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September 2013

The Ongoing Quest for Interoperability
By Selena Chavis
For The Record
Vol. 25 No. 12 P. 10

What’s it going to take to bridge the integration gap? Try collaboration and cooperation for a start.

The momentum created by the rollout of federal initiatives such as value-based purchasing and accountable care has created the potential to transform health care delivery. Industry professionals generally agree that performance-based reimbursement models will drive providers away from the fee-for-service models that have existed for decades to one in which quality underpins everything.

The ability of HIT systems to speak to each other seamlessly has been identified as a critical component to the success of these initiatives. Unfortunately, it remains a serious stumbling block. “Interoperability is key to the whole notion of payment for quality and cost-effectiveness,” says Paul DeMuro, JD, CPA, MBA, MBI, a health care and corporate law attorney with Schwabe, Williamson & Wyatt and a postdoctoral fellow at Oregon Health and Science University School of Medicine. “You have to have all the information available in the electronic medical record.”

The federal push to improve interoperability over the last several years has achieved some success, but the Office of the National Coordinator for Health Information Technology (ONC) acknowledges that it has been limited in scope. In a 2012 Health Affairs article, the agency noted that, in 2010, only 19% of hospitals reported that they exchanged clinical information from health records with providers outside of their own system.

One of the primary reasons given for the limited progress is a lack of interoperability between disparate EHRs. “Historically, there was no incentive for EHR vendors to be interoperable,” notes Harry Greenspun, MD, senior advisor for health care transformation and technology with the Deloitte Center for Health Solutions. “Now, with the exchange of information needed for the value-based environment, the ability of organizations to interact becomes much more important.”

Hurdles to Clear
Many scenarios exist as examples of how a lack of interoperability has hindered organizations from complying with federal initiatives. Consider the typical effort to form an accountable care organization, a key federal initiative that is fundamentally structured to incentivize participating health care groups for achieving an aggressive set of cost and quality measures built on improved communication, data sharing, and decision making.

To increase their chances of succeeding, providers must determine how their own EHR can communicate with disparate systems found in their partner organizations. Industry professionals point out that this often requires the creation of costly interfaces, a solution that frequently turns out poorly for both parties.

Then there are hospitals trying to improve performance scores under the competitive landscape of value-based purchasing. Often, these organizations must invest in advanced point-of-care clinical decision-support applications, technology that typically is not offered in a basic EHR package. And because most EHRs were not built to support integration with third-party applications, the cost for the construction of additional interfaces can become quite pricey.

These are just two examples of many roadblocks, say industry experts, who acknowledge that the road to true interoperability is complicated. “Interoperability is a big word with a definition that is far reaching,” says Julie Dooling, RHIA, director of HIM practice excellence for AHIMA. “If it were easy, we would have this fixed by now.”

On the bright side, several collaborative efforts currently under way hold promise for bringing the industry together. However, much of their success will depend on cooperation among all stakeholders, according to Elizabeth Amato, HIT vendor relations manager with the New York eHealth Collaborative (NYeC), a consortium of states and vendors that works to develop policies and standards promoting HIT advancement. “There is a convergence taking place … the draw and the value of HIE [health information exchange] has grown,” she notes. “Vendors have taken an active role in helping because their customers need this to meet regulatory requirements.”

As the driving force behind the EHR/HIE Interoperability Workgroup, the NYeC is partnering with Healtheway, a nonprofit firm that manages the eHealth Exchange, the successor to the Nationwide Health Information Network Exchange, on a program to test and certify EHRs based on standards that enable the reliable transfer of data within and across organizational and state boundaries. Announced late last year, the coalition selected the Certification Commission for Health Information Technology (CCHIT) to carry out the testing and certification program. The workgroup’s public-private partnership features 42 technology vendors, states that include more than one-half of the US population, and Healtheway.

As a result, Amato notes that the industry is on the verge of a breakthrough in two important areas of interoperability: health care providers’ ability to send and receive summaries of care within their clinical workflow and to look up patient records seamlessly across disparate EHRs.

Collaboration and Cooperation
Recent collaboration among stakeholders may be a sign of more cooperative efforts to come. Nevertheless, some industry experts suggest that vendors could do more to promote interoperability. DeMuro says vendors often hold the power because many agreements require their permission to build interfaces and integration capabilities with other applications. “The whole notion of having to get permission is one more hurdle,” he says, pointing out that vendors are in the market to sell products and haven’t necessarily felt it was their responsibility to get on board with the interoperability push. “Each vendor thinks they have the best systems, and they are all trying to sell it.”

Greenspun suggests that, in the past, the concept of interoperability did not necessarily align with a vendor’s profitability goals because a closed system was a more lucrative model. “There’s a broad spectrum of vendor interest. There are those who want to work together and those who are not as incentivized or interested,” he explains. “It often depends on whether interoperability is a high or low priority for their customers.”

Federal initiatives such as value-based purchasing and meaningful use are beginning to impact how providers view their EHRs and future purchases, says Dooling, adding that such thinking may be a factor in some vendors’ newfound interest in working more collaboratively. “We do see that some organizations are rethinking their EHR technology because they are not prepared for stage 2 of meaningful use and beyond,” she notes. “For those that have not invested heavily in technology at this point in time, it’s certainly something to be aware of when going into new contract negotiations.”

To support providers in their efforts to meet stage 2, the ONC requires that certified EHRs incorporate the Direct Project secure messaging protocol to meet the electronic transmission requirement for summary of care records. While only 16 vendors and a total of 36 products have met the requirement, the expectation is that many more will follow suit by next year.

The pilot phase of the CCHIT compliance testing and certification program was announced in March. Once the program is complete, the following three EHR certifications will be offered:

HIE Certified Direct: certifies compliance with the Direct Project protocol for EHR and health information service provider systems, ensuring that providers can send secure health information over the Internet;

HIE Certified Community: enables clinicians to share patient information within and across care delivery communities for EHR and HIE systems; and

HIE Certified Network: enables HIE-to-HIE connectivity and connection to the eHealth exchange.

According to Healtheway Executive Director Mariann Yeager, there is strong vendor support for where the current interoperability movement is headed. “For vendors, [interoperability] simplifies the process,” she explains. “It enhances the value of their systems to their customers.”

In addition to the collaborative efforts of the NYeC and Healtheway, other national interoperability networks have emerged. For example, Surescripts has expanded its interoperability program to include not only ePrescribing connectivity between physician offices and pharmacies but also secure clinical messaging. A newcomer to the scene, CommonWell is an alliance of leading EHR vendors that intends to provide patient record look-up services within a proprietary network.

Vendors with both of these initiatives have joined the Interoperability Workgroup and committed to use its standards for health information exchange.

The Critical Role of Standards
While the industry has made progress in terms of adopting standards to promote information exchange, many industry insiders agree that the absence of a common set of standards remains the greatest barrier to achieving true interoperability. Despite citing meaningful use requirements that promote standards such as LOINC, RxNorm, and SNOMED CT as a step in the right direction, DeMuro says the industry still needs a standard EHR infrastructure to achieve success.

“The health care industry needs a mandated platform,” he says, while pointing to the success other industries, such as banking and railroad transportation, have experienced in that regard. “Every vendor says theirs should be the system. I don’t think anything out there is the solution.”

Greenspun says having too many standards on the market can create a conundrum for vendors as they try to decide how best to align with long-term industry movements. “There are lots of different standards. Which ones are vendors going to support?” he notes. “Moving forward, cost will definitely be a factor.”

The various definitions of what constitutes interoperability can be a barrier to the widespread adoption of standards. In a recent discussion with a provider, DeMuro made note of how some organizations believe they have almost “arrived” because they are working on information exchange with their major partners. “That’s a start, but what if a patient visits a minute clinic?” he says, adding that an industrywide EHR standard is the only answer to ensure complete patient records.

In an effort to get EHRs more aligned with this concept, the CCHIT’s certification program centers on “plug-and-play” capability that will enable clinicians to view and download patient information from outside their organizations without having to go to a website. It also will lower the costs associated with writing separate interfaces for each EHR and support data aggregation for improving population health strategies.

It’s a necessary step, according to CCHIT Executive Director and CEO Alisa Ray, MHA. “There have been voluntary standards in the marketplace for a while,” she says. “One way of helping providers is through certification—to say the products do what they say they do.”

An Expensive Proposition
According to Greenspun, the concept of interoperability originally focused on EHR-to-EHR interactions. However, the concept has evolved to mean something much greater. “There are so many challenges to the broad exchange of health information,” he says. “Interoperability is just one.”

Dooling agrees, suggesting that, on a basic level, interoperability needs to support “accessing the right information at the right time” to most effectively align with value-based purchasing and other federal performance-based initiatives. There are many components and challenges to creating the kind of seamless flow of accurate information necessary for capturing and sharing, she adds. “Organizations need to be able to connect documentation with quality measures,” Dooling explains. “The lack of interoperability will impact the bottom line.”

With or without an industry standard, interoperability is an expensive proposition, Greenspun says. The question becomes who will bear the brunt of the cost.
Under the present fragmented system of piecing together interfaces to make disparate systems communicate, hospitals often incur huge debt, much of which is unexpected. “There are lots of different systems and different versions on the market,” Greenspun says. “Every IT environment is different. It’s complicated.” Emphasizing more extensive interoperability pushes the costs to the vendor community, where many must balance the need for interoperability against the proprietary nature of their own systems.

Considering the current state of progress, some industry professionals pose this question: How big of a barrier will interoperability remain to the widespread exchange of information?

“Just because systems are not interoperable doesn’t mean they are not communicating,” Greenspun says, pointing to current efforts to create interfaces and workarounds to exchange patient data. “Is that going to be practical in the long term? Do we work with what we can do or do we make huge investments to get it at a level of high performance?”

Dooling says industry workgroups are working diligently to reach a middle ground where all parties can share in the creation of interoperability standards. “We all live in the same health care household,” she says. “Whoever you are, we all need to be working together to reach the same goal.”

— Selena Chavis is a Florida-based freelance journalist whose writing appears regularly in various trade and consumer publications covering everything from corporate and managerial topics to health care and travel.