By John D. D’Amore
2019 saw significant activity on the issue of interoperability in the healthcare industry. Notably, the federal government issued proposed rules for implementation of the 21st Century Cures Act. This legislation that passed with a bipartisan vote in 2016 is designed to expedite the development of new medical products and bring innovations to patients more efficiently.
In support of that goal, the Cures Act directed the Department of Health and Human Services (HHS) “to adopt standards and policies that advance health IT to enable and stimulate the trusted exchange of electronic health information… to enable patients’ records to follow them when and where they need it,” according to Don Rucker, MD, National Coordinator for Health IT. An entire section of the Cures Act is focused on health information exchange and interoperability, defined as exchange and use of electronic health information “without special effort on the part of the user.”
With that clear mandate, in a set of Proposed Rules announced early in 2019, both CMS and ONC (HHS’s Centers for Medicare and Medicaid Services and the Office of the National Coordinator, respectively) weighed in on the details of how to achieve the goals of the Cures Act. (Final Rules are expected in the first quarter of 2020.) Both organizations promote the adoption of open application programming interfaces (APIs) to give patients (and their caregivers) access to their records. (We use APIs every day.
They are the software protocols that enable applications to talk to each other. Apps that tell us the weather, when our train should arrive, what’s in our bank balance and more are using APIs to communicate with a central data source.) Specifically, the government is promoting use of the HL7 FHIR® (Fast Healthcare Interoperability Resources) API to get access to the information in electronic health records.
So, you might be tempted to ask, “are we done yet?”
The FHIR standard looks to many like the answer to interoperability, and it does offer many benefits. Much in the way that APIs have made information flow across the internet, FHIR will unlock even more data and enable it to flow through the healthcare ecosystem. Eventually, electronic health records (EHRs) will be able communicate via APIs into our favorite apps—although this will not occur overnight.
But here’s the rub: FHIR doesn’t necessarily make the information that flows fit for use in downstream applications. No matter where you are in the world, you can find your location on a map using longitude and latitude and a Google API service. But the way we express clinical information is much less consistent.
As just one example, a patient’s medications in one EHR might be encoded using the National Library of Medicines’ RxNorm vocabulary. Another system might use the FDA’s method, the National Drug Classification. Yet another could use a proprietary library such as First Databank. To further complicate things, a doctor might simply make a note of the fact that a patient is taking a certain medication without using any codes at all.
As the authors of a recent Deloitte Insights survey noted, “FHIR is only one piece of the interoperability solution, and there is a continued need to expand the scope of FHIR-enabled use cases. Standardization of medical vocabularies, incentives, and other barriers are outside of the scope of FHIR.” So, when information is returned as a result of a FHIR API request to an EHR, it’s not necessarily going to return data that can be immediately usable for the receiving software program. Each data source will speak different languages, or at least different dialects, for the foreseeable future. To stretch the language analogy: FHIR will make it possible to hear all the people around you, but you won’t get a simultaneous translation to understand what’s being said.
In healthcare, there is still much work to do “in the middle” to make it feel like we are all speaking the same language, even as we continue to document clinical care in different ways, all of which are acceptable. The industry has shown that it’s not likely to adopt a single way to express clinical concepts. Clinicians are trained to document differently and each instance of each EHR manages clinical data differently.
Even if we could standardize on the use of a single EHR vendor, which is unlikely, variation in documentation will live on. Absent a Star Trek Universal Translator in every doctor’s hand, the issue of semantic interoperability will remain with us in 2020—but the floodgates are opening.
John D. D’Amore, President and Chief Strategy Officer, Diameter Health has nearly two decades experience providing informatics and strategic insight to healthcare organizations. He co-founded Diameter Health in 2013 to address the issue of clinical data quality, a key factor in the ability to effectively use clinical data for quality reporting, risk adjustment and care management. Previously, John was Vice President at Eclipsys (now Allscripts) overseeing enterprise performance management solutions. Before joining the health information technology industry, John worked at the largest health system in Texas overseeing clinical informatics, decision support and business intelligence. He also served as an analyst at Health Advances, a consultant to healthcare and life sciences.
John has published on best practices in population health and presented at national forums on how information technology can improve medical outcomes. He is a technical advisor to the National Committee for Quality Assurance and an editor of HL7’s standard for care summaries, the Consolidated Clinical Document Architecture. He holds a biochemistry degree from Harvard University and a graduate degree in clinical informatics from the University of Texas, School of Biomedical Informatics.