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.
“That bend you described, I describe as a detour,” responded Bonvino of Greater Houston Healthconnect. Prior to the passage of the HITECH (Health Information Technology for Economic and Clinical Health) Act as part of the ARRA (American Recovery and Reinvestment Act) in 2009, Bonvino said, “We were on the path towards robust interoperability, but for a variety of reasons, it was unachievable. So back in 2009, when we were in the midst of an economic crisis, and HITECH funded initiatives, first, meaningful use of certified EHRs, and then connecting those EHRs—that was difficult.”
Bonvino went on to say, “So that shortcut called DIRECT, which was really secure email, has certainly offered some uses cases, but definitely not the definition of interoperability. As an old electrical engineer and data systems guy, I can say that [DIRECT] was like a fax machine replacement, and there’s nothing wrong with that, but it wasn’t interoperability. So when we talk about interoperability as a journey, it is a journey, however, there are several core components to what an HIE must put in place. There are core functions and core infrastructure that must be put in place across a community to support many use cases, and ultimately, population health.”
Burghard noted that, as she put it, “I’ve spent most of my career building large databases, and a lot of people don’t have an appreciation of the value of all the discussions that have to take place. Chris, how do you keep the troops in line in the early stages?”
“You have to focus on the value, and determine the value proposition for each of the stakeholders individually,” RelayHealth’s Ingersoll replied. “For a health system, for example, it will not only be their objectives, but clinical practice goals and referrals, and their satisfying their constituents. So how do we get to a stepwise approach to interoperability, to enable to share information accordingly? There are steps that can be followed, but meaningful use, even with Stage 2, the detour to the dirt path as some have described it, it did do some good things, including forcing vendors to open the CCD space and fix some problems. So meaningful use Stage 2 did force vendors to open up those EHRs and force vendors to structure the CDA document.
So Many Non-Technological Discussions
“The reality is that it’s not just a technology challenge,” Burghard noted. “We were discussing just before we came on here about the reality of the politics of this. Early on, I helped build a data consortium in Massachusetts. And 90 percent of the discussions were political discussions: what do we do with the data, what will happen? How does that political discussion get mitigated and for that angst to go away and the focus to shift to value?
“I’ve spent the last five or ten years figuring out some of the social aspects of this,” Sittig said. “Whenever something can directly benefit you or save you money you’re willing to share. When it’s going to cost you money it’s harder to share. And that’s what we’re seeing right now. Everyone’s waiting for these new payment models to come in, to incentivize us. In informatics, we’re eager to share. We think the new models will incentivize sharing.
“And as networks get more established around value-based care, that will become the nudge, if you will,” Burghard said.
“And if you look within the large healthcare delivery system, we’ve basically created our own HIE,” Sittig noted. “We’re exchanging data with providers that aren’t within our system but also aren’t competitors; they’re partners. And we’re seeing advances with customers in Epic, who have the same information systems, and people are starting to do it, just because it’s so easy to do. And I think that’s what CommonWell is trying to do, is to replicate that same ease of data exchange. And usually, the exchange is outside the record.
“Dean, I couldn’t agree with you more, regarding your comment about needing to go outside clinical workflow,” Bonvino concurred. “In our experience, that does not work. And that’s where the deep integration must take place. That’s one of the drivers. We don’t want to build this and have it be unused. The data needs to appear in my Epic system. I don’t want to have to exit to a portal and come back. And the whole suite of applications within the EHR that make it useful.”
“Right now, there’s not maturity on the standards side,” Ingersoll acknowledged. “It's custom work to connect your system to another system Smart on FHIR has the potential, but it’s not available right now. It’s one of the reasons they went from Stage 1, sharing pieces of a health record, to Stage 2, the requirement to share the CDA.”
“Another challenge we’ve seen in surveys, is around creating large data sets,” Burghard said. “And that is, what’s the relevant data to share at the point of care? And it would change by specialty focus. Are any of your organizations trying to tease out these questions, for better clinical decision-making
“Physicians want to see the meds the patient is on, important lab or test results, maybe some images, and relevant notes,” Sittig explained. “There’s mixed success because physicians will have a huge amount of data they’re responsible or looking through. So even though we say that we want clinicians to have this data, it creates huge amounts of data, and clinicians will want summaries of information.”
“That’s a central focus of all these initiatives, and they all have governance processes around asking physicians what type of information is displayed, how much is displayed, how it’s displayed, in what order,” Gilman emphasized. “So that’s being defined. And that’s an active role for HIEs and other exchange initiatives. And I want to go back to the issue of policy initiatives. Earlier on, we didn’t have physician participation because they were concerned about what was viewed, and what their liability might be for inappropriate viewing or use. Or if they looked at 100 labs, but the 101st lab might have told them something else? House Bill 2641 [in the Texas Legislature] holds providers harmless—if you as a physician provide information to an HIE and another provider uses that inappropriately, the provider who shared the information has a safe harbor and is shielded from liability. So that’s a significant action that Texas has taken, to support this idea of health information exchange, and taking away one of the potential barriers to provider participation.”