For primary care physicians to speak to specialists in the best interest of the shared patient. ... The language of data
Healthcare won’t improve until it speaks the same language May 2015
Contents
Why doesn’t interoperability exist?
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Why is change needed?
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But what of the patient?
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What does the future look like?
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References
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At the core of the challenges facing healthcare providers today is
an inability to communicate. There is a need for physicians to speak to patients in a language patients can understand. For primary care
physicians to speak to specialists in the best interest of the shared patient. For payers to speak to both providers and patients in a way that delivers value. And for the inner workings of the healthcare operation—the data and information that underpins the entire system—to speak to anyone. The language of data, and the technology that facilitates it, has
confounded the healthcare industry for decades. There is an endless commentary among healthcare administrators about the dearth of
meaningful business intelligence despite an overwhelming amount of available data. There’s an old sailor’s poem that goes, “Water, water everywhere, nor any drop to drink.”
This has been revised by speakers and writers to “Data, data everywhere and not a drop to drink.” Part of the problem is a lack of connectivity; a lack of interoperability. That buzzword—interoperability—has been
defined by the Healthcare Information and Management Systems Society (HIMSS) as “… the extent to which systems and devices can exchange
data, and interpret that shared data. For two systems to be interoperable, they must be able to exchange data and subsequently present that data such that it can be understood by a user.”1 In simpler terms, systems
need to speak the same language in order to communicate. One person speaking Greek to a person speaking Spanish does not yield a very
interesting or productive conversation. It is the same thing with data. The HIMSS definition continues: “Interoperability means the ability of health information systems to work together within and across
organizational boundaries in order to advance the effective delivery of healthcare for individuals and communities.”
Why doesn’t interoperability exist?
There are many reasons for the lack of interoperability in healthcare
data and technology. First, the complexity of the issue is daunting. As
HIMSS defines it, there are three levels of health information technology interoperability: 1) foundational, 2) structural and 3) semantic. •
“Foundational” interoperability allows data exchange from one
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information technology system to be received by another and does
not require the receiving information technology system to be able to interpret the data.
• “Structural” interoperability is an intermediate level that defines
the structure or format of data exchange (i.e., the message format
standards) where there is uniform movement of healthcare data from one system to another such that the clinical or operational purpose and meaning of the data is preserved and unaltered. Structural
interoperability defines the syntax of the data exchange. It ensures
that data exchanges between information technology systems can be interpreted at the data field level.
• “Semantic” interoperability provides interoperability at the highest level, which is the ability of two or more systems or elements to exchange
information and to use the information that has been exchanged. This level of interoperability supports the electronic exchange of patient
summary information among caregivers and other authorized parties via potentially disparate electronic health record (EHR) systems and other systems to improve quality, safety, efficiency and efficacy of healthcare delivery.
Beyond the technological complexity, there is an economic undertone around the lack of interoperability. There are countless technology
vendors developing software on multiple platforms, speaking different
technological languages. And there is little incentive for vendors to work together for fear of losing business to a competitor that might replicate
their offering given too much insight into their structure and makeup. In
fact, many technology vendors have developed proprietary languages for the very purpose of keeping competitors (and end users) in the dark.
Why is change needed?
As the Centers for Medicare & Medicaid Services and the Office of
the National Coordinator for Healthcare Information Technology (ONC)
continue to ramp up expectations and carrot-versus-stick reimbursement scenarios, information technology has been front and center.
Specifically, the mandate that healthcare providers implement
“meaningful use” has been considered to be the first step on the road
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to interoperability. According to HealthIT.gov, the ONC’s website,2 meaningful use is defined as using certified EHR technology to:
• Improve quality, safety and efficiency and reduce health disparities. • Engage patients and family. • Improve care coordination and population and public health. • Maintain privacy and security of patient health information. Ultimately, it is hoped that the meaningful use compliance will result in: • Better clinical outcomes; • Improved population health outcomes; • Increased transparency and efficiency; • Empowered individuals, and; • More robust research data on health systems. Meaningful Use Stage 3 was recently announced, and it was in a
comment period through May 29, 2015. The rule gives more flexibility
and simplifies requirements for providers by focusing on advanced use of EHRs and eliminating requirements that are no longer relevant. Despite improvements to the rule, a recent survey of 1,400 healthcare providers
by cloud-based EHR vendor athenahealth Inc.3 uncovered a disheartening story:
• 36 percent of survey respondents are not currently participating in meaningful use
• 76 percent indicated they are frustrated by the complicated attestation process
• 42 percent are extremely unfavorable in their opinion of meaningful use • 65 percent stated that they are not very worried about financial penalties Beyond meaningful use, the ONC released its road map and plans
to accelerate standards development. The road map aims to ensure
that a “majority of individuals and providers” effectively share data “at a nationwide level” by 2017. By 2024, ONC hopes that we’ll have a
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“learning health system” where interoperability allows patients, providers,
researchers and others to truly engage in population health management.4 The road map lays out four near-term goals: • Establish a coordinated governance framework and process for nationwide interoperability.
• Improve technical standards and guidance for sharing and using a common clinical data set.
• Advance initiatives for sharing health information according to common standards, starting with a common clinical data set.
• Clarify privacy and security requirements. The road map is a welcome refresher of the HITECH Act initiatives,
but detractors are many, and they are vocal. A group of senators, led
by Sen. John Thune, have expressed dissatisfaction with the fractured data exchange landscape, saying, “After spending $28 billion so far of the $35 billion total taxpayer investment, significant progress toward
interoperability has been elusive.” They believe Meaningful Use Stage 1
merely incented widespread adoption of EHR systems that are “difficult to use and lack the ability to exchange information without costly upgrades.” To that end, Congress has called for decertification of EHR technologies
that do not actively encourage and allow for healthcare IT interoperability.
But what of the patient?
When one sets aside the structural and financial mandates around
interoperability and puts the focus where it should be—on the patient—the discussion shifts. As consumerism and healthcare knowledge deepen,
patients are starting to demand the same ubiquitous access to their data that they receive in other industries. Patients are tired of completing
duplicate forms, of unnecessarily repeating expensive, potentially harmful tests and feeling that the various players in their healthcare story are not on the same page of the script.
Patients and clinicians don’t care about complexity of legacy systems. They just want their healthcare to be managed more efficiently and
effectively. They want their providers to be able to exchange information seamlessly, like banks do through ATMs, or like Amazon, which allows
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customers to browse multiple stores all on one platform. As Dan Haley, vice president of government and regulatory affairs at
athenahealth, told InformationWeek, “We’re often asked the question,
‘Why don’t these systems talk to each other?’ We’re long past the point
in every other sector of worrying what platform they’re on.” In healthcare, it’s all about what platform you’re on. And that is because most of the information technology in healthcare is pre-Internet.”5
And that’s key. Healthcare EHR systems have been built on a faulty foundation. A recent blog on interoperability puts this quite clearly:
“They have been designed primarily to follow the money and capture the necessary data to collect reimbursements for care—rather than actually helping physicians and other care providers deliver better patient care. As a result, the patient is treated as an afterthought and more of an
abstraction, rather than the focus of the healthcare delivery process.”6
What does the future look like?
By 2016, CMS wants 30 percent of Medicare payments to be linked to fee-for-value reform models, and 50 percent by 2018. Interoperability
is of huge importance to hospitals that are attempting to create patient-
centered medical homes or successful accountable care organizations. Without a consistent language and easy access to all data on every patient regardless of site of care, this vision cannot be achieved.
But just imagine the future in an interoperable state. All your care providers know everything about you—your family history, conditions, medications and test results. They understand how to move you toward health and
away from healthcare. They speak the same language and, as a result,
are able to communicate with you, about you. It’s not simple and it won’t
be quick. But the end game is certainly worth overcoming the challenges.
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References
1. HIMSS, “What Is Interoperability?,” April 5, 2013. Available at http://www.himss.org/library/interoperability-standards/ what-isinteroperability. Accessed Feb. 23, 2015.
2. HealthIT.gov, “Meaningful Use Definition & Objectives.” Available
at http://www.healthit.gov/providers-professionals/meaningful-usedefinitionobjectives. Accessed Feb. 27, 2015.
3. The Camden Group, “Meaningful Use Infographic | New
Attestation Deadline Reminder,” March 12, 2015. Available at http:// blog.thecamdengroup.com/blog/meaningful-use-infographicnewattestation-deadline-reminder. Accessed Feb. 23, 2015.
4. Hospitals & Health Networks, “Feds Ease Meaningful Use Reporting Timeline, Set Interoperability Goals,” Jan. 30, 2015. Available at
http://www.hhnmag.com/display/HHN-newsarticle.dhtml?dcrPath=/ templatedata/HF_Common/NewsArticle/data/HHN/Daily/2015/ January/meaningful-use-timeline-blog-weinstock. Accessed March 1, 2015.
5. InformationWeek, “Healthcare Interoperability: Who’s the Tortoise?” Nov. 21, 2014. Available at http://www.informationweek.com/
healthcare/electronic-healthrecords/healthcare-interoperability-whosthe-tortoise/d/d-id/1317627. Accessed Feb. 23, 2015.
6. Holon, “There’s No Magic Bullet for Healthcare Interoperability,” Oct.
29, 2014. Available at http://www.holonsolutions.com/blog/theres-nomagicbullet-for-healthcare-interoperability/. Accessed Feb. 27, 2015.
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