It’s time to expand our thinking about Interoperability

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By Jerry Rankin

For healthcare delivery to become efficient and friendly to providers, the healthcare workforce at large, and the consumer, we need to broaden our definition of interoperability beyond the sharing of standardized clinical history.

We have made progress

With the 2009 passage of the Health Information Technology for Economic and Clinical Health (HITECH) Act, the federal government provided some $36 billion in funds to provide incentives to the industry to adopt certified electronic health records (EHRs). This paved the way for a shift from paper records toward a more standardized and interoperable digital record. Measured by adoption, the program was a resounding success. By 2017, some 96% of nonfederal acute hospitals and nearly 9 in 10 office-based physicians had adopted certified EHRs. New standards were promulgated as requirements for EHR certification, such as Direct (secure email), and the C-CCD (a consolidated clinical summary). Standards for the discovery and exchange of records from networks of third parties were developed, variously known as NWHIN, or later the Sequoia project, and similar efforts were born—including Sequoia’s Carequality and Commonwell. More recently, there has been work toward a Trusted Exchange Framework and Common Agreement (TEFCA) further maturing these national exchange frameworks.

While these early efforts focused on the exchange of summary clinical documents, there has also been progress toward exchange of more discreet, just-in-time sets of patient data via Application Programming Interfaces (APIs) and, more specifically, Fast Interoperability Health Resources (FHIR) APIs.

Changes coming

On March 9, 2020, the Office of the National Coordinator for Health Information Technology (ONC) issued updates to the Health IT Certification Criteria, which will require a broad set of FHIR APIs to be made available for patients and population health purposes, as well as outlines rules of the road for how patient information can be shared and blocked.

In a companion effort, the Center for Medicare and Medicaid Services (CMS) issued a rule addressing Conditions of Participation for many Medicare and Medicaid related Health Plans. This will require them to implement FHIR API based methods of making claims-based health records available to patients, health plans, and others.

What these rules have in common is they are fundamentally about providing a summary or discrete component of a clinical record to a third party, largely as a means of reducing duplication, improving quality, and making providers more efficient. Both rules are hugely consequential, which will become obvious as they take effect. With FHIR and market innovation, coupled with policy initiatives to accelerate them, we are seeing the long overdue emergence of an interconnected healthcare ecosystem. This evolution is taking place rapidly, and poses a challenge to the industry of how to bridge legacy systems (where the data resides today) into this new ecosystem of FHIR-enabled data liquidity.

We need to go further

Where perhaps the federal government left off, the industry has continued to move forward. Some examples include:

The HL7 Da Vinci Project is a collaborative effort addressing, to a large degree, the nagging problems in workflow between payers and providers, such as coverage requirements discovery or prior authorization. We all need to applaud the work of the Da Vinci project.

The FHIR at Scale Task Force (FAST), sponsored by ONC, is tackling technological barriers to enabling FHIR API-based exchange at a national scale.

In another industry collaboration, IHE International and HL7 are collaborating in Project Gemini to bridge the standards and workflows of each leveraging FHIR.

Beyond exchange between clinical systems

These are all worthy efforts, but healthcare is an ecosystem with great complexity even within the four walls of a delivery organization. Lots of things need to be connected to interoperate.

Operational systems such as Supply Chain need to be integrated to EHRs, point of care systems, and finance to promote streamlining of healthcare operations, and to free hospital clinical staff from paper, phone, and fax purgatory. And further, Supply Chain needs to provide data in combination with clinical data to support analytics, leverage AI, and ultimately to support a broad understanding of the role of supply chain in value delivery and clinical outcomes. 

To this end, HIMSS has proposed a Clinically Integrated Supply Chain Outcomes Model (CISOM) addressing this very need.

In the world of asset management or even patient and staff “location”, RTLS technologies can be leveraged to streamline location of these valuable assets and integration of that data into other systems in the healthcare enterprise. As solutions expand, we will be able to incorporate more location-based intelligence services and data into the efforts to streamline healthcare through interoperability.

The industry also needs to move forward to bring these combined clinical and operational data streams to analytics and to AI, creating a clinically connected healthcare operations platform.

While the proposal here is not that all these initiatives deserve a “standard”, so much as recognizing that interoperability in healthcare is key to streamlining and automating as much as we can, leveraging the services and capabilities of the ecosystem.

This also means when we think about interoperability, we think more broadly than “integration” or “integration engine” and EHR centric “clinical summary exchange” whether in C-CDA or FHIR.

Think about all the interoperability needs your organization has and whether you have the technology and partnerships, with multiple capabilities, to meet these needs and build a comprehensive platform for connected health.

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