By Drew Ivan, EVP of product and strategy of Rhapsody.
It was generally recognized by 2009 that the health care industry was long overdue when it came to adopting electronic systems for storing patient data. At the time, hospital adoption of electronic health record (EHR) systems was at about 10 percent while electronic record keeping was commonplace in most other industries. EHR technology was widely available, yet doctors and hospitals were still using paper charts.
The HITECH Act of 2009 was part of a broader stimulus package that financially nudged hospitals and eligible professionals to adopt and use EHRs. The meaningful use incentive program began a national, decade-long project to adopt, implement, and optimize EHR software. The program was a huge success, judged by the most obvious metric, EHR adoption. Today, nearly 100 percent of hospitals are using electronic health records. This means that records are safe from physical damage, far easier to analyze and report on, and – in theory at least – easier to transfer from one provider to another.
However, when viewed through the lens of return on investment, the success is less impressive. The federal government has spent $36 billion to encourage providers to adopt EHR systems but the industry has spent far more than that to procure, implement and optimize the software. Yet, hospitals are seeing reduced productivity, doctors face a huge documentation burden, and interoperability remains an unsolved problem. The first two problems are the consequence of workflow changes brought on by the EHR systems, but interoperability roadblocks ought to have been eliminated by implementing EHR systems, so why is it still so difficult to transfer records from one provider to another, or from a provider to the patient?
Health IT experts generally consider three categories of obstacles to interoperability:
- Business disincentives: allowing medical records to move to a different provider makes it easier for patients themselves to move to another provider, and helping customers switch health care providers is contraindicated by usual business practices (even though HIPAA states that patients are entitled to receive copies of their medical records and may direct copies of their records to be sent elsewhere.)
- Technical challenges: Meaningful use set a fairly low bar for cross-organizational data exchange requirements, and it did little to ensure that EHR systems could understand data sent from another system. Although these problems are largely resolved today, there is still the impression that “interoperability is a hard technical problem”.
- Network effects: point-to-point connections between providers are impractical, but the network approach also has its drawbacks. The assortment of HIEs and national interoperability initiatives is huge and confusing, and it’s not obvious which network(s) an organization should join.
There may have been an assumption that when medical records moved from paper to electronic format they would immediately become more interoperable, but by 2016, the level of interoperability was far below what patients and regulators expected. As a result, the 21st Century Cures Act of 2016 was passed by Congress and signed into law by the outgoing Obama administration. The law’s scope included a number of health care priorities, including a patch for the interoperability gap left by Meaningful Use. Cures explicitly forbids providers, technology vendors, and other organizations from engaging in “information blocking” practices.
Earlier in 2019, the Office of the National Coordinator for Health IT (ONC) issued a notice of proposed rulemaking (NPRM) that defined exactly what is (and what is not) meant by “information blocking.” Once adopted, the expectation will be that a patient’s medical records will move according to the patient’s preferences. Patients will be able to direct their data to other providers and easily obtain copies of their data in electronic format.
In parallel with Cures and its clarifications, ONC is working on a Trusted Exchange Framework and Common Agreement, which will create a “network of networks” and a single on-ramp to the national interoperability grid. This ought to simplify the process of selecting and connecting to various networks and boost the overall level of interoperability.
What should organizations be doing today to get ready for the forthcoming age of interoperability?
- Understand HIPAA, 21st Century Cures, and ONC’s NPRM, because different types of organizations will have different obligations.
- Determine the different places within the organization that patient data is stored and what capabilities exist to transmit the data.
- Prepare a strategy sending that data to one or more data-sharing networks. Since most networks use the same core set of standards – including HL7 v2, FHIR, CCD, C-CDA, and IHE profiles – the fundamental building blocks will be the same no matter which interoperability approach is used.
As interoperability moves from being an unfulfilled promise to a mandate, organizations will find themselves faced with a compliance project rather than a technology roll-out. The best way to head off problems is to become educated and start laying the groundwork for a good interoperability strategy.