Seamless interoperability. It's part of the dream for how electronic health records will improve healthcare, since it would let caregivers know a patient's history wherever that person is treated. In reality, what many CIOs, clinicians and patients deal with is a patchwork of data standards, vendor conflicts, state laws and federal regulations that sharply limit data sharing.
In practical terms, lack of interoperability means it's sometimes difficult for Mrs. Jones' digital records to move from her doctor's office-based EHR to a nearby hospital when she's admitted for gallbladder surgery.
Among the obstacles preventing true interoperability: lack of cooperation among EHR vendors, state laws that block access to patient data and financially unstable health information exchanges. Clearing these hurdles is going to require some creative thinking, vendor cooperation and the political willpower to put patients' needs ahead of vested interests.
Is The Standards Stalemate Over?
"Different vendors adhere to different standards for each clinical domain: medications, allergies, medical problems," says Dr. Rasu Shrestha, medical director, interoperability and imaging informatics at UPMC. That differing vocabulary can sometimes present problems as clinicians try to share patient records. The federal government has made major progress to help resolve the problem by adding interoperability requirements to Meaningful Use regulations that govern federal subsidies for EHR implementation, but moving clinical data within a large health system remains difficult.
When the Office of the National Coordinator for Health IT released its Stage 2 final rule in August 2012, the ONC director at the time, Dr. Farzad Mostashari, emphasized that, in order to demonstrate compliance, providers must be able to show evidence of at least one successful transmission of patient data from their EHR to one from another vendor. The point is to demonstrate a core capability: the ability for providers to exchange an electronic summary of care, with all the clinical data elements, between different EHRs. The MU Stage 2 document warns: "If we do not see sufficient progress or that continued impediments exist such that our policy goals for standards-based exchange are not being met, we will revisit these more specific measurement limitations and consider other policies to strengthen the interoperability requirements..."
The message was clear: If EHR vendors don't offer a better way to talk to one another, regulators would become more prescriptive in terms of data standards. Vendors are only slowly getting the message.
Epic, for instance, uses the NDC standard to code medication data in its EHR system, despite the fact that RxNorm is more widely accepted as a national standard. While Epic is in no hurry to embrace RxNorm inside its software, it has created what it calls an "NDC-to-RxNorm walk," which is essentially a bridge to convert from one language to the other. It's a start. "A few years ago, many vendors had the 'my way or the highway' attitude," says Shrestha. "Now they realize they can't play that game anymore."
Vendors may see interoperability as a threat -- after all, some providers choose an "all-Epic" implementation, for example, to lessen integration problems. But as patients demand more data sharing across providers, that strategy won't be enough. "To be competitive in the future, vendors are going to have to open their systems," says Pam Matthews, senior director of informatics for HIMSS, the professional organization for hospital information managers. HIMSS is helping frame the discussion and making it easier for vendors to cooperate by recently publishing a definition of interoperability and creating a resource library on the topic.
Really, the industry needs a definition of interoperability? It's true that stakeholders sometimes disagree on such basics, and so the HIMSS definition helps everyone shoot for the same targets. HIMSS defines interoperability as the "ability of different information technology systems and software applications to communicate, exchange data and use the information that has been exchanged." Data exchange is supposed to let clinicians, labs, hospitals, pharmacies and patients share data "regardless of the application or application vendor."
Such interoperability should be both syntactic and semantic. Syntactic means separate systems can exchange data, using languages like XML and SQL. Semantic means the systems have the ability to transmit data with "unambiguous, shared meaning."