- Lately the discourse among healthcare leadership surrounding interoperability has morphed into a debate about information blocking — is it a real barrier to health data exchange or simply a red herring unfairly directing blame at EHR companies?
David Kibbe, MD, CEO and President of DirectTrust, argues that information blocking is a real threat to health data exchange; however, he does not believe EHR companies are restricting data flow maliciously.
“It’s not necessarily occurring because of the evil intent of business practices,” Kibbe told EHRIntelligence.com. “There’s an awful lot of information blocking that occurs as a result of a lack of understanding of technical standards, implementations that are done in a non-standard way, or implementations that leave out capabilities that ought to be part of the implementation.”
Addressing barriers to interoperability
According to Kibbe, pointing fingers is not a productive way to end information blocking or improve standardization.
“I would love to relieve the parties of this moral burden and have people really focus on the problems and the barriers they’re encountering,” said Kibbe.
DirectTrust is presently attempting to eliminate technical barriers to interoperability by encouraging organizations to allow more diverse kinds of file sharing. Specifically, organizations only able to send and receive files in a Consolidated Clinical Document Architecture (CCDA) format have trouble exchanging data with organizations only able to use PDF files.
*Editor's note: a previous version of this article incorrectly stated Kibbe had recently met with a large health system unable to send PDF files.
Kibbe said this kind of barrier to communication could be considered information blocking and does not serve any particular organization’s self-interest — there is simply a misalignment of technical standards. Certain care settings are more likely than others to run up against this kind of roadblock.
“There are healthcare provider organizations who need to exchange health information who don’t have the capabilities to create CCDA documents. Think about home health agencies or long term care facilities that don’t have an EHR system,” he said. “They can participate via Direct and only send a PDF document because their systems can create PDF documents. That means they are effectively blocked from communicating with facilities using CCDA formats.”
While Kibbe claims that blaming EHR companies for information blocking is largely unproductive, he also maintains EHR companies will ultimately be responsible for making the necessary changes to overcome these barriers.
“The EHR vendor needs to say, ‘okay, we will allow you to send messages that are just PDFs,’” he said. “These kinds of problems in health information exchange are there and they need to be addressed. The important thing is to keep working at it so the parties that want to exchange can do so without those barriers being there.”
For its part, DirectTrust is making efforts to increase standardization through educational resources offering guidance about how certain sets of standards can be used together to improve data exchange.
One such resource is the recent collaborative white paper between DirectTrust and HL7 about using the Direct trusted exchange framework along with FHIR standards.
“It shows the possibilities of moving away from the siloed idea that just because you use one particular type of exchange for interoperability you can’t use another,” said Kibbe.
DirectTrust and FHIR provide standards for different aspects of health data exchange and so can be used in a complimentary way. While FHIR provides specifications that standardize file formats and data elements, Direct provides a framework for standardized security and transport:
DirectTrust solves the problem of trust. As hospital B, how do you trust hospital A is reliable for health information exchange without having to negotiate the terms of the security and trust and identity controls in place in both environments or register a party interested in communicating? That works when you have 50 connections, not when you could have 50,000. If hospital A is making a query to hospital B, the DirectTrust framework provides FHIR users with that first connection that says, “I’m knocking on your door, and here’s a credential that proves I am who I say I am in cyberspace.”
In addition to the collaboration with HL7, DirectTrust is also embarking on a new joint project with the College of Healthcare Information Management Executives (CHIME). The initiative to universally deploy the Direct standard aims to improve the reliability of interoperable exchange for CHIME members and member organizations. As with the collaboration with HL7, healthcare organizations will optimally use the Direct standard alongside other standards.
“This is not an effort to replace other forms of health information exchange, but we’d like to be sure everyone can use Direct exchange,” said Kibbe.
Kibbe asserts increasing collaboration between healthcare organizations, health IT developers, and interoperability services providers will help to break down remaining barriers to seamless exchange.
“I’m not a zealot about information blocking,” said Kibbe. “Million dollar fines aren’t necessary. Open and transparent discussion about these issues will help.”
Toward this end, DirectTrust has created educational resources to open up a line of communication with EHR companies.
“We have a clinicians workgroup and we published a fairly short but detailed set of recommendations about how EHR vendors can make their Direct capabilities usable and user friendly and how they can focus on features and functions that ought to be there. That’s the kind of thing we want to do,” he said.
Overall, Kibbe is optimistic about the direction healthcare interoperability is heading.
“People are starting to look at solving these problems through collaborative efforts,” said Kibbe. “That’s very important because there isn’t any one-size-fits-all interoperability solution. There isn’t any one-size-fits-all trust framework. There are going to be a series of options. We’re starting to sort that out now in healthcare.”