Across the healthcare ecosystem, it’s hardly a secret that providers struggle to get pertinent medical information from exchange partners who use a different electronic health record (EHR) from their own. And if the provider wants to do something impactful with that health data—say receive it in a way that facilitates improvement in patient care, for example—the struggle becomes even more real.
These viewpoints were confirmed in KLAS’ Interoperability 2016 report last October which found that, based on a previously-developed interoperability measurement tool, providers are reporting very low rates of impactful data exchange. In the report from the Orem, Utah-based KLAS, which included interviews with more than 500 EHR end-user clinicians, providers were quick to say that interoperability is more than just access to outside patient records. For interoperability to truly move the needle on better care, outside records must be (1) available, (2) easy to locate, (3) situated within the clinician workflow, and (4) delivered in an effective way that facilitates improvement in patient care. But KLAS found that true “home runs” in which all four criteria are met were only reported by 6 percent of providers surveyed.
Indeed, the concern that “real” interoperability in healthcare has yet to be accomplished is not new. But recently, there have been developments on at least one major front: big-name EHR vendors have shown an increased willingness to collaborate as their hospital and health system clients ramp up the pressure for patient data to be made available whenever and wherever they need it.
To this end, early on in 2016, five major health IT vendors—athenahealth, Epic, eClinicalWorks, NextGen Healthcare and Surescripts—signed on to be the first to implement Carequality’s framework for interoperability and data sharing principles. Carequality, a Washington, D.C.-based public-private collaborative and an initiative of The Sequoia Project, released its interoperability framework the previous December, which consisted of multiple elements, including legal terms, policy requirements, technical specifications, and governance processes. Prior to the framework, health information exchange was preceded by one-off legal agreements between individual data sharing partners, which involved lengthy and costly negotiations and inconsistent experience in the quality and quantity of data exchanged.
This partnership was also particularly noteworthy as there have been rifts between the Verona, Wisc.-based Epic Systems and the CommonWell Health Alliance, a vendor-led interoperability initiative, of which athenahealth is a founding member. Epic had until recently refused to cooperate with CommonWell; but, publicly anyway, that quarrel seems to have been quashed.
More evidence of vendor collaboration is the very recent agreement between Carequality and CommonWell that will make CommonWell a Carequality implementer on behalf of its members and their clients, enabling CommonWell subscribers to engage in health information exchange through directed queries with any Carequality participant. Carequality will also work with CommonWell to make a Carequality-compliant version of the CommonWell record locator service available to any provider organization participating in Carequality.
Indeed, the effects of these efforts could ripple through the industry as together, CommonWell members and Carequality participants represent more than 90 percent of the acute EHR market and nearly 60 percent of the ambulatory EHR market. More than 15,000 hospitals, clinics, and other healthcare organizations have been actively deployed under the Carequality framework or CommonWell network.
How else will this agreement spur interoperability progress? According to Micky Tripathi, Ph.D., president and CEO of the Massachusetts eHealth Collaborative, the arrangement is “akin to AT&T and Verizon Wireless cell phones finally being able to talk to each other.” Tripathi, who was heavily involved in the facilitating and negotiating of the agreement as he sits on the board of directors of The Sequoia Project and also does project management work for CommonWell, says that as it previously stood, there was a lot of development, network formation, and maturity on both sides, but in siloes. “Providers were facing issues on the ground level,” he says.
Tripathi mentions a large provider organization he knows that is switching from Cerner to Epic. Previously, that organization’s switching from Cerner to Epic could have led to complications, as Cerner is in CommonWell but not in Carequality, and vice versa for Epic. “The [organization’s] CIO said to me six months ago that he’s not looking forward to the conversations he will have to have with his clinicians, which is that you have great interoperability with your current system, and your future system, but the bad news is you won’t have the interoperability with the same people. Now he doesn’t have to say that to his doctors anymore since [they all] are connected to the same people regardless of what network you are on,” Tripathi says, speaking to the impact of the agreement.
Adding more specificity, Tripathi notes the core interoperability functionalities that people are able to do now, such as sending lab results and the direct sending of email messages from one provider to another. “This ability to query from one system to another was the last core building block, and at least from a technical and network perspective, that is now solved.”
There is also another subtlety to the agreement that Tripathi points out as being significant: per this arrangement, an Epic customer, for example, who wants to purchase the CommonWell record locator service, will now have it be available to them within Epic’s platform, serving as a layer on top of the vendor’s Care Everywhere interoperability software. “It’s almost like using Internet Explorer, Chrome, or Firefox,” says Tripathi. “An Epic customer can purchase the Surescripts record locator service or the CommonWell record locator service, or both. Epic and others have committed to being indifferent; they will offer it in their platform integrated into the workflow of the provider based on what service the provider wants to purchase,” he says.
Upping the Ante
Representatives from both Carequality and CommonWell, and plenty of other health IT associations, were present at KLAS’ most recent Keystone Summits as leading providers and vendors came together to first adopt a set of metrics to measure interoperability and then go out into the field and get clinicians’ perceptions and experiences around health data exchange.
The aforementioned interoperability report that was a result of these meetings and surveys found that while Epic customers “are in a league of their own” when it comes to sharing with each other, success is average when exchanging with different EHRs. athenahealth came out on top when it came to its ability to share data with different EHRs, and that’s largely due to the Watertown, Mass.-based vendor “having made a strong pitch as a company to have interoperability be a differentiating characteristic for them,” notes Tim Zoph, chair of the KLAS Interoperability Measurement Advisory Team (IMAT), long standing healthcare CIO and client executive and strategist with Impact Advisors. “They won’t charge for interfaces and they are advanced in building their architecture,” Zoph says.
Zoph continues, “Everyone feels like their vendor can certainly do more, and what’s fair and what came from the KLAS conference is that vendors want to make sure that if they are going to build their [systems] with this capability, there needs to be a commitment from the provider side to take advantage of the capability and make interoperability a priority,” Zoph says. “So the net of it is, this will require a collective industry effort—yes, more functionality, and data into the workflow that’s more easily navigated by clinicians, but it also will require providers making it more of a priority to interoperate.”
Tripathi agrees with Zoph, noting that vendors have said they have done what they can for where the industry stands right now. “Vendors are saying, ‘you are connected now, so now it’s up to you.’ There are no more excuses from a technology perspective for not doing it.”
Still, there is some skepticism regarding exactly how data is being exchanged, even via these initiatives. Michelle Mattson-Hamilton, a U.K.-based associate principal at consulting firm ST Advisors, says that she recently was speaking with an executive from a large health information exchange (HIE) organization who said while the public PR around these interoperability efforts is positive, the way they actually work tells a different story. “For a patient to opt-in to CommonWell, you have to go to every single location that has the service and physically opt-in to the CommonWell network. That’s how it works now. But is that [sustainable] long-term?”
Expanding on this point, Mattson-Hamilton notes that data blocking in healthcare is not making the front page news as frequently as it was in 2015, and “while many vendors have made voluntary interoperability pledges and are moving slowly towards improved interoperability, there are few disincentives for slow movement,” as a small number of penalties and barriers are competitively beneficial for some vendors, she says.
Nonetheless, Zoph points to initiatives such as CommonWell and Carequality as ways to “build regions.” In fact, in the aforementioned KLAS research, providers reported optimism about the potential of these initiatives to dramatically improve nationwide interoperability. These organizations reported nearly universal optimism that CommonWell is a “game changer.” Mattson-Hamilton agrees that these efforts are overall very beneficial, noting that CommonWell and Carequality are continuing to gain members and footprint, and are “moving data [mostly] for very little cost or for free.”
Standards and the Future
Tripathi adds that now that the query problem is solved via the CommonWell/Carequality agreement, the next step is to improve on the content challenge. He notes that right now, the vehicle for exchanging multi-type clinical information is the continuity of care document (CCD) and clinicians aren’t happy with that for a variety of reasons such as too much optionality and not enough standardization. “So if I get a CCD from Allscripts and one from Epic, they are not the same. There are weird quirks. This agreement doesn’t solve the content issue,” he says. “In a way, all it does is make it easier for you to get that thing that you weren’t happy about to begin with. That’s the next challenge—how do we actually improve on that content so you’re happy with what you get back?”
There has been no shortage of hype surrounding the potential of the [Fast Healthcare Interoperability Resources] standard that can enable providers to package discrete bundles of data rather than entire documents. FHIR represents a shift away from a document-centric approach to a data-level access approach using application programming interfaces (APIs), thus making it attractive to all interested parties—vendors, providers and app developers.
Mark Pasquale, principal at Chicago-based The Chartis Group, and a former healthcare CIO and CTO, says FHIR indeed allows for more atomized data sharing. He notes that the FHIR and IHE (the Integrating the Healthcare Enterprise) standards still have a ways to go in maturity, however. “Some of the resources have reached a fairly mature level, but others are still developing. But once they mature and incorporate the FHIR standards, we’ll get to true interoperability. It’s definitely picked up pace, especially in the last year.”
Other industry experts agree with Pasquale on both the potential of FHIR, as well as on its current rudimentary state. Richard C. Howe, Ph.D., executive consultant at Colleyville, Texas-based HCG Healthcare IT Consulting, says FHIR-based apps—which could enable one app to be connected to a data repository, like the EHR, underneath it, “will help from a technical point of view.” But, he adds, “The physician in an office practice doesn’t even know what we’re talking about. It gets down to the physician or practice manager saying, what’s in it for me? There are a lot of benefits, such as connecting to specialists; it’s just a matter of convincing the primary care practices of the value.”
Howe says that undeniably, one of the problems with interoperability is the lack of a firm set of standards. “Without those standards, we’re kind of talking different languages on both sides of the fence. I remember when HL7 [Health Level Seven International] came along and this was going to be the standard that would solve all of this, but 100 different variations emerged, so it didn’t solve the problem. So we need firm standards. But I think FHIR will help solve a lot of the problems. If it works technically and it’s easy, physician groups will pick it up.”
To this end, Tripathi says that throughout the CommonWell/Carequality negotiations, there were discussions around moving to FHIR right now, but it was decided that as much as stakeholders would love to “flip the switch,” it’s simply not ready yet. “We need to lay the groundwork for the legal framework, get the trust model in place, and get the data flowing with the methods we have now, and as FHIR matures, we can evolve to the enablement of it,” he says. Tripathi notes that vendors such as athenahealth, Cerner and Epic are all funders and sponsors of HL7’s The Argonaut Project, so they are “putting their money where their mouths are, are willing to do it when it’s ready and are paying to advance it.”
Pasquale says, “As each one of the different service modules in the FHIR standard goes through a maturity process, and as each of these services goes through a maturity model, the vendors themselves will have to put the same web services into products. So you’ll see these vendors in their releases coming out with more of the FHIR standards, and when you combine that with more mature processes, I see the path as really wide open now.” He predicts that over the next two years, interoperability will improve even more, and adds, “I believe within a few years, we’ll have true interoperability.”