Seeking Interoperability in a Sea of Data

While it has been an elusive goal for years, the costs associated with not having standardization are mounting and "interoperability is becoming the main act" for healthcare leaders, says an HIT expert.

This article appears in the November 2015 issue of HealthLeaders magazine.

Interoperability of electronic health records and other healthcare IT systems remains elusive. Healthcare organizations clamor for it and the federal government voices support, but until very recently providers and vendors have lacked incentive to do more than create isolated networks. Yet many providers around the country are creating their own workarounds to achieve at least partial interoperability. These efforts take a lot of work, but technology leaders undertake them in pursuit of cost savings and patient safety.

The Institute for Electrical and Electronics Engineering defines interoperability as "the ability of two or more systems or components to exchange information and to use the information that has been exchanged," and that is the commonly agreed-on aspiration of all stakeholders in healthcare.

"There is a cost for the lack of standardization and the lack of interoperability," says Jonathan B. Perlin, MD, PhD, MSHA, FACP, FACMI, who is chief medical officer and president of clinical services for Nashville-based Hospital Corporation of America, which includes 168 hospitals and 113 freestanding surgery centers in 20 states and England, and reported revenues of about $37 billion in 2014. "Organizations, ours included, are compelled to create workarounds to make different devices or different information systems share the information. We need standards that get us to plug-and-play."

In April, at the request of the U.S. Congress, the Office of the National Coordinator for Health Information Technology (ONC) issued its Report on Health Information Blocking, which concludes, "based on the evidence and knowledge available, it is apparent that some healthcare providers and health IT developers are knowingly interfering with the exchange or use of electronic health information in ways that limit its availability and use to improve health and health care."

The result of so-called information blocking, which has become a cause célèbre, is an additional layer of data charges.

"Clearly, the support that the government provided created extraordinary investment in health IT with the promise and the aspiration that information would flow along a superhighway to follow and inform patient care," Perlin says. "The promise was a superhighway, not a toll road."

Beyond the road map

The ONC is focused on this problem with its 10-year interoperability road map, initially released in January. But it is difficult to pinpoint just how much the lack of more seamless interoperability is costing U.S. healthcare. Health system executives are unable to produce a firm dollar figure, and various reports tend to lump interoperability costs in with the rest of the higher costs that uncoordinated, fee-for-service care imposes upon the industry.

A Robust Health Data Infrastructure, a 2014 report prepared for the Agency for Healthcare Research and Quality by JASON, an independent scientific advisory group, estimates that if data mining and predictive analytics could work on interoperable health information, it should be possible to reduce significantly the estimated $60 billion–$100 billion of annual healthcare fraud in the United States.

And perhaps more important, the report states that "the data also will contribute to improved understanding of the economics of healthcare delivery, both in the aggregate and for particular instantiations that either outperform or underperform the aggregate in achieving beneficial outcomes."

Choosing Wisely, an initiative of the American Board of Internal Medicine Foundation, aims to reduce the over-ordering of tests and procedures. "Think of interoperability as being a key way to reduce the extra ordering of tests," says David Allard, MD, chief medical information officer of Henry Ford Health System, a five-hospital system whose flagship Detroit hospital has 877 beds. Such reductions would save Henry Ford "probably tens of millions dollars" annually by following the recommendations of the initiative, he says.

Why interoperability is difficult

Studies published in 2010 and 2014 by the President's Council of Advisors on Science and Technology list numerous scenarios where enhanced health IT interoperability could benefit the United States. So why does the nation continue to come up short on interoperability?

The answer is complex, but part of it is that interoperability already exists in many forms—much as before the Internet coalesced it was a series of networks that eventually became joined together by common protocols. The good news: Healthcare already has a set of such common protocols that routinely pass information between information systems not well-known for exchanging and using each other's information. Some of these common protocols were set in place by the federal meaningful use incentive program. The bad news: The protocols are unevenly adopted, reciprocal use agreements to "share and share alike" patient information with consent still require too much negotiation, and shared use cases often emerge only when providers discover or develop common business incentives to share information with each other. Such use cases are still rare.

"Many of our healthcare organizations don't really want to share data because they'd be sharing it with a competitor, and that would cost them money," says Dean F. Sittig, PhD, a medical informatics professor at University of Texas Health Science Center and School of Biomedical Informatics and a member of the UT-Memorial Hermann Center for Healthcare Quality and Safety.

"It's all too slow," says Marc Probst, chief information officer at Intermountain Healthcare, the 22-hospital system headquartered in Salt Lake City, which has been in the process of installing Cerner EHR software systemwide. "We're putting too much trust in the industry to pull it off on their own versus strong direction and mandates from the government. I am stating this as an über-conservative, but we are losing lives due to our inability to implement meaningful standards."

Others note that government intervention brings its own set of concerns to the interoperability debate. "More recently, we've had congressmen and senators talking about interoperability," Sittig says. "That's out of their league. A lot of our problems with interoperability surround [a] lack of agreed-upon uses. We have standards. We just don't agree to use the standards."

More than a technical challenge

"Technologically, we can share data," says Joel Vengco, vice president of information and technology and chief information officer of Baystate Health, a six-hospital system headquartered in Springfield, Massachusetts, in the state's Pioneer Valley region. "We can open up, create an API [application program interface]. The challenge is not technical, but rather about the vendor community working with its users to ensure cost-effective interoperability.

"We've got an Epic organization right now in our region," Vengco says. "They desperately want to connect to the Pioneer Valley Information Exchange, but the issue for them is that they are charged per transaction." The PVIX portal is an electronic way for member providers to access patient medical information.

A patchwork of networks—some private HIEs, some public HIEs, and some EHR vendor–operated HIEs—does allow relatively inexpensive and convenient record location services within each network. In Michigan, for instance, a high concentration of Epic EHR usage has allowed Epic's Care Everywhere platform to flow EHR data among 11 healthcare systems in the state, as well as other health
systems across the country running Epic.

"We were probably the earliest adopter in this market with Epic," says Subra Sripada, executive vice president, chief transformation officer, and system CIO of Beaumont Health, a three-hospital system in southeastern Michigan that reported total revenue of about $2.4 billion in 2013. "About three years ago, I reached out to my fellow CIOs to say, 'We are competitors in the market, but we shouldn't be competing on data.' "

Just on its own, in the first half of 2015, Beaumont shared 511,000 records with other healthcare systems in the United States via Care Everywhere, Sripada adds. "We can pull data from anybody that has Epic across the country, and they can pull data from us" due to Epic's reciprocal use agreements, which all Epic customers agree to when they activate Care Everywhere.

"We spend an awfully large amount of time trying to get records from other organizations, and we've found that we do notice a decrease in that since we've put in Epic," Henry Ford's Allard says. "We're now exchanging somewhere around 750,000 documents per quarter with other organizations [running Epic] for the purpose of getting health information on our patients that we're actively taking care of, and we're just not spending the amount of time at that [as we had to in the past]."

Common ground among competitors

When traditional competitors find common cause, technology barriers to interoperability can be overcome, even when no common EHR or HIE exists between the two. For instance, Detroit Medical Center—which includes eight hospitals, 140 clinics, more than 2,000 licensed beds, and 3,000 affiliated physicians—is in the process of negotiating a reciprocal use agreement with nearby Henry Ford that will allow each provider to exchange continuity-of-care documents, even though Detroit Medical Center runs Cerner EHR software, not Epic.

Henry Ford's pediatric practices are performed at Detroit Medical Center, says Mary Alice Annecharico, RN, Henry Ford's senior vice president and chief information officer. "We have an absolute need to be able to share clinical information with them on a regular and consistent basis," she says.

Once the reciprocal use agreement is finalized, electronic documents based on Health Level Seven International's Consolidated Clinical Document Architecture (CCDA) will begin flowing between Detroit Medical Center and Henry Ford, Allard says.

The technological foundation for such transfers was laid when both Cerner and Epic software were required to support CCDA as part of being certified in the meaningful use federal incentive program. Rather than requiring a third-party HIE, the communication will occur via existing support provided by Epic's Care Everywhere and Cerner's Resonance connectivity capabilities.

"Interoperability is becoming the main act," says Joe Francis, chief information officer of Detroit Medical Center. "We have a Pioneer accountable care organization here. I need to know everything that's going on with my patient, no matter which venue of care they're in, so interoperability becomes the underlying driver for being able to do that. We have 38 hospitals in southeast Michigan, as well as umpteen clinics. So a patient can go anywhere. Getting that information from those other organizations so you can build those missing pieces into your record of that patient—that's what I consider interoperability."

The need for a patient identifier

Lack of a nationwide patient identity standard is one area where Congress has made its own blocking law that continues to bedevil healthcare interoperability efforts. "We don't have a good way of identifying patients across systems," Sittig says. By federal law, the U.S. Department of Health and Human Services is prohibited from establishing a national patient identifier until legislation is enacted specifically approving the standard.

The blocking law was pushed by privacy advocates, but such concerns can be mitigated, Sittig says.

"We're not going to have true interoperability until we have a unique patient identifier, or at least a way for people who want to share their records to obtain a unique patient identifier," Sittig says. "The government wouldn't have to give this out. The government could just make a way for me to get one. I can get an employee identification number from my private business, so I don't have to use my Social Security number. There's lots of ways the government could give out a number, and then I could just give that number to every healthcare provider I went to, so they could share the data. It's a better solution than we've got now for sharing data."

Sittig also notes that many patients do not want their data shared. "I've always worked in hospitals or for healthcare, and I know there's a lot of employees that won't go to their own organization for healthcare because they don't want their employer to know what's wrong with them," he says.

Different routes to interoperability

Effective as a way to move beyond the privacy concerns and shortcomings of paper or faxed documents, CCDA represents one of meaningful use stage 2's major interoperability common denominators and also is in widespread use as a way to share EHR data via HIEs around the country.

Certain HIEs also offer record location services that, combined with methods of expressing patient consent to share information with other providers involved in their care, allow providers to query patient data that might reside at various hospitals or clinics. Such services are also core elements of Care Everywhere and another patient record information–sharing network, CommonWell Health Alliance, a set of services promoted initially by a group of EHR vendors, with the notable exception of Epic.

State HIEs offer their own variants. The Massachusetts Health Information Highway, known as Mass HIway, launched in 2012, initially permitting the encrypted pushing of messages containing medical records. This pushing technology leveraged the Direct protocol, an EHR secure messaging standard required of all meaningful use stage 2–certified software, for use in many short-term interoperability initiatives. In 2014, the Mass HIway then added query-and-retrieve capability throughout the state.

More than 500 organizations in Massachusetts currently participate in Mass HIway. Physicians who belong to the Mass HIway can, with a click display, request records that may reside in an incompatible EHR, which may allow the treating physicians to avoid duplicative or expensive tests when making their diagnoses.

"We've really been on a tear," says John Halamka, MD, chief information officer of Beth Israel Deaconess Medical Center—a Boston-based 649-bed teaching hospital. He also is a member of the governing health information technology council of the Mass HIway. "In April, we did 2 million transactions and we are completely financially viable."

Low cost to providers has driven adoption of Mass HIway, Halamka says. "We went to Blue Cross Blue Shield of Massachusetts and Partners HealthCare and Beth Israel Deaconess and said, 'Would you be willing to pay 10 times the cost of the service so that we can charge two-doctor practices $5 a month?' That's what we did. I'm more than happy to pay $50,000 a year because, boy, the value I get from healthcare information exchange is enormous, and by doing that, the big guys subsidize the little guys. Even at that price point, once you get enough volume, the whole thing works and the HIE, the HIway, doesn't go broke."

Another aspect of Mass HIway that lowers its operating costs: Unlike many other HIEs, the HIway does not act as a central repository of health information, leaving that job to other service providers who charge separately for those services.

Interoperability can also follow a different path to drive a sufficient number of healthcare organizations to participate on a statewide level. In Michigan, a high priority was to alert care providers when their patients were going to the hospital or the emergency department.

The solution, coordinated at the state level, arose from state legislation mandating an exchange initiated by the sender (a push exchange) of an admission-discharge-transfer (ADT) message from hospitals and emergency rooms—and the nine regional HIEs in the state to which they belonged—to doctors, specialists, therapists, and other patient-authorized providers. While not as comprehensive as some of the data exchanged via CCDAs, ADT updates are making a difference in Michigan, providers there say.

"Just getting people to send ADTs to a statewide service was prioritized by all these different groups as the No. 1 thing that everybody wanted, but then there was just a lot of pushback," says Tim Pletcher, DHA, executive director of Michigan Health Information Network Shared Services (MiHIN), a public and private nonprofit collaboration that has been formally designated as Michigan's statewide HIE by cooperative agreement between the Michigan State Health Information Exchange program and the Office of the National Coordinator for Health Information Technology.

"By packaging things up as a use case," Pletcher explains, "we were able to then ask Blue Cross Blue Shield of Michigan, one of the commercial payers in our state, 'Hey, all that money you give out in incentives—would you tie some piece of it to people doing this use case?' "

Over an 18-month period, aided by MiHIN's existing statewide patient-provider attribution service, the state was able to go from zero to collecting information on 92% of all admissions in the state. "That happened because they connected their incentives and payments to the use case as part of this population health incentive," Pletcher says.

His advice for other interoperability initiatives is to stop trying to solve so much of the interoperability problem at first. "People have been kind of swinging for the fence, and even something as simple as an ADT process has millions and millions of dollars of opportunity for people to sort of get on the same page," Pletcher says. "It is a giant bootstrapping activity to all of the next pieces. Every community has to figure out a strategy that works for them."

Rationale for federal rules

Still, the big problem for the industry is that while individual common interests and use cases may yield pockets of cooperation here and there, that is not sufficient to achieve nationwide interoperability. For years, policymakers have deliberated whether a nationwide set of reciprocal use agreements, also known as rules of the road, are necessary as well.

Such rules would define not just common data standards, but also common protocols for communicating patient consent, as well as identity matching and record location. Even between two systems such as Detroit Medical Center and Henry Ford, the agreements must be in place before any data can flow. "We just need to figure out: How do we do it safely within the construct of what we are regulated to protect? And how do we traffic that information, then store and utilize it?" Henry Ford's Annecharico says. Epic Care Everywhere and CommonWell govern certain reciprocal use within their own networks, but not with health systems in the other network.

Providers still struggle to achieve interoperability even within their own systems if they have multiple vendors' EHR software. Advocate Health Care, with the aid of a systems integrator, built a unified portal for discharged patients that draws from ambulatory settings running the Allscripts TouchWorks EHR for the 1,800-physician Advocate Medical Group, as well as the Cerner Millennium EHR running at nine of Advocate's 12 hospitals, says Mike Delahanty, vice president of information systems application projects at Advocate, which is based in Downers Grove, Illinois, and reported total revenue of $370 million in 2013.

"We wanted this to be a portal for all of Advocate," says Delahanty. "There are other EMRs besides these two in play. We came up with our own patient identifier. We came up with a scheme to get that loaded, how to match it up with our enterprise master patient index, so we knew we were getting the right person, so that we could tie them to all the different EMRs." Like other providers, Advocate has standardized on CCDA documents.

"Composable" standards allow organizations to select and assemble components in various combinations to satisfy unique user requirements. Support for Fast Healthcare Interoperability Resources (FHIR)—a composable set of data standards and APIs defined by HL7 that allows for versatile data exchange uses—is just beginning to become popular in healthcare. One such use is to permit discrete transmission of 16 elements of CCDAs instead of always sending entire documents that then must be interpreted by the receiving EHR or other health information technology.

How interoperability helps patients

Having information returned in FHIR format will simplify continuity of care for populations, according to Jeremy Marut, director of enterprise architecture at Hackensack University Medical Center, part of the 11-hospital, 1,717-licensed-acute-bed Hackensack University Health Network.

Due to its versatility, FHIR will show up in many different use cases throughout healthcare. One of the first on deck is another approach to interoperability sometimes known as the "HIE of one."

Hackensack is an early implementer of FHIR. Motivated by two concussions his daughter received, and the hassles of transporting her medical records from location to location, Hackensack's vice president and chief information officer, Shafiq Rab, MD, MPH, CHICO, recently convened a gathering of five technology vendors to implement a link between Hackensack's Epic EHR via FHIR to Hackensack's new mobile application to assemble data from various providers. When a patient presents to a new provider, as Rab's daughter did during her course of treatment, Hackensack grants that new provider access to the patient's assembled record, including ADT summaries of care and demographics.

"The beauty in the way we are doing it is we are putting the power in the hands of the patient," Rab says. Business reasons for Hackensack were not his primary motivation. "It's because my child had a concussion and we went to different doctors' offices and no information was there," he says. "Secondly, we want to empower our patients."

Rab says the move toward the "HIE of one" is a direct response to ONC's Report on Health Information Blocking, because patients cannot be denied their EHRs under the HIPAA Omnibus law. "That's why we are developing this app," he says. "It takes away the lame excuses of exchanges, the lame excuses of HIEs, the lame excuse of interfaces. All that nonsense goes away. We should fight for a common cause through selfless acts—and urgently, as our patients need us now."

By moving the results of queries away from CCDAs and toward FHIR elements, Hackensack will also enable a more usable longitudinal record query when a patient presents, Marut says. "When we have one patient present, we do a query within a 500-mile radius. So you're getting a lot of CCDs, and each one with a lot of information. And if you ask a doctor, they want to see it, but they don't necessarily want to see all the junk."

Beware unintended consequences

Indeed, one concern about interoperability falls along the lines of the familiar phrase, Be careful what you wish for. Physicians are already bombarded by electronic notifications and alerts from within their own health systems. Is healthcare prepared for even more coming from other care venues?

Detroit Medical Center's Francis acknowledges the importance of the issue. "We don't necessarily alert on every ADT," he says. "The fact that somebody is in the ED because they have a broken foot doesn't mean that I should be alerted because I'm treating them for COPD. You have to have intelligent alerts."

The changing interoperability landscape may also call into question some of the substantial investments made in traditional HIEs. Detroit Medical Center belongs to one of the local Michigan-certified HIEs to pass ADTs, lab results, immunizations, and syndromic surveillance to the state. But another implication of arrangements such as that being finalized between Detroit Medical Center and Henry Ford is the prospect that increasing numbers of interoperability solutions will not involve an HIE but instead data flowing directly between providers, aided and abetted by EHR software vendors working more in cooperation—and less at odds—with each other.

"The major EHR vendors have got the cash," Francis says. "They're willing to pull this stuff together, and it's even better, to a certain extent, than what an HIE can give you."

Providers agree the nation must also find a way to avoid making patients sign multiple consent agreements by arranging an agreement for common data sharing and rules of the road that govern all the disparate networks—whether it's Care Everywhere, CommonWell, or HIEs.

"We should have one standard, but unfortunately, it's not there yet," Rab says.

Yet another interoperability challenge is to slipstream record location and retrieval into clinicians' regular workflows, Allard says. "The trick is working it into regular workflow. If I have to go browse through a library of available information on every patient, it just sort of grinds things to a halt and it's hard to get it done. You can't just dump mail into people's inbox."

Reprint HLR115-2