Healthcare Interoperability: Who's The Tortoise?

9 Healthcare Innovations Driven By Open Data

Interoperability may not have gotten enough attention in the early days of Meaningful Use's electronic health records (EHR) gold rush, but it's now taking center stage as healthcare providers, government agencies, vendors, and committees consider how to support the exchange of data easily and securely.

It's about time, industry executives say. Enabling interoperability among disparate systems would have advanced healthcare IT more than any initiative the federal government actually implemented, Dan Haley, vice president of government and regulatory affairs at the cloud-based EHR vendor Athenahealth, told InformationWeek.

"In 2015, the notion you can have 'meaningful use' of information technology that does not enable interoperation is ridiculous. You could strip away all the other requirements and only require interoperation," he said. "The government is not going to mandate interoperability, and the government is not going to subsidize its way to interoperability. We'll get to interoperability when doctors demand the same interoperability as they demand from every other aspect of technology in their lives."

[How to get there? See: A Serious Proposal For Healthcare IT Interoperability.]

Patients and clinicians are starting to demand the same ubiquitous access to their data they receive in other industries. Patients are tired of completing duplicate forms; of unnecessarily repeating expensive, potentially harmful tests; and of ordering CDs or files of medical records -- if they can recall who treated them years ago. Physicians are fed up with getting faxed reports and then trying to locate the pertinent information, and practices must figure out how to communicate with payers.

Government agencies and facilities demand interoperability, too. Lack of standards is expensive: The Statewide Health Information Network of New York is a network of 10 nonprofit regional health information organizations (RHIOs) -- but many providers won't participate, because it costs up to $30,000 to create an interface between their EHR system and the RHIO, New York eHealth Collaborative director David Whitlinger testified in August.

There has been plenty of talk and planning. This year, the Office of the National Coordinator for Health IT (ONC) published its 10-year interoperability plan, and recently the eHealth Initiative unveiled its 2020 roadmap, which addresses interoperability. Both separately and within numerous committees, leading EHR developers, startups, health information exchanges, and others focus on ways to improve EHR interoperability, so physicians and patients can seamlessly and easily exchange, search, and access records.

Some blame certain EHR vendors for creating closed systems designed not to play well with others, said Dr. Charles Sawyer, chief health information officer for Geisinger Health System, which uses Epic. But that oversimplifies an extremely complex issue, he said.

"It's very easy to point fingers at folks. People underestimate how challenging this work is," Sawyer told InformationWeek. "I think the vendors are being cautious before spending lots of research and development money before a standard is more clearly defined."

Some EHR systems, like Epic, were designed long before cloud and APIs, executives said. Others leveraged newer technologies like cloud and APIs from the start. But clinicians and patients want them all to exchange files with one another -- just like financial firms, which enable consumers to withdraw funds from any ATM, regardless of bank. Or like Amazon, which lets consumers browse and order items from stores -- both Amazon and other sellers -- via one platform.

"We're often asked the question, 'Why don't these systems talk to each other?' We're long past the point in every other sector of worrying what platform they're on," Haley said. "In healthcare, it's all about what platform you're on. And that is because most of the information technology in healthcare is pre-Internet."

HISP steps
To further interoperability, as part of Meaningful Use Stage 2 and to try to end healthcare's reliance on faxes, beginning Jan. 1, clinicians must use a secure messaging method to file at least 10% of referrals. Called Direct, the protocol enables secure point-to-point messaging -- something "we've been doing in the regular email world since the 1990s," said Dr. Seth Flam, CEO of the cloud-based EHR developer HealthFusion. "But still, [Direct] is not free-flowing, and it's still an issue."

Under Direct, messages go through health information services providers (HISPs), which secure and send information between providers, after confirming senders' and receivers' identities. However, there was no mandate that different HISPs talk to one another, Flam said. As a result, physicians using one HISP might not be able to communicate with those using a different HISP.

"Now everyone is scurrying, but I'm a little skeptical that [on] January 1, the infrastructure will be there for doctors to meet the standard. And it's completely out of their hands," said Flam. Vendors "can't make HISP XYZ connect with another HISP."

Others are more optimistic.

"It was only a few years ago that Direct was a drawing on a whiteboard. Now it's a regulatory requirement in use by tens of thousands of physicians every day," said Dr. David McCallie, Cernersenior vice president for medical informatics, said in an interview. "These things happen, but you keep having to work at it. People underestimate how much good Meaningful Use has done."

Industry alliances
Rather than wait for mandates, stakeholders labor in organizations such as the CommonWell Health Alliance (whose members include Cerner, Allscripts, Athenahealth, Greenway, and McKesson, for example) and Carequality (which includes Epic, Siemens, Greenway, and Kaiser Permanente). They're trying to craft secure standards acceptable to all, hoping industry-driven initiatives will move faster than potential federal mandates.

Alliances, which often work with government agencies, seek voluntary and open standards for interoperability, Judy Faulkner, Epic's founder and CEO, told InformationWeek. But first, participants must agree on the definition of interoperability, a term that can mean many things to many members of the healthcare world.

"It goes from rather restricted -- which I hear used a lot, a Meaningful Use type definition -- to its full interpretation, where you can look at [data] and it's everything," she said. "There are a lot of standards. Reducing the number of standards in interoperability will be nice, too."

Alliances and consumer demand worked in other industries (VHS versus Betamax, for example), and healthcare executives hope their industry follows a similar path.

Extending interoperability
Given their increased financial burden and role in healthcare, consumers will demand more interoperability across the industry, said Lisa Maki, co-founder and CEO of PokitDok, a HIPAA-compliant, cloud-based e-commerce platform for healthcare purchases.

"There are patient records [and] patient information, but you also have interoperability about the business areas of health around consumer experiences, around booking and paying for their experiences," she told InformationWeek.

So, while the initial road to interoperability may take far less than the government's 10-year plan suggests, side roads could add to the journey's length and timeframe.

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