When it comes to interoperability in healthcare, there’s no question that the journey has become more complex recently, even as sometimes-halting, inconsistent progress towards genuine interoperability is taking place in various corners of U.S. healthcare. That was the high-level consensus among a group of healthcare leaders participating in a panel entitled “Uncovering the Key to Interoperability” that took place on Dec. 8 at the Omni Hotel at Westside, during the Health IT Summit in Houston, sponsored by the Institute for Health Technology Transformation (or iHT2, a sister organization to Healthcare Informatics, under the Vendome Group corporate umbrella).
The panel’s moderator on Tuesday afternoon was Cynthia Burghard, who was joined by Tony Gilman, COE of the Texas Health Services Authority (THSA), the Austin-based statewide health information exchange (HIE) facilitating agency; Nick Bonvino, CEO of Greater Houston Healthconnect, the Houston metroplex’s HIE; Dean Sittig, Ph.D., professor of biomedical informatics at the University of Texas Health Science Center at Houston; and Chris Ingersoll, vice president of solution architecture at the Alpharetta, Ga.-based RelayHealth.
Panelists (l. to r.) Burghard, Bonvino, Ingersoll, Sittig, and Gilman
The panelists’ discussion was very wide-ranging, across policy, industry, clinical, patient engagement, and vendor-partnering aspects of the issues around achieving true interoperability in U.S healthcare. To begin with, IDC’s Burghard led panelists in a broad discussion of the functional definition of interoperability. UT-Houston’s Sittig reported that “My friend Adam Wright from Harvard and I developed a definition of interoperability for a paper. We said it wasn’t about the database structure, but rather a data model for exchange, including the right syntax, meaning the structure of the data, and the right pragmatics, meaning the form of the data,” he said. In fact, Sitting outlined five key use cases for interoperability, using the acronym “EXTREME,” which he had coined for the purpose. “EXTREME” stands for “EXtract, TRansfer, Move, Embed.”
As Sittig explained, “’Extract’ means the ability to take data out of a database and use it for population health or analytics. ‘Transfer’—as for a referral, with a CCD or CDA standard, means sharing data with another provider. ‘Exchange’ means exchange data, as into an HIE. How to put data in and participate becomes the issue. We have a distributed model in Houston,” he noted. “We have to be ready for a query at any time of day, from any EHR [electronic health record] to us, for example.” Then there is “’Move.’ If you want to change from one EHR to another, how do you move data from one system to the next? This is challenging; it’s hard to change EHR vendors.” Finally, there is “’Embed’: the ability to embed an app into an EHR. Can I build an app into an EHR that interacts with that data, perhaps using FHIR [the Fast Healthcare Interoperability Resources standard]? Vendors are not being as receptive to changing their user interfaces as providers would want,” he pointed out.
Agreeing that that model was a useful one to further discussion, Burghard asked, “Per those five models, where are all of you at right now?” “It varies by community and by use case,” THSA’s Gilman said. “So we have different levels of change occurring in Houston, San Antonio and Austin, and other networks are still emerging and aren’t really exchanging yet. And some communities are focused on care coordination, while others are focused on different modes of transportation.”
Further, Gilman noted, “Some communities want robust exchange, while others are just focused on direct, point-to-point transfer. Some want to share information across whole communities, health centers, jails, information with managed care organizations, ADT—admission, discharge, and transfer—information, for example. On top of that,” he said, from my point of view, when I think of working with local HIEs, or interoperability statewide, I think of three things. One is, it needs to be in production. Nothing’s interoperable unless it’s live. Two, data needs to be structured from both systems involved. And three, you need a use case that is clear. Are you using it for care coordination? To report information to state data registries? To send just basic demographic information, or demographic data to a health plan? In each use case, the interoperability is (looks) different.”
Was Meaningful Use a Detour to Interoperability?
“Is there a level of maturity as you go through these use cases, where an organization has created a repository for research; second stage might be to exchange data with another organization?” Burghard asked her panelists. “And if there’s a path or roadmap that might be followed?”
“I wish there were a roadmap,” THSA’s Gilman said. “I think the road took a big bend with federal meaningful use, where we focused on robust record exchange, and then a focus on DIRECT secure messaging. There are some use cases that can be supported by DIRECT-based messaging, but essentially, robust exchange is where we’re going. You need a centralized data repository, and sharing between organizations. Then you need use cases to promote sharing across communities.