- The concept of a network-of-networks lies at the center of several stakeholder efforts to achieve true interoperability.
Stakeholders in the public and private sector have touted the benefits of a nationwide network-of-networks for years. Networks-of-networks essentially link all participating healthcare organizations together through common standards to enable cross-organization exchange.
In January, ONC released the first draft of its Trusted Exchange Framework and Common Agreement (TEFCA). The voluntary health data exchange framework is designed to achieve a nationwide network-of-networks through the establishment of qualified health information networks (QHINs).
Beyond TEFCA, the Sequoia Project’s Carequality Interoperability Framework also offers HIEs, vendors, payers, and healthcare organizations guidelines to implement health data exchange standards and participate in a network-of-networks. These and other initiatives have helped spur improvements in interoperability and connectivity.
While these efforts have been successful in pushing interoperability forward, HealtHIE Nevada Executive Director Michael Gagnon asserts there’s still a long way to go.
“It’s no one’s fault — it’s just that the whole health information technology industry has to mature and it hasn't yet,” Gagnon told EHRIntelligence.com.
This maturation process is poised to accelerate as the healthcare industry moves away from fee-for-service toward value-based care.
The business case for health data exchange
In the fee-for-service healthcare system, Gagnon said there existed little incentive for providers to actually engage in health data exchange. Clinicians had more incentive to repeat procedures than obtain existing test results or diagnoses from other providers.
“If I'm a diagnostic center and I can order that test again, what's my incentive to go look it up and not have it done if I can bill for it again?” said Gagnon. “If it's easier for me to just go do it again and I get paid for it, then I'm going to do it. If I'm not going to get paid for it, then I'm going to seriously consider whether I'm going to go try to look it up.”
Under a value-based care system where providers are reimbursed for boosting care quality, improving patient health outcomes, and engaging in health data exchange, the value proposition for sharing data increases.
Now that providers have a compelling business case for data sharing, it is incumbent upon HIEs to ensure healthcare organizations and facilities are connected and health data is accessible. For its part, HealtHIE Nevada has connected the vast majority of care facilities and healthcare services providers in its area.
“I've got most of my diagnostics in my state,” said Gagnon. “I've got almost every imaging center connected — there might be one left. And almost every local and national lab is connected. So any tests a provider might repeat, I pretty much have already.”
But incentivizing and connecting healthcare organizations aren’t enough to achieve the level of interoperability most stakeholders want to see. Gagnon stressed the need for stakeholders to narrow down, select, and implement the same standards in a consistent way.
“Healthcare has every standard we need,” said Gagnon. “They're all out there, but they're not adopted. That’s really the issue.”
Encouraging stakeholders to agree on health IT standards adoption can be a frustrating, time-consuming process.
“The EHR vendors don’t really want to come together and form one way of doing anything,” said Gagnon. “That places burden on them to develop everything in a single way. They’d have to all agree on a standard, and what happens when you try to do that in healthcare is that you end up with something that’s really watered down.”
An example of a widely-adopted, watered-down standard is the Continuity of Care Document (CCD), which is based on the HL7 Clinical Document Architecture (CDA).
“The CCD is kind of our most widely-adopted standard today,” said Gagnon. “And if I see two CCDs from two different vendors, they look different.”
Greater specificity in standards development and adoption may help to prevent this kind of variation. ONC’s TEFCA is one example of a consensus-based effort attempting to promote stricter widespread standardization in healthcare.
Taking steps toward creating a nationwide network-of-networks
As written, the TEFCA draft prompts healthcare organizations, payer organizations, health information exchanges (HIEs), and federal entities to meet requirements that would enable them to become QHIN participants. As QHIN participants, entities would gain access to certain health data exchange services and achieve interoperability with each other. QHINs would also connect to each other to facilitate health data exchange between organizations participating in different QHINs.
This QHIN-to-QHIN connectivity would form the basis of the voluntary network-of-networks outlined in TEFCA.
“It’s a step in the right direction, but it needs work,” Gagnon stated.
According to Gagnon, the first part of TEFCA — which establishes an exchange framework — is well-designed to enable effective, legal data exchange.
“TEFCA creates an environment that says if you come in via CommonWell, you’ll be able to connect and work with providers part of SHIEC’s Patient Centered Data Home,” explained Gagnon. “That’s great if it tears down those barriers and allows providers one way in.”
“Everyone has to sign a common agreement so you can share data,” he continued. “It tears down that barrier of the legal and operational interoperability capabilities.”
However, Gagnon views TEFCA’s approach to enforcing health data standardization among QHINs as overly prescriptive.
“The second part is dictatorial about the way you do that, and that was the problem,” said Gagnon. “For example, a standard that stuck out to me was something called the brokered broadcast query. It’s a completely unworkable solution.”
The brokered broadcast query allows providers to query every other network where a patient may have existing data to locate specific information.
“That’s going to give me something like 200 results,” said Gagnon. “The chances of you finding anything, and the chance of that happening in real time in any kind of fast way are near zero. And you are going to leave a lot of information out. To me, that’s unworkable.”
Ultimately, Gagnon recommends TEFCA dictate what rather than how participating organizations need to accomplish it.
Gagnon believes there are several potential approaches that may help to achieve the level of data standardization required to support the network-of-networks described in TEFCA. He floated one approach in a 2018 Blockchain in Healthcare Today paper that outlines how blockchain could support a nationwide patient index.
“I’m not saying it’s the only way,” said Gagnon. “Of course it’s not. We could also take a simple biometrics approach. But what TEFCA should be saying is, ‘You have to find a way to get that data from every other network where this patient has been seen,’ and leave it at that. If someone wants to use an open application programming interface or FHIR for that, they should be allowed to.”
In the long term, Gagnon echoes the sentiments of other HIE and interoperability leaders in envisioning health data exchange functioning in a way that resembles the banking industry.
“I can use my ATM card in any nation — I mean worldwide — and get cash,” he said. “Things like that are going to happen in health.”
While the healthcare industry is more heavily regulated than other industries, Gagnon maintains this goal is within reach in the near future.
“The data we have is much more complex, but it's definitely evolving,” said Gagnon. “I am very positive about the fact that we are going to have a nationwide network within the next three years.”