Commentary: What about interoperability?

John W. Loonsk

Installed base of non-interoperable EHRs may pose another barrier

The recommendations for Stage 3 of meaningful use are now out for comment. Coincidentally or not, there is a new degree of pessimism about when health IT interoperability will ever be achieved. The issue of progress, or relative lack thereof, on interoperability surfaced just before the election with members from both houses of Congress questioning whether HITECH funding of electronic medical records should be continued without interoperability standards or more rigorous meaningful use requirements in place.

Some dismissed the questions from Congress as election season rhetoric, but at the same time, many industry professionals have again resigned themselves to a long, slow road ahead. Recent, non-political, Congressional testimony suggested interoperability is still another decade away. And there are enough renewed discussion threads of potential “interoperability solutions” by newbies and statements of dispirited resignation by old hands to substantiate a serious trajectory problem.

HIT’s déjà vu all over again

Information exchange and interoperability have long been seen by people involved in health IT as being central to achieving meaningful outcomes with technology. Health IT professionals certainly recognized that providers needed to adopt health IT to start, but they also have long held that the data needed to be mobile and not stuck in a particular IT system or organization for many of the benefits of health IT to develop. Given how vague and ill-defined interoperability can be, and given the sparse empirical evidence for some of these assumptions, it is a little surprising how resolute the professionals are with these conclusions. Perhaps it comes from the practical challenges of trying to support continuity of care, or of working to aggregate data for quality, efficiency, public health, and research purposes, or from simply battling the obstacles to making disparate hospital systems work together.

For many of these same professionals, HITECH and its billions of dollars for health IT were thought to be a potential interoperability game changer. It was the first major national investment in health IT. And with the magnitude of the funding, the “hook” of the meaningful use mechanism, a second generation certification program, and the mission of supporting the needs of health reform, many felt we should have turned the corner on interoperability. Yet for those in the trenches, interoperability is still an uphill grind if not largely elusive. They just aren’t seeing many health IT systems that can easily process information that other systems provide. While information exchange is advancing in some ways, without broader exchange and the interoperability needed to process “foreign” information, health IT can actually act to increase the unnecessary information that a provider has to review rather than help make the provider more efficient.

The corner seems to have been turned on the adoption of electronic medical records, but many remain worried that the same is not true for interoperability. The interoperability trajectory is not proportionally steep, the HITECH tools to accelerate to this goal seem to be receding, and the newly installed base of largely non-interoperable EHRs may now be yet another obstacle to achieving a fully interoperable health IT infrastructure.

LOWTECH?

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.