EHR Interoperability: Not There Yet

The promised land of EHR interoperability continues to lie just over the horizon.

There remains a significant gap between standards published by the federal government and the reality in hospitals and physicians’ offices. In theory, now that Fast Healthcare Interoperability Resources (FHIR) is the universal standard for interoperability, data-sharing among providers, health plans, and patients should be easy. Likewise, developers should be able to integrate their SMART on FHIR apps with virtually any EHR, and the resulting integrations should work seamlessly across multiple platforms. “Should” is the key word here because claims of interoperability do not match with reality on the ground. 

A need for provider education

Earlier this year, the Office of the National Coordinator for Health Information Technology (ONC) reported that 95% of Certified Health IT developers met the Dec. 31, 2022, compliance deadline to enable access to information through application programming interfaces (APIs) “without special effort.” 

Despite these claims, true EHR integration is a rarity, based on our experiences and conversations with FHIR app developers, providers, and EHR companies. The ONC has certified nearly 300 EHRs to be interoperable with FHIR-enabled apps, but only a few allow developers to integrate apps with their EHRs.

As a result of its focus on enforcing data-sharing requirements only for EHR vendors, ONC has not given clear directions to clinicians and staff about their responsibilities to share the information. Of the 878 claims of information blocking filed so far with the ONC, nearly 700 have been against providers.  Adding to the problem, the ONC’s education outreach to providers regarding the benefits of data-sharing has been inadequate. 

The ONC’s data-sharing rules mandate making data available to patients upon request, and many EHR developers have developed the functionality to enable these requests. Providers, for their part, generally report that patients are not requesting access to their data, and when patients do, providers most often simply direct them to a patient portal. 

However, most providers simply are not aware of the rules requiring them to deliver data to patients in the apps that patients prefer. If the industry is ever going to reach a point at which well-integrated apps facilitate seamless sharing of patient data between organizations, that must change. We must actively engage providers in the conversation about data-sharing and highlight the benefits of giving the best treatment to their patients when their patients can share data with them from other providers.

Impartiality needed

Interoperability has been a long-held but elusive goal for the U.S. healthcare system. Three years ago, for example, the U.S. Centers for Medicare and Medicaid Services (CMS) adopted the interoperability rule, which sought to remove many of the barriers that prevent patients from accessing their health data. 

Additionally, an information blocking provision went into effect in 2021 that requires EHR vendors, providers, and other groups to share healthcare data. Last year, ONC also published the Trusted Exchange Framework and Common Agreement (TEFCA), which sets a nationwide standard for interoperability. However, former ONC head Donald Rucker has called out the agency for leaving loopholes that limit patient access.

FHIR is the standard that enables this interoperability, and FHIR-based apps are designed to be used with any FHIR-capable EHR. However, despite this work toward developing standards and, contrary to ONC claims, widespread EHR interoperability continues to elude much of the U.S. healthcare industry. Part of the reason behind this lag is simple glitches, which are realistic to expect whenever there is development and adoption of a new technology standard. Further, companies sometimes – intentionally or not – make false claims about their products. For example, look no further than several large EHR companies, which have paid fines to settle claims that they misrepresented the capabilities of their software.  

However, leaving aside glitches and mistakes by companies, it is clear that ONC certification alone does not guarantee successful app integration in the field, as many IT stakeholders continue to confront challenges that stand in the way of interoperability. 

Certification is a great starting point, but we need two more things for a successful implementation:

1. Enumerating the WHY of certification to each stakeholder responsible for information sharing (benefits of doing it and perils of not doing it in terms of patient care). 

2. Defining and enforcing the consequences for all stakeholders.

Information sharing is a relay race. All team members need to do their part to complete the race to achieve interoperability.