Many in the healthcare industry struggle over the true definition of interoperability. According to University of Texas Health School of Biomedical Informatics professor Dean F. Sittig, Ph.D., oftentimes, when people talk about interoperability, they’re talking about it from their own point of view or their own use case that they’re interested in.
As such, Sittig, who is also a member of the Houston-based UT-Memorial Hermann Center for Healthcare Quality and Safety, thought it was time to write a definition on what an open electronic health record (EHR) was. Sittig has promptly indentified five use cases for open EHR technology and health IT interoperability under the acronym of EXTREME: EXtract: extract patient records while maintaining granularity of structured data; TRansmit: authorized users transmit patient records to other clinicians without losing structured data; Exchange: exchange enables organizations to participate in health information exchanges (HIEs) regardless of which EHR they use; Move: move enables organizations to switch EHRs without incurring extraordinary data extraction and conversion costs; and Embed: embed enables organizations to develop new EHR features of functionality and incorporate it into clinicians’ workflow.
The idea of this EXTREME model is to talk about five of the key stakeholders in healthcare interoperability: patients, clinicians, researchers, developers, and administrators, and from each of their standpoints, try to understand or say what interoperability means to them, Sittig says. From there, Sitting and others wrote down different requirements that systems would have to do to meet these cases, as well as the questions that would be raised from them.
Sittig says that some of these use cases are happening in patient care organizations around the nation, and others aren’t. For the ones that aren’t, people are clamoring for them to occur, he says. One such use case that’s not happening too often is that an organization should move their patient records from one EHR to another, he notes. “Say you bought a new system and you want to export all of your records from one to another, right now that’s not an easy thing to do. That would be a huge process and cost a lot of money. But there are people who are moving from one EHR to another, especially now that small EHR vendors are not meeting advanced meaningful use criteria. Physicians are moving to more robust EHRs,” he says.
Dean F. Sittig, Ph.D.
What’s more, Sittig says that with interoperability and health IT in general, there is a “socio-technical” problem, meaning there are legal, organizational, and people constraints on IT systems just as much as there are technical limitations. “A lot of people focus on the technical limitations and say we’re not achieving the interoperability we want because of those. I’d say that’s not the case at all. In a lot of cases the healthcare delivery systems don’t want to exchange data with their competitors. They blame it on a technical reason, either big or small, because they don’t want to do it anyway,” he says. Sittig gives an example of two hospitals that are currently trying to merge and they’re arguing about whether they’re going to let the nurses in the other system see the data. “It’s not a question of technical capabilities, but instead one of giving them log-ins or not,” he says.
To this end, speaking of an Office of the National Coordinator for Health IT (ONC) report released last month on health information blocking, Sittig says the blocking is coming more from the healthcare providers than from the vendors. “It’s happening and it would be better for the patients if it wasn’t happening, but there is a huge business around this. It’s not completely about patient care,” he says. “These are multi-billion dollar businesses,” he continues. “If we shared all the data that people want us to share, we would lose a significant amount of revenue, so much so that it would make us a lot smaller, maybe even put us out of business. Until that changes, and there are federal laws that people are talking about now, we won’t have interoperability,” Sittig says.
David McCallie, M.D., senior vice president of medical informatics at the Kansas City-based EHR vendor Cerner, is surprised at the degree of concern expressed by Sittig when it comes to information sharing. In addition to his Cerner job, McCallie wears several different hats when it comes to interoperability, as he was integral in the creation of Direct and the CommonWell Health Alliance. McCallie says that the first step to stopping information blocking is greater transparency. “What’s actually happening? Is data blocking occurring? We know it is, so the next questions are where and why? The government needs to ensure there’s transparency, and that will fix a bunch of problems right on the spot,” he says.
“The second biggest thing the government can do is keep up on changing the reimbursement models so that data sharing is actually a good business practice to the point where if you share and can receive data, then your ability to manage patients to high quality and low cost care goes up,” McCallie says. “Then provider organizations will demand from the vendors, local HIEs, and other service providers to make data sharing work because they can’t survive without it. In a fee-for-service world there is not much incentive to share, but in a pay-for-quality world, there is a lot of incentive to share,” he says.
David McCallie, M.D.
As such, McCallie has fears of an ill-conceived attempt to regulate interoperability by focusing on regulatory-driven standards. “We may regret it because the technology world moves so much faster than the regulatory world, and you could end up locking into really bad standards,” he says. For example, he adds, the industry is now in a transition from document-centric sharing, which is the current ONC standard for meaningful use, to discrete data element sharing which will be enabled by FHIR (Fast Healthcare Interoperability Resources) that’s emerging from HL7 (Health Level Seven International). “FHIR is a much more powerful and flexible and a better way to do it, but it would be a shame if we locked into the document-centric model because that’s all there was available at the time rule got written. You would make a huge mistake if you did that. We’re anxious to avoid that and let market forces take care of that, and transparency is a way to make market forces work,” McCallie says.
Sittig agrees on the point of paying for quality rather than services, saying it would solve all of the problems and would make organizations want to share data since they want to make money and stay in business. Still, he says most folks would be surprised about how provider organizations view success in the market. For instance, Memorial Hermann decided to have its own HIE rather than join Greater Houston Healthconnect, a large regional HIE in Texas. “They have decided that they’re big enough all by themselves to have their own HIE, and they think they will be more successful in a value-based environment in which they control all the hospitals and physicians that their patients go to,” Sittig says. “They don’t want the patients to go outside of their network. I don’t think that’s what accountable care organization (ACO) model had in mind.”
However, McCallie says he is seeing institutions agree to work together to take on risk. “Be it an ACO or some future successor to ACOs, those organizations will put in place robust data sharing, highly coupled to the requirements of the ACO—so not only clinical data, but also appropriate financial data,” he says. At same time, he notes, those organizations need to have connectivity to the broader community, but perhaps at a lower bandwidth and with less sophistication.
Enter CommonWell, which McCallie advocates as the standard way for everyone to connect. He says the alliance is currently at the low-level document-centric data sharing phase, but inside, the network is completely neutral with no advantages or disadvantages. “A given provider might have high bandwidth connectivity in his local database behind his at-risk population, but if his patient is in a car accident in Florida and got an MRI, and he needed an EKG in his local record, he won’t get that from his high bandwidth local HIE. He’ll get it from a national connectivity through something like CommonWell, and I think those two can coexist,” he says. McCallie says he likes to call it a “virtual HMO” (health maintenance organization), though that term hasn’t caught on yet. “Not all your patients will be in that high bandwidth network, and that’s why it’s virtual. As a provider you may participate in multiple independent ACOs, and your patients are free to move around under the current rules, so you need activity to the broader world,” he says.
With regards to another barrier to true interoperability, McCallie says that that while CommonWell is predicated on the belief that you need specific services— an identity management service and record locator service—to make connectivity easy and robust, the eHealth exchange, another data sharing network, is not predicated on those same beliefs. “Some of its members, mainly the federal government partners, actively did not want a central identity management service for fear of political repercussions of having a database of all the patients. CommonWell basically looked at the eHealth model and said that’s not going to scale; we need to have identity management service and record locator service,” McCallie says.
So while conversations between the two networks are being facilitated, McCallie notes that the mismatch in capabilities is a huge roadblock. “If you have a data sharing network like CommonWell that’s predicated on strong identity management and record locator service, and you’re trying to bridge that to a data sharing service that doesn’t believe in that, that’s a challenging bridge to build. I won’t say it’s impossible though,” he says, adding that there isn’t an obvious solution to the problem. “At some point we just need to be able to go and get the record wherever it is, and not worry about which ATM machine works with which bank. We did that already and it was painful.”