Interoperability: Staying the course, long and meandering though it may be
The path to interoperability has been a circuitous one over the past 13 years, veering off in directions that weren't anticipated when the concept became an industry-wide initiative in 2004. So much has transpired, so many variables introduced and so many contingencies encountered that it is easy to lose track of the original intent and purpose of an interoperable architecture that spans the entire healthcare spectrum.
Yet those directly involved in the advancement of interoperability say despite all the detours, the course remains straight ahead to achieving full-scale connection across all systems and entities in the healthcare continuum.
Jon Elwell, CEO of Boise, Idaho-based Kno2, contends that the original integrity of the infrastructure remains intact, though it is not without hiccups in the system.
"We have a fairly unique perspective because we get insights from end users and vendors across the continuum," he said. "Technology vendors will echo to us the difficult operating environment they're in, with legislative changes and dealing with customer preferences – it puts them in a precarious position.
"Our conversation with them is that they need to see how their customers operate, the time and money involved, and how they are struggling with it," he added. "Their customers are hoping for better solutions to interoperate with their community, they are confused over direct messaging and document inquiries and overall they want a better path."
The evolution of interoperability has been one of fits and starts over the course of nearly a decade and a half. One path has splintered off into different trails, which has made it hard to continue forward, said Theresa Bell, president and CTO of Kno2.
"The definition of interoperability is a key part of the discussion," she said. "The roadmap from the ONC has veered off into multiple paths, so it has become a 'choose your own adventure book' process. It speaks to the complexity of it."
There are various forces at work to make achieving interoperability a difficult proposition, not the least of which is making disparate systems compatible despite a billion lines of code and hundreds, if not thousands of standards.
Yet there are two major initiatives that are overriding the dissonance and enabling a harmonic convergence – CommonWell and Carequality, said Tushar Malhotra, head of integration at Marlborough, Mass.-based eClinicalWorks.
"These are the two driving forces," he said.
The CommonWell Health Alliance provides a mechanism for exchange between providers, based on the concept of establishing linkage with a patient in the eClinicalWorks EHR, managing all the identities at the central level. Once that linkage is established, he said it enables an exchange of data through consolidated clinical document architecture.
"That is what eClinicalWorks supports as a mean to connect with the set of organizations that are part of CommonWell," Malhotra said. "It allows for easy data exchange between those who are connected."
The interoperability between eClinicalWorks and CommonWell has existed less than a year, Malhotra said, with the catalyst being "the isolation of the data…the industry wants EHRs to be able to exchange data outside their system boundaries."
The other initiative, Carequality, started in the same time frame and has rapidly developed in 2016. The biggest advantage, Malhotra said, is that there are no long-term agreements for sharing data, which he calls "a cumbersome process."
The computer science term "crosswalking" is at the heart of health IT data conversion projects. Through automated mapping that can be easily pared with disparate codes, crosswalking guarantees better system and user connectivity performance to effectively preserve interoperability efforts, says Sita Kapoor, CIO and chief architect of Piscataway, NJ-based HealthEC.
Crosswalking helps ensure a high level of interoperability via mapping of healthcare data standards such as HL7, LOINC, SNOMED, CMS regulations, HIPAA, NLM, Medicare, Joint Commission, CPT, HCPS, NQF and NDC as well as ICD-9 and 10. Data is also archived and formatted in a variety of incompatible file types and data sets across EHRs, acute and ambulatory transactional clinical and financial systems, claims, federal and commercial payers, institution or facility and pharmacy databases.
"Everyone is trying to achieve data at the point of service and while data is a broad term, healthcare is made up of individuals, one person at a time," Kapoor said. "Trying to process of that is a big challenge and that is where interoperability comes in – how to connect, how to exchange. Crosswalking is between systems, not an integral record we can do anything with."
Interoperability's journey to date is still in an early stage, Kapoor said, having transitioned from "research and development" to the "engineering" stage, where it continues to be presently. The next stage – which she estimates is still five years in the future – is "production," where "it will become a commodity, where competitive pricing is where it should be."