Interoperability's long journey to reality

It's still a long, winding, confusing road, but progress appears just ahead
By Bernie Monegain
10:53 AM
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Interoperability has been part of the healthcare lexicon for at least a couple of decades. At some level, data liquidity has been achieved – as demonstrated annually at the IHE Connecthathon and the Interoperability Showcase at the annual HIMSS Conference & Exhibition, popular venues that always garner enthusiastic participants and audience.

But it’s still not happening at the scale we need.

Thankfully, at no other time in history has there been such a concentrated push for interoperability as there is today. Perhaps the need has become more obvious since the widespread adoption of electronic health record systems. Maybe the industry has gotten a second wind. Maybe the movers and shakers are finally impatient to make it happen. It could be simply that the stars are aligned.

Whatever the reason, interoperability is center-stage. It doesn't mean that it is done, or that the road to interoperability will be an easy ride. But, suddenly industry insiders seem more abuzz and determined to push forward.

Roadmap to interoperability

On Jan. 30, the Office of the National Coordinator for Health IT released its draft roadmap to interoperability. The document, “Connecting Health and Care for the Nation: A Shared Nationwide Interoperability Roadmap Draft Version 1.0,” recommended some actions to take toward interoperability.

The "time has come for us to be more explicit about standards," National Coordinator Karen DeSalvo, MD, said in a Jan. 30 press call. The 150-page plus roadmap addresses everything from governance, standards and certification to privacy and security. "Health IT that facilitates the secure, efficient and effective sharing and use of electronic health information when and where it is needed is essential to better care, smarter spending and a healthier nation," DeSalvo said in releasing the roadmap.

The ONC invited public comment on the draft document through April 3, 2015. By the beginning of March, more than 400 comments were posted, many of them long and detailed.

Doug Fridsma MD, president and CEO of the American Medical Informatics Association, and formerly chief science officer at ONC had not yet parsed the roadmap at the beginning of March.

But, when it comes to interoperability, he's sure about many things.

"I've always relied on IEEE definition for what interoperability is," he said. "There's a broad range of different definitions for interoperability that are out there, but I've always liked the IEEE definition because it's actionable and it's measureable."

IEEE is the Institute of Electrical and Electronics Engineers. Its definition for interoperability is in two parts.

"It's the ability of two or more systems to exchange information," Fridsma said. "That's the first part. The second part is the ability of the systems to use the information that's been exchanged."

Interoperability is defined as exchange and use. Exchange without use – without being able to achieve what you want to achieve with the exchange of information, is not interoperability, in his view.

"The thing that's nice about that particular definition," as Fridsma sees it, "is it means that you have to define interoperability in terms of this thing that you want to do."

"So exchange and use," Fridsma said. "And if you define the use in measureable ways, you can actually start measuring the progress that you're making toward interoperability."

So, you think measurable is really important? "I do," he said. "Because you can't improve the things you can't measure."

Fridsma also advocates getting very clear on what it is the nation wants to achieve with regards to interoperability. "We have to be very specific about what that is," he stressed, adding that since the "P" in HIPAA stands for "portability," one of the goals might be for patients to have truly portable electronic health records that can move from one system to another.

"You know, it can be exported from one and imported into another," he said. "That may be a very laudable goal – and it's measurable."

Joyce Sensmeier, RN, HIMSS vice president of informatics, agrees that in discussing interoperability it's critical to keep the patient front and center – and care providers, too. She said the roadmap addresses this well.

"One of the challenges I've seen over the last couple years is really we focused on the technical aspect of interoperability – we as an industry in general," she said. "And, while, of course that's an important part, I think we've missed out on thinking about the providers, the individual clinicians as well as the organizations.

"It starts with them," she added. "For example, a clinician working with a patient, documenting their care, and then capturing that into the record, and then having that record be the source of truth, so to speak, for that data – and having that data accessible wherever that patient goes. To me, interoperability begins with that – and it ends with that."

"We have not talked much about the patient," Sensmeier said. "We get busy trying to solve those tough technical problems and forget about the fact that there's an important component of the patient and the providers."

That may be so, but five Republican senators recently criticized the draft roadmap for being too general and missing 'nitty-gritty technology specifics."

"We have been candid about the key reason for the lackluster performance of this stimulus program: the lack of progress toward interoperability," Sens. John Thune of South Dakota, Lamar Alexander of Tennessee, Pat Roberts of Kansas, Richard Burr of North Carolina and Mike Enzi of Wyoming, wrote in a March 4 Health Affairs blog.

IHE and FHIR
Meanwhile a number of groups are working on various aspects of interoperability. One that seems to have caught the imagination of many in the industry is FHIR. It's pronounced "fire," and it stands for Fast Healthcare Interoperability Resources.

Charles Jaffe, MD, CEO of standards organization HL7, is an avid proponent.

As Jaffe described it in an Oct. 17 interview with Healthcare IT News, "FHIR represents a departure from the notion of messaging and document-centric ideas."

"FHIR is such a significant advance in accessing data, delivering data and the enormous, enormous flexibility inherent in the model," he adds. FHIR doesn't specify the content; FHIR specifies what we mean by the content."

He describes FHIR as a platform and a set of rules.

It originated with interoperability consultant and developer Grahame, Grieve, of Melbourne, Australia. Grieve sits on several HL7 committees.

John Halamka, MD, CIO of Beth Israel Deaconess Medical Center in Boston, is a fan of FHIR and the Argonaut project.

"It’s a perfect storm for innovation when stakeholders, resources, and political will align," he wrote in his Dec. 4, 2014 blog. "The Argonaut Project is a great example of policy and technology solving real problems in a reasonable timeframe driven by the value proposition that interoperability via open standards benefits all."

Sensmeier, though, is more circumspect. She started the Connectathon more than a dozen years ago. Also, the growing and popular Interoperability Showcase at the annual HIMSS conference – now evolved far beyond what anyone first envisioned – was her brainchild. She's earned her interoperability stripes.

She is cautious when it comes to FHIR, noting that the testing under way is not as advanced as the testing conducted at the Connectathons. FHIR testing is more akin to a hackathon, she said. Sensmeier is partial to the IHE framework she developed more than a decade ago. IHE stands for Integrating the Healthcare Enterprise. IHE has proven its rigor at one Connectathon after another over more than a decade, she noted.

"Those are very important efforts," Sensmeier said of FHIR, "but they're beginning efforts, and FHIR is not a mature standard. We need to build our infrastructure on mature things that we know work. That said, of course, we still want to look at innovation and what's coming down the pike. So, I put FHIR and the Argonaut Project in that category."

Meanwhile the Argonaut Project – a collaborative created by HL7 and joined by Epic, Cerner, MEDITECH, Mayo Clinic, Intermountain Healthcare, Partners HealthCare and several other marquee vendors and providers – is at work on ways to speed the development and adoption of FHIR to push interoperability forward.

This article first appeared in the April 2015 print issue of Healthcare IT News.