Electronic Health Reporter

The Department of Health and Human Services (HHS) filed its annual year-end report to Congress at the start of 2019. The 22-page report summarized nationwide trends in health information exchange in 2018, including the adoption of EHRs and other technologies that support electronic access to patient information. The most interesting takeaway has to do with the ever-elusive healthcare interoperability.

According to the report, HHS said it heard from stakeholders about several barriers to interoperable access to health information remain, including technical, financial, trust and business practice barriers. “These barriers impede the movement of health information to where it is needed across the care continuum,” the report said. “In addition, burden arising from quality reporting, documentation, administrative, and billing requirements that prescribe how health IT systems are designed also hamper the innovative usability of health IT.”

To better understand these barriers, HHS said it conducted multiple outreach efforts to engage the clinical community and health IT stakeholders to better understand these barriers. Based on these takeaways, HHS said it plans to support, through its policies, and that the health IT community as a whole can take to accelerate progress: Focus on improving interoperability and upgrading technical capabilities of health IT, so patients can securely access, aggregate, and move their health information using their smartphones (or other devices) and healthcare providers can easily send, receive, and analyze patient data; increase transparency in data sharing practices and strengthen technical capabilities of health IT so payers can access population-level clinical data to promote economic transparency and operational efficiency to lower the cost of care and administrative costs; and prioritize improving health IT and reducing documentation burden, time inefficiencies, and hassle for health care providers, so they can focus on their patients rather than their computers.

Additionally, HHS said it plans to leverage the 21st Century Cures Act to enhance innovation and promote access and use of electronic health information. The Cures Act includes provisions that can: promote the development and use of upgraded health IT capabilities; establish transparent expectations for data sharing, including through open application programming interfaces (APIs); and improve the health IT end user experience, including by reducing administrative burden.

“Patients, healthcare providers, and payers with appropriate access to health information can use modern computing solutions (e.g., machine learning and artificial intelligence) to benefit from the data,” HHS said in its report. “Improved interoperability can strengthen market competition, result in greater quality, safety and value for patients, payers, and the healthcare system generally, and enable patients, healthcare providers, and payers to experience the promised benefits of health IT.”

Interoperability barriers include:

• Technical barriers: These limit interoperability through—for example—a lack of standards development, data quality, and patient and health care provider data matching. Addressing these technical barriers by coordinating to establish the technological foundation for standardizing electronic health information and by promoting exchange of that information can considerably remove these barriers.
• Financial barriers: These relate to the costs of developing, implementing, and optimizing health IT to meet frequently changing requirements of health care programs. The cost to adjust health IT to meet these requirements can impact innovation and the timeliness of technical upgrades. Specific barriers include the lack of sufficient incentives for sharing information between health care providers, the need for enhanced business models for secondary uses of data, and the current business models for health systems or health care providers that do not adequately focus on improving data quality.
• Trust barriers: Legal and business incentives to keep data from moving present challenges. Health information networks and their participants often treat individuals’ electronic health information as an asset that can be restricted to obtain or maintain competitive advantage.

Elsewhere, the Center for Medical Interoperability, located in Nashville, Tenn., is an organization that is working to promote plug-and-play interoperability. The center’s members include LifePoint Hospitals, Northwestern Memorial Healthcare, Hospital Corporation of America, Cedars-Sinai Health System, Hennepin Healthcare System, Ascension Health, Community Health Systems, Scripps Health, and UNC Health Care System.

Its mission is “to achieve plug-and-play interoperability by unifying healthcare organizations to compel change, building a lab to solve shared technical challenges, and pioneering innovative research and development.” The center stressed that the “lack of plug-and-play interoperability can compromise patient safety, impact care quality and outcomes, contribute to clinician fatigue and waste billions of dollars a year.”

More interoperability barriers identified

In a separate study, “Variation in Interoperability Among U.S. Non-federal Acute Care Hospitals in 2017,” showed additional difficulty integrating information into the EHR was the most common reason reported by hospitals for not using health information received electronically from sources outside their health system. Lack of timely information, unusable formats and difficulty finding specific, relevant information also made the list, according to the 2017 American Hospital Association (AHA) Annual Survey, Information Technology Supplement.

Among the explanations health systems provided for rarely or never using patient health information received electronically from providers or sources outside their health system:

• Difficult to integrate information in EHR: 55 percent (percentage of hospitals citing this reason)
• Information not always available when needed (e.g. timely): 47 percent
• Information not presented in a useful format: 31 percent
• Information that is specific and relevant is hard to find: 20 percent
• Information available and integrated into the EHR but not part of clinicians’ workflow: 16 percent
• Do not trust accuracy of information: 10 percent
• Vocabulary and/or semantic representation differences limit use: 7 percent

Hospitals, when asked to explain their primary inability to send information though an electronic exchange, pointed to: Difficulty locating providers’ addresses. The combined reasons, ranked in order regardless of hospital classification (small, rural, CAH or national) include:

• Difficult to find providers’ addresses
• Exchange partners’ EHR system lacks capability to receive data
• Exchange partners we would like to send data to do not have an EHR or other electronic system to receive data
• Many recipients of care summaries report that the information is not useful
• Cumbersome workflow to send the information from our EHR system
• The complexity of state and federal privacy and security regulations makes it difficult for us to determine whether it is permissible to electronically exchange patient health information
• Lack the technical capability to electronically send patient health information to outside providers or other sources

Additional Barriers

The report also details other barriers related to exchanging patient health information, citing the 2017 AHA survey:

• Greater challenges exchanging data across different vendor platforms
• Paying additional costs to exchange with organizations outside our system
• [Need to] develop customized interfaces in order to electronically exchange health information

“Policies aimed at addressing these barriers will be particularly important for improving interoperable exchange in health care,” the report concluded. “The 2015 Edition of the health IT certification criteria includes updated technical requirements that allow for innovation to occur around application programming interfaces (APIs) and interoperability-focused standards such that data are accessible and can be more easily exchanged. The 21st Century Cures Act of 2016 further builds upon this work to improve data sharing by calling for the development of open APIs and a Trusted Exchange Framework and Common Agreement. These efforts, along with many others, should further improvements in interoperability.”

What healthcare leaders are saying about interoperability

While HHS said it conducted outreach efforts to engage health IT stakeholders to better understand these barriers, we did too. To further understand what’s currently going on with healthcare interoperability, read the following perspectives from some of the industry’s leaders. If there’s something more that you think must be done to improve healthcare interoperability, let us know:

Chris Talbot, Ascom North America

Digitization has shown us many of the limitations of existing tools and processes for managing collaborative workflows, and many CIOs are starting to realize how much they need next-generation clinical workflow solutions. I’m looking forward hearing from hospitals that have developed a vision and strategy to actuate their data and drive collaborative, team-based care. I’m particularly interested to see new digital centralized monitoring units, and understand how hospitals are orchestrating and marshaling medical device information in collaborative workflows to achieve measurable enhancements in patient care.

Nick Semple, PA Consulting

Is healthcare inoperability going to happen? When? Who? What is the federal government doing about it? Interoperability is happening but so far in a fragmented rather than a concerted, orchestrated way. While there are national and regional initiatives, there is still some way to go. The federal government’s vision for interoperability was ahead of the healthcare industry when the vision was established in the early 2000s. Through federal incentives to ensure greater adoption of EHRs and healthcare technology, hospitals and provider groups have made advances to set the stage for interoperability; i.e.: they have moved from a paper based to an electronic health record. However, lack of standardization and information “locked” within a specific EHR has been a challenge. There also is increasing pressure on vendors and payers/providers to share information. The main driver for interoperability has been the establishment of HIEs at the community, regional and state levels, as well as industry/vendor-led interoperability networks. There is now growing use of HIEs to facilitate interoperability. In 2018, the DirectTrust HIE saw an exchange of 274 million Direct message transactions between DirectTrust users in 2018, up from 168 million transactions in 2017.

Charles Aunger, Health2047

The .com boom happened in 1999, but healthcare didn’t come around to the tech revolution until 2008 – that’s almost a full decade behind. When it did finally arrive, the digitalization of healthcare introduced a number of challenges that continue to shape healthcare interoperability (or lack thereof) today. For one, the healthcare industry lacks trust and transparency, both of which are crucial to an interoperable system. Additionally, healthcare infrastructure is lacking and slow to evolve. Health data remains locked in silos, ownership is blurred and transportability is difficult. To have true healthcare interoperability, players and providers alike will need to have access to technology that allows them to utilize the right data, at the right time. Ultimately, the healthcare industry will achieve interoperability when it solves its connectivity issue. Technology, such as blockchain, holds the potential to create consistency, give patients confidence that their data is being used appropriately, reduce friction in payments by tying providers and payers together, and increase connectivity through decentralized internet and computer networks across geographic areas. As of now, we need to avoid innovation for the sake of innovating. The good news is that we have the tools we need to create a transparent system that will improve the quality of care for all.

David Niewolny, Real-Time Innovations

Healthcare data has traditionally been very siloed due to security concerns and the lack of interoperability. The ONC is making progress in making EMR data more portable via their efforts on data blocking and support of the latest HL7 standard, Fast Healthcare Interoperability Resource (FHIR). Unfortunately, this effort is largely focused at the enterprise/IT level and the largest opportunity for interoperability to transform healthcare is at the device level. The ability to drive down cost and improve patient care via AI-powered clinical decision support (CDS) systems is not possible due to the lack of available data. The data entered into an EMR is not comprehensive nor timely enough. Capturing streaming data from all patient connected devices via a standards-based interoperability platform that aligns syntactic, semantic and organizational levels of interoperability would enable a data revolution in healthcare.

Liz Westbrook, Ingersoll & Rooney

A pair of proposed rules released by CMS and ONC last week is a grab bag of interoperability-related policy recommendations. To the Administration’s credit, these wide-reaching would-be regulations demonstrate a real commitment to advancing interoperability and improving health IT for patients, but the assortment of proposals feel a bit like throwing everything against a wall to see what sticks; moreover, some proposals seem half-baked. There is widespread support for the rules’ provisions to crack down on information-blockers by naming and shaming bad actors. Information-blocking has been recognized as an obstacle to interoperability for some time now but with little done to stop it. These rules would give HHS some teeth in enforcement, while carving out necessary exceptions to protect privacy and health information exchange. I think CMS is jumping the gun in rushing to out new FHIR-based standards for EHR certification. There was little notice for what would be a massive undertaking and after years of heavy-lifting to get providers onboard with EHRs under meaningful use, this could be very costly and time-consuming. CMS and ONC are missing an opportunity to better leverage health information exchanges to accomplish some of their interoperability and transparency goals. Better HIE-integration and utilization across the country could accomplish some of the objectives laid out in the proposed rules without being onerous for providers.

Niko Skievaski, Redox

Nothing will change immediately, but this proposed rule builds on CMS’s efforts to improve interoperability in healthcare, which translates down to patient access, smoother data exchange and better care coordination.  It is meant to give patients access and control over their information and discourage information blocking. On the backend, the rule is encouraging the industry to adopt standardized APIs to enable that easier access from any format using any device. With the main standard being FHIR, we’ll still see some growing pains, but it’s certainly a step in the right direction.

Tim Coulter, Prepared Health

Recent advances in healthcare interoperability have made it easier to exchange “chart-level data”– blood pressure, medication, lab results—between hospitals and physicians. New proposed CMS regulations would get us closer to where we need to be, which is to connect more and new sources of data. Ultimately, this would include all that happens outside of the hospital or doctor’s office and inside the home: day-to-day care tasks like home health visits, physical therapy or how a patient is responding to medication. We’ve seen that social determinants emerging from the home have a bigger chance of impacting outcomes and preventing readmissions than traditional clinical data. And the exchange of chart-level data is not available to everyone, most importantly home-based providers and family caregivers who are taking care of their loved ones every day. They’re left out of the conversation and that’s what we’re trying to solve with our Prepared Health network. Family caregivers want to get answers quickly and securely. And since they’re on the front lines, when that data does reach them, it’s often outdated and there’s no avenue for them to communicate with the hospital case managers in charge of patient outcomes. Until the entire care continuum is connected, we’ll still have a blind spot into the best course of action for patients and loved ones.

Carl Natenstedt, Z5 Health

Much of what we saw from HIMSS was focused on making records accessible to the patient, which is admirable and long overdue. (We just saw a struggle in our office for several people to find their own immunization records, which really ought to be as easy as looking up your credit score.) But even if the necessary improvements in transparency and interoperability are made to bring information to the patient – and that’s a big if – there’s no guarantee that every healthcare provider will use the same system to provide them. There’s no guarantee that they’ll adopt systems that will play well with others. The noble goal of connectedness and the ugly reality are far apart. We’d love to see every hospital sharing information with every other, but we’re not expecting to see it anytime soon.

Wesley Madden RN, BSN, NantHealth

While CMS certainly struck on the right chord ensuring patients have more access to their data through API’s there are still many silos that are not addressed especially with medical devices. It will be great for patients to have more information pushed through to their records but capturing that data and doing the normalization that still needs to happen for presentation into flow sheets and records will still be limited due to different communication protocols across medical devices.

Drew Ivan, Rhapsody

Healthcare is an expansive landscape, and the word “interoperability” can mean different things to different areas of the industry. As a result, interoperability gets a bad reputation and is considered a significant pain-point across healthcare. However, the tools to solving interoperability are readily available – it will take adopting a new perspective on the issue, to help address the challenges of interoperability at a higher level. Presently organizations experience the bulk of their interoperability issues when sharing and receiving data with other outside organizations. This is caused by technical and legal barriers, as well as lack of incentive to move data in these ways. The federal government’s investment through Meaningful Use, has not had its desired effect (encouraging EHR and digital health record adoption), and ultimately has not delivered improved data flow between organizations and patients. As such, Congress passed the 21stCentury Cures Act of 2016 to encourage use of EHR data and discipline undue information blocking. Regulations to prevent information blocking and to improve patients’ access to their own data were recently released for public comment by ONC and CMS. As these rules move through the process and become policy, the industry will have a regulatory mandate that helps shift the focus from hoarding data to sharing it.