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August 30, 2010

How Do You Define Interoperability?
By Robert N. Mitchell
For The Record
Vol. 22 No. 16 P. 20

Without a precise, standards-based definition, healthcare organizations run the risk of losing context when exchanging data.

Interoperability means different things to different people and organizations. While a common agreement on what it means to healthcare may never be reached, it’s important that everyone understands how it’s being defined. Clarity of terminology is particularly important in today’s overabundant, acronym-filled landscape where ARRA, RHIOs, EMRs, EHRs, HITECH, and HIEs are being discussed extensively.

At Phoenix Children’s Hospital, Vice President and Chief Information Officer (CIO) Bob Sarnecki agrees with the general principles of what’s trying to be achieved with interoperability and intercommunications among healthcare systems. “I actually tried to explain interoperability and HL7 [Health Level Seven International] to my board recently,” a discussion that included interesting and eye-opening examples for executive leaders, he says.

A Baseball, a Football, and a Puck
“The way I explained it to my board is I started out with a brown paper bag with two baseballs inside,” Sarnecki recalls. “I went to two different board members and put the baseballs in front of them. I said let’s pretend for a minute that the two of you agree you want to build the absolutely best baseball team that’s ever existed. You start with these two brand-new baseballs and begin building your stellar league. As you move forward, you realize that building the best team involves lots of investments and may require more funding than you have, so you start looking at other leagues and teams, trying to find ways to come up with more money.

“I then gave a football to another member and said you look over here at this person and he has a football and that’s not really a baseball, but maybe there’s a way to translate things so that when you throw the baseball, it becomes a football before it gets to the next person. And when he throws you the football, it becomes a baseball before it reaches you,” he continues. “Each of you agree that he can keep his rules and you can keep yours, and you will do the translations in the middle and try to pass the football and baseball back and forth” and that works OK for a while. “But now the organization is bigger and still needs more money to invest in creating interoperability, so you go to the next board member and give him a hockey puck. Now you have a hockey puck that you need to translate moving forward, and it needs to become a football for this person and a baseball for that person. Before you know it, you have accomplished a place where everyone can play the game, regardless of whether it’s a hockey puck, a baseball, or a football.”

By now the standard is somewhat diluted, Sarnecki notes, to the point where the real possibility of standards is difficult to achieve because everyone understands different rules and is expecting everyone to translate their rules back and forth. “The problem is that if the only thing you needed to do is pass the ball from one place to the next, then that would be one thing, but there’s a context that’s lost as you move from one set of rules to the next,” he says.

One organization may look at transactions categorized under a patient number. Another finds a patient visit number for every encounter regardless of the associated patient number. “Thereby I have a different set of rules on either side, and the systems don’t know how to keep the context between each of the rules,” Sarnecki says. In principle, everyone knows what they’re looking for, but it’s exceedingly difficult to achieve undiluted results because there are many different people with many different rules.

Protecting the Context
Part of the difficulty with a common definition is the way today’s health information systems are designed, where most can’t easily communicate with each other. Even a hospital’s workflow can change the intended context. “When it’s an inpatient, everything is encounter based, so the physicians are first looking at a snapshot of what’s happened most recently,” Sarnecki says. “When the patient is on the ambulatory side, it becomes more nonencounter based; the physician is looking at key milestones of interactions which dictate whether the patient is doing well or not.” On occasion, workflow forces the two extremes in interoperability, making it difficult for the systems to talk to one another.

Even Charles Jaffe, MD, PhD, CEO of HL7 International, one of several national standards organizations, has difficulty defining interoperability. “It depends on whom you ask,” he notes. “For the healthcare industry in general, the concept of interoperability is still vague. A textbook explanation is that interoperability means the seamless and unambiguous exchange of data between two electronic systems. There is also the concept of semantic interoperability, which is important because it implies that you can reuse the data that one system has received.”

Jaffe says data reuse is implicit to the meaningful use concept as defined in the American Recovery and Reinvestment Act, and the notion of interoperability requires more than seamless data exchange. The need for a consistent structured vocabulary is critical to the concept. “If you and I don’t agree on what a term or concept means and how to express it, then we fail to achieve any degree of interoperability. A computer overlooks nothing. Second, the way we express ourselves in English is also an issue when converting free text to structured data,” he says. “An example: I turn to a nurse and say, ‘Give the patient a medication for pain.’ That’s very different than if I say to the nurse, ‘Give the patient a pain medication.’

“If the nurse comes back and says, ‘Do you mean this?’ then we may have solved the dilemma. But the computer can’t come back and ask a follow-up question, or at least not today’s computer systems,” he adds. “Ambiguity in terminology, setting, or role really matters today. The question of interoperability is a loaded one, yet it’s fundamental for understanding what healthcare technology can achieve.”
“I don’t think there’s a common definition of what it means; it’s almost as broad as meaningful use,” says Chuck Christian, CIO at Good Samaritan Hospital in Vincennes, Ind. “I think it’s one of those terms that can mean a lot of different things depending on who you ask.”

For Christian, who regularly speaks with executive leaders at Good Samaritan, interoperability means systems must be able to talk to each other. “But that raises the question ‘at what level?’’” he says.
It’s apparent that even at a federal level, an interoperability definition may be changing. “From the outset, interoperability meant the exchange of discrete data (eg, lab results). But if you look at recent definitions, such as those coming from the NHIN Direct initiative [a project designed to expand the standards and service definitions that constitute a national health information network], it’s more about pushing discrete encounter information, which can be physician notes, demographics, and lab results in a packet either for the continuity-of-care record or continuity-of-care document,” Christian says.

At Good Samaritan, he tells executives the term centers around the patient experience. “I define interoperability as how we exchange information for the patient,” he explains. “For me, that’s discrete data. It’s not packets of data; it’s a lab result, a test result, or demographic information. It’s encounter information that we can move from one place to another, either to a physician’s EMR or the state health department. To me that’s interoperability because it’s a rapid aggregation of information at a micro level, creating macro views out of the information that’s before you” that helps to provide better patient care.

Douglas Fridsma, MD, PhD, acting director of the Office of Interoperability and Standards at the Office of the National Coordinator for Health Information Technology (ONC), says healthcare professionals sometimes think of interoperability as a binary process. “Either you are interoperable or you’re not,” he says. “However, I think that there’s much more nuance to it than that.”

Interoperability, he notes, is the ability to parse information so it can be displayed or transmitted. “However, if you speak French and I speak German, we haven’t been able to exchange any information. And there’s this notion of semantic interoperability—the ability to use information in a useful way. When people talk about interoperability, there’s interoperability at a technical, transportation layer. There’s also interoperability at a data element level,” he says. “Can we take two different data elements and merge them together? There’s a semantic layer and even things like business processes, which include whether you are getting the information at the right time and place. Also, was it collected in a way that makes it applicable for that context?”

Whether there’s a consensus on interoperability or whether one can be achieved may come down to whether the term’s nuances have been articulated to the point that when people say data exchange is interoperable, it can only mean one thing. “The first step is to have clarity vs. consensus,” Fridsma says. “When we say we can exchange information, we think we have achieved interoperability.” The meaning must be clear in all data-exchange formats. For example, there are different levels of interoperability depending on whether data are exchanged via a PDF file or if they are coded information that can be used for clinical decision support. “It’s not so much consensus [but] rather clarity in what do we mean when we say interoperability,” Fridsma says.

The National Role
Most HIT leaders agree a national standard should be established that everyone could move toward. A good place to start such a movement is at the ONC under the leadership of David Blumenthal, MD, MPP. “But where it goes from there isn’t clear,” Sarnecki says. “We should have Dr. Blumenthal working with hospitals to find out what the interoperability standards need to be between hospitals and physician practices and not letting the vendors do this because they do not have a vested interest in changing what they put their research and development dollars into.

“Alternatively, hospitals have a vested interest in getting the most information to move between various areas, and that’s where ARRA incentives come into play. It needs to start with Dr. Blumenthal and move to the hospital’s CMIOs [chief medical information officers] and CIOs to define interoperability that’s independent of a vendor solution,” he adds. “As a CIO, it’s important that we define things such as meaningful use, but at a national level we need a group that says this is the standard we want vendors to adhere to, not just say we have a rough set of standards that everyone needs to certify against. What is it that we need to change about the systems, and what kind of standards are going to open the doorway to interoperability?”

Clearly, the more precise the definition, the easier it is to use the information. And the results should be impressive. “I think we’re going to get to a much higher quality of care because we won’t have to be doing translations or taking things from one format and moving it to another format,” Fridsma says.

— Robert N. Mitchell is a freelance writer based in King of Prussia, Pa.