more important than ever as more data points and companies are attempting to enter the space, creating more health data than the industry may know what to do with. While legacy EHR vendors have historically been accused of information hoarding, recent industry developments have signaled the year 2017 may make significant gains in working toward actual data sharing, integration among vendors, providers. 

Care everywhere

Access to healthcare services is changing in the digital age. From alternative care settings to telehealth companies, supply and demand for healthcare services is in flux. As athenahealth CEO Jonathan Bush recently told Healthcare Dive, before such events hospitals had control over the supply of healthcare services and as more supply becomes available to patients, it's important for caregivers to connect to patients.

While evidence suggests that neither retail clinics nor telehealth are becoming replacements for ED utilization thus far, it's important that these services are actually being used. "Care is actually moving away from the hospitals," Dr. Rasu Shrestha, Chief Innovation Officer at UPMC, said during a panel at the National Health Policy Conference (NHPC) in January. "The brick and mortar hospitals that we know today will not be the focal point of healthcare delivery tomorrow."

As care moves away from hospitals, whether at large or in part, it will be important to integrate health data from all over the care spectrum to get a full picture of a person's well-being. 

WebMD Health Services Chief Medical Officer Dr. Michael Sokol told Healthcare Dive that the trend toward well-being could potentially include data on a host of patient information such as work/life balance, mindfulness and volunteerism information. He notes one of the challenges in the space is integrating all that information in one place as both payers and health systems deal with multiple vendors. He offers physical wellness companies may offer that single view into a patient's picture of well-being. 

Dr. Brian Levy, VP, global clinical operations & product management at Wolters Kluwer told Healthcare Dive when it comes to the actual benefits of health data, there's a lot of hype around wearables but "I don't think most of that data is worthwhile to be brought into the EMR. I think patients realize that doesn't impact everyday care." Levy sees data around disease specific information for patient populations such as blood glucose levels as more worthwhile data coming into HIEs and EMRs.

That doesn't mean, though, that there isn't room for patient-generated or patient-focused data in the health IT space. Michael Gagnon, chief technology officer at Vermont Information Technology Leaders (VITL), the designated operator of the Vermont HIE, said it's still a challenge to get provider data in a readable format but "I think we will see more and more patient data and other sources will come in" to the care continuum. Some potentially important data points may include social determinants of health, Gagnon said, such as whether a patient has transportation to a healthcare visit or information related to their housing situation or socioeconomic status. "Those things are becoming more and more important in our environment because they describe a patient’s ability to have access to care," Gagnon said. "Even if care is available, can they get to it?" 

Open season

Speaking of EMRs, recent news has shown that legacy vendors are taking cues from other, more connected industries by warming to the idea of interoperability. In interviews at HIMSS17, Healthcare IT News reported top executives from Allscripts, Cerner and Epic revealed they are offering APIs that facilitate interoperability and patient identification.

Last year, a report published by Health 2.0 found small IT companies said they faced major challenges integrating digital solutions into large vendors’ EHRs. But the landscape is changing. Bush, while at HIMSS17, told Healthcare Dive what has changed in the health IT industry between 2014 and today at athena and in the market at large is the emergence of the potential for platform. The ability to integrate and connect among doctors, caregivers, payers, wellness providers, EHRs, digital health, etc. requires a new architecture and style of business.

With the Meaningful Use program, there was the sense of being interoperable for interoperability's sake, according to Levy. Now, "I think we're starting to move on to show some of the actual downstream benefits of interoperability," he said. The questions should now be "What do we do with the data?" and "How do we realize the benefits of the data when we can share it?'"

Why providers are thinking about interoperability standards

Providers want to see a patient's full picture of health and some providers, such as Christi Curl, director of performance improvement, clinical quality, Hardin Memorial Health, a Transcend Insights customer, believe outcomes are affected by how much or little of a patients' profile a caregiver can see. With integrated systems, a better picture is given, Curl told Healthcare Dive at HIMSS17.

Unfortunately, even if some technology is integrated, an added challenge for caregivers is the lack of standards for health data. "While we’ve made progress in the last three to four years and have the promise of FHIR, the standards in healthcare from a data exchange standpoint are very weak," Paul Shenenberger, CIO, Summit Health Management, told Healthcare Dive.

He called C-CDA an "interesting government play" but said it's not really effective for data sharing and the reconciliation providers are being asked to with the template is "completely unrealistic." Gagnon said CCDs and C-CDAs are complicated as they are great documents for care transitions but can be difficult to disassemble into disparate elements or make schematically useful for a standardized document because of its flexibility in nature. In addition, it can be a challenge to know which information is new in a C-CDA. "You get all these CDAs and then they have conflicting information or extra information so how do you extract that out into a single patient record is now becoming a challenge," Levy said. Being interoperable for care transitions is different than being interoperable for population health, Gagnon added.

athenahealth's CMO Todd Rothenhaus was a little more blunt on C-CDA in a recent interview Politico's Morning eHealth, calling the template "a giant XML piece of crap."

Adding to the uncertainty surrounding health data standards, Shenenberger said the government seems to have a "complete lack of interest" to implement a national patient identifier. In a recent blog post, Dr. John Halamka, CIO at Beth Israel Deaconess Memorial Center, laid out what he believes should be next steps for the national health IT agenda after attending HIMSS17. Two of the 10 principles he laid out were particularly noteworthy: 1) Stop designing health IT by regulation and 2) Establish a national patient identifier. He wrote creating such an identifier "would remove a barrier to seamless interoperability."

Currently, a lot of interoperability hinges on a clean master patient index (MPI) and that takes time and investment. UPMC, using best-in-breed EMRs across its organization, invested in dbMotion in 2007 to tie together the systems and create a MPI. Beyond an MPI, what's creating a more opportunistic interoperability environment are APIs and the willingness of some of the large vendors to open their systems up out of necessity, Ed McCallister, CIO at UPMC, told Healthcare Dive. "The model of being able to have a closed environment and not be interoperable is behind us" due to pressures from Washington, DC and patients demanding access to their health records.

"We need to be able to open those systems and create interoperability through open APIs [but] it starts with the master patient identifier," McCallister said. Shenenberger agrees the promise of APIs are going to help data sharing but does caution it may be some time before legacy EHR companies introduce them into their systems.

Therefore, Shenenberger notes interoperability needs to be at the heart of every purchase discussion. "As we purchase these systems, integration is often an afterthought." Physicians/end-users should be involved in conversations to help understand what integrations and work-flows may be helpful.

"Interoperability is at least as important as functionality" for EMR systems, Gagnon said, adding providers should emphasize interoperability when first contracting with vendors, which will make the system more extensible going forward. However, just because a vendor states it complies with a standard, that doesn't mean that standard is well adopted or, as in HL7's case, tailored to read as a provider wants it to read.

"HL7 interface projects are the bane of all of our existence," Shenenberger said, adding vendor conversations need to evolve so APIs, not Hl7 interfaces, are a de facto conversation talking point.

Gagnon adds when in vendor discussion, providers should analyze outputs to get a sense how accurate and complete their documents may be for an organization's interoperability needs.

Trying not to get left behind

"One of the things we’ve allowed ourselves to persist in the industry is this concept of how painful and how much fidelity of data you lose by switching from one EMR vendor to another. So, it’s created an artificial gap in competitiveness in the landscape which I think has actually reduced the competitive nature of the overall EHR marketplace which has tapped out some of the innovation," Shenenberger said. He believes MU created an incentive where many EMR vendors created MU-compliant systems that weren't innovative in how healthcare is delivered.

Shenenberger's comments echoes Halamka's blog which states it's time for innovation to enter the health IT space. As UPMC's Shrestha stated at NHPC, one of the biggest impediments to innovation is complacency. And complacency in the healthcare space could be detrimental. Speaking at the same panel as Shrestha at NPHC on innovations disrupting healthcare, Dr. M. Chris Gibbons, chief health innovation adviser, FCC, said healthcare as it's traditionally been practiced is threatened to be left behind.​ He stated in the future, the physician's role will extend beyond just treating the patient. As potential medical devices such as wearables and voice assistants begin to disappear into clothing and into environments, Gibbons envisions a future where a patient could be treated by smart devices in the environment. For example, a smart room could detect a child with asthma had changed their breathing pattern while sleeping and raise the humidity of the room and/or administer albuterol via a smart vent so the child breathes in the medication. The child's parents would then get an automated text message about the interaction to know it happened. In this futuristic scenario, a medical adverse event was prevented without a physician. "It's an entirely new way of thinking," Gibbons said.

While not speaking directly on EHR systems, Gibbons' vision underscores that as new tech tools (perhaps artificial intelligence) and new data points enter the space, the network becomes more important. However, this presumes that data integration can be done correctly and accurately. If the industry continues to deal with fractured health data and lag behind on innovation, then it will be harder and harder to take the first big leap to next generation tools as technology's capabilities continue to advance.

Even with particular hospitals and health systems, if health data isn't seamless, patients may pick up on that and take their business elsewhere. Therefore, though it may be a painful process, the need for standards and interoperability are desperately needed for innovative care to move forward.