The federal government has put in motion a ten-year plan for establishing a nationwide learning health system made possible through incremental improvements to healthcare interoperability. Who could stand opposed to a healthcare system that ensures that patients are receiving the most informed care at a given moment in time?
A better question is: What does that level of healthcare integration entail?
Understanding the difference between the current status of healthcare interoperability and the destination set by industry leaders is crucial to evaluating the progress being made across the healthcare industry.
Considering the importance of advancing interoperability in healthcare, what follows is a breakdown of the concepts and organizations currently playing a part in laying the foundation for a learning health system.
What interoperability means in healthcare?
It is not possible to discuss the efficient exchange of health without first addressing the meaning of interoperability. Legislators have recently taken to using the words “true” and “wide” to describe a state of interoperability, which serves to cloud an basic understanding of the concept.
The Healthcare Information and Management Systems Society (HIMSS) has provided the most thorough understanding of healthcare interoperability when its board approved a tripartite definition of the term.
As defined by HIMSS, healthcare interoperability occurs at three levels. The first is foundational which “data exchange from one information technology system to be received by another and does not require the ability for the receiving information technology system to interpret the data.”
The second level is structural and “defines the structure or format of data exchange (i.e., the message format standards) where there is uniform movement of healthcare data from one system to another such that the clinical or operational purpose and meaning of the data is preserved and unaltered.” According to the HIMSS, this level of interoperability is all rules that don’t change the data that is exchanged in a material way.
The third and final level of interoperability is semantic, which HIMMS has described as the pinnacle of health data exchange. According to the organization, it “takes advantage of both the structuring of the data exchange and the codification of the data including vocabulary so that the receiving information technology systems can interpret the data.” In this sense of the term, health IT systems speak the same language and therefore do not require a level of interpretation to make patient health information actionable.
Two other terms are essential to an understanding of healthcare interoperability — and both are borrowed from information technology in general. They both have to do with interfaces.
At its most basic, an interface allows two systems to communicate. Consider the interface as a translator. This go-between enables the data elements of one system to be available to another in a recognizable format.
An application programming interface (API) represents an interface at scale. Rather than different one-off means of communication between two systems, an API simplifies the setup by offering a streamlined manner for interacting with a given system.
APIs are a standard part of the lives of smartphone users. Apple and Android APIs enable developers to write applications that can work with Apple and Android operating systems to perform dedicated functions. In short, APIs give developers a static vocabulary necessary to speak with the OS.
In order for APIs to prove beneficial to the greatest numbers of developers, the systems they interface with must make use of common and better yet widely accepted standards. In healthcare, a handful of standards have gained a strong enough foothold.
Understanding health IT standards and APIs
Emerging health IT standards such FHIR get most of the attention these days, but others that predate it are common and necessary to health data exchange currently.
Imaging is an important component of healthcare, but few beyond radiologists likely appreciate the value of the DICOM standard. The National Electrical Manufacturers Association owns the copyright Digital Imaging and Communications in Medicine (DICOM), the mechanism enabling medical imaging devices such as picture archiving and communication systems (PACS) to exchange images with other systems.
In earliest days of the EHR Incentive Programs, two health IT standards vied for contention — the clinical document architecture (CDA) and the continuity of care record (CCR). Two standard development organizations (SDOs) were behind the two information models: Health Level Seven International (HL7) and the American Society for Testing and Materials (ASTM International), respectively.
Despite proposals for harmonizing the two, CDA won out in subsequent stages of meaningful use and now exists in the popular consolidated CDA format (C-CDA). The Office of the National Coordinator for Health Information Technology (ONC) only included the C-CDA in its 2014 and 2015 Edition certification criteria.
"ONC is entirely behind the use of FHIR, but the fact is that the marketplace will decide the utility of FHIR."
Keeping with meaningful use requirements for the moment, the Direct standard is a standard used by healthcare organizations and providers to exchange health data in a secure manner. The Direct message protocols are a byproduct of ONC’s Direct Project. Most know it as Direct secure messaging, but DirectTrust President & CEO David Kibbe, MD, MBA, has stressed that it is capable of much more.
“That primary use case is one that has led to people saying that it's basically secure email,” he said. “But actually it's much broader than that. It's a transport protocol which has a lot more capability than simply to be used as a means of person-to-person communication. That's very valuable; that use case is very important. It creates a connection between two people that a fax doesn't do very well electronically.”
The transport protocol also supports server-to-server as well as server-to-endpoint exchange.
“As the healthcare provider organizations start using Direct exchange for that primary use case — care coordination, transitions of care, and so forth — they're starting thinking about using it for moving data from point A to point B for other use cases. That starts to involve the protocol being used in those other ways,” he added.
Despite its close association with the EHR Incentive Programs, Direct exchange and messaging continues to grow as a result of new use cases. By the close of the 2016 third quarter, healthcare organizations connected to DirectTrust health information service providers (HISPs) and using Direct exchange was up 62 percent over the previous year, an increase of 69,000 organizations. What’s more, approximately 22 million transactions were processed over that same time period.
All the rage these days are the Fast Healthcare Interoperability Resources, a set of specifications and an API with the purpose of simplifying healthcare interoperability. According to HL7 CEO Charles Jaffe, MD, PhD, FHIR works just like other online services.
"FHIR uses the exact same technology as does Google," he said. "When you ask for the five best restaurants in Baltimore, there's not a database of restaurants in Baltimore. Google goes out and looks for that query on the web, albeit with a rather exotic algorithm to find those things, and assembles that information for you."
Also comprising the specifications are proven internet standards for security and authentication.
"We didn't reinvent; we use the ones that are used around the globe for authentication and security. If I'm going to another system and present credentials, the other system will allow me to query its data," he added.
One challenge that proponents of FHIR face is its status as an immature draft standard which Jaffe was quick to put in perspective.
"ONC is entirely behind the use of FHIR, but the fact is that the marketplace will decide the utility of FHIR," he maintained. "We use the WIFI standard, which has always been a draft standard, so now we're up to 802.11ac. The industry is making modems and receivers to use that specification. It's not a normative standard, yet it works, yet it's hundreds of times faster than we had 2-3 years ago. Whether ANSI gives it its blessing or not, we have advances in technology which make it a difference in how we communicate. And I believe FHIR will be the same way."
Who’s who of healthcare interoperability
SDOs such as HL7 and ASTM develop standards. Accreditors such as DirectTrust, the Electronic Healthcare Network Accreditation Commission (EHNAC), and Health Information Trust Alliance (HITRUST) ensure that HISPs and health information networks use the standards correctly. But who are the organizations actually enabling health data exchange?
Regional health information organizations and health information exchanges have facilitated health data exchange between providers in certain areas of the country with mixed success. Researchers have attributed a large number of HIE challenges to poor sustainability plans considering that the most successful networks have strong use cases and buy-in from numerous providers, payers, and other stakeholders.
"That's the challenge — you have to have that long-term vision but see the use case building blocks that will get you there."
"Here in Michigan we have similarly seen a use-case focused approach and it has worked very well. It has allowed payers to get on board, such as Blue Cross Blue Shield of Michigan, and be a key pillar of sustainability because with each use case that is valuable to them they can create incentives for providers to participate in it," explained University of Michigan professor and researcher Julia Adler-Milstein, PhD.
"It's the right way to go, but the challenge is keeping the big picture in mind because you don't want to build in such a use-case specific way that in the long run you can't build toward more comprehensive interoperability. That's the challenge — you have to have that long-term vision but see the use case building blocks that will get you there," she added.
More recently, the focus on healthcare interoperability has turned to attempts at facilitating health data exchange at the national level and spurred new competition between familiar foes — namely, athenahealth, Cerner, and Epic Systems.
Case in point, there are Carequality and CommonWell Health Alliance.
The latter is a not-for-profit trade association of health IT companies launched back in 2013 that focuses on enabling interoperability between their technologies. As of August 2016, CommonWell boasted of having 8,000 sites committed to using its services, a number comprising 4,700 hospitals, ambulatory, and post-acute provider sites across the United States and its territories.
Carequality, meanwhile, is an initiative overseen by The Sequoia Project (née Healtheway), which also operates the eHealth Exchange that provides nationwide HIE connectivity. The initiative had the purpose of developing rules of the road for organizations working to enable health data exchange between their systems or networks. The Carequality Interoperability Framework was implemented this year by EHR companies athenahealth, Epic Systems, eClinicalWorks, and Next Gen and health information networks Surescripts and HIETexas to much success.
CommonWell has the back of athenahealth and Cerner; Carequality, athenahealth and Epic. As things currently stand, only athenahealth is a participant in both health data exchange initiatives. What's more, the company was recently rated by KLAS higher than 11 other EHR vendors for its ability to share data with other EHR systems.
This had led to some public sparring between the EHR companies, most recently athenahealth and Epic. Last March, the former’s CEO Jonathan Bush criticized Epic for charging Epic EHR users for transactions via its Epic Care Everywhere health data exchange service and refusing to be a part of CommonWell after leadership from Epic said the vendor-backed network was an “aspiring” one compared to Carequality.
Last month, Epic issued corrections to a Bush interview with MedCity News in which he claimed that the former was holding back health data exchange. Perhaps fueling Epic’s corrections was news that Carequality was continuing to advance healthcare interoperability. Since August, Carequality-enabled information sharing increased to more than 11,000 clinics and 500 hospitals and the number of care documents shared to more than 50,000, The Sequoia Project announced.
Health IT standards and the organizations using them are achieving milestones in advancing healthcare interoperability. However, the goal of a learning health system characterized by seamless health data exchange remains a ways off.