Commentary: What about interoperability?

Installed base of non-interoperable EHRs may pose another barrier

How, with all of HITECH, did we arrive back at a distant future for interoperability? Perhaps there was not enough money to overcome the entrenched interoperability problems of healthcare? Perhaps money alone is not enough? Opinions here vary as much as they do with potential solutions. It should be noted, however, that much of the political leverage of HITECH has been focused on quality measurement rather than interoperability in the early stages of meaningful use. There has only been so much pressure to apply and the lion’s share of it seems to have gone into process and quality measures. The theory has been that health reform and measuring quality will pull together the meaningful health IT that is needed to achieve it, rather than the competing approach of engineering the health IT needed to improve the quality of healthcare that can be performed.

Some health IT people point to the interoperability testing components of the certification process as also being problematic. One issue, perhaps inherent to how HITECH is structured, is that certification is only applied to EHRs. For testing in other industries and even testing of successful health IT systems like e-prescribing, all or most of the participant systems and organizations are certified – not just one piece. There have also been many comments about the overall lack of specificity of the interoperability related criteria of meaningful use. Of course, this lack of specificity can be traced upstream to the general lack of well-specified, unambiguous implementation guidance for most of the health transactions that need to occur.

Finally, many health IT professionals continue to point to the lack of a business case for the transactions that are being advanced to move health information around. Health IT implementation guidance includes standards for terminologies (for which there has been substantial progress in meaningful use) and standards for messages (groupings of data to support an activity) and technical transactions. The most prominent transactions of downloading data to a patient (Blue Button) and pushing data to another provider (Direct) do not align with compelling business cases for healthcare information exchange or requisite interoperability. Blue Button may align with efforts to make healthcare more patient-centric, but patient mediated electronic information exchange, such as that which would be fostered by non-portal personal health records, is almost non-existent. And stated bluntly, what does a provider get out of pushing data (via Direct) to another provider? It may be the right thing to do, and it may be itself pushed by meaningful use measurement, but it is not a compelling need for the provider who must initiate the action.

Measure at least once

Certainly one part of forward movement on interoperability will be to move from what is traditionally a gross, subjective, and qualitative assessment of its state to a fine-grained, objective, and quantitative one. Health IT interoperability is now almost always talked about in subjective and coarse terms. “Semantic interoperability” and “plug-and-play” are bandied about as interoperability goals, but are characteristically referred to as either existing or, mostly, not. Interoperability, however, is both multifaceted and nuanced. There are data, transactional, business, cost, privacy, policy, and incentive elements of interoperability. And almost all of these elements have shadings and nuances of impact.

Effective interoperability measurement will help with decisions about what else can be done to move forward faster. Measurement, at least, will substantiate a need to double down or change course on activities to bring interoperability back to being a possibility for the present.

John W. Loonsk is chief medical information officer of CGI Federal.

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