Paving the Way for Interoperability

Achieving interoperability is a top priority for the Office of the National Coordinator for Health IT (ONC) and for good reason. While billions have been spent on EHRs, studies find that most of these products don’t communicate well with each other and clinicians are not too optimistic.

But the tide could be turning with several developments offering a new sense of urgency. The JASON report issued late in 2013 acknowledged the “immense challenges” facing efforts to create a robust health data infrastructure but also noted the numerous potential benefits. This report has led to the federal Health IT Policy Committee and ONC’s effort to create an interoperability roadmap.

In December, Congress passed a federal budget that also directs ONC to decertify those products that don’t interoperate.

Also in December, a new report built upon the JASON report laying out recommendations for an infrastructure that could achieve interoperability among EHRs and integrate data from all sources.

‘Ambitious goal’

According to a post on the ONC blog, Health IT Buzz, it’s important to “pursue this ambitious goal” because “there has been an explosion of data that could help with all kinds of decisions about health. Right now, though, we do not have the capability to capture and share that data with those who make decisions that impact health—including individuals, healthcare providers and communities.” The post was authored by National Coordinator Karen DeSalvo, MD, MPH, MSc; Jon White, MD, ONC acting national deputy director; and Michael Painter, senior program officer, Robert Wood Johnson Foundation.

“Data sharing is a critical piece of this equation. While we need infrastructure to capture and organize this data, we also need to ensure that individuals, healthcare professionals and community leaders can access and exchange this data, and use it to make decisions that improve health.

“Broadening data beyond the four walls of the doctors’ office will give healthcare professionals a more holistic view of their patient’s health. Sharing that data among members of the healthcare team will also lead to greater care coordination. Ensuring this data is used in meaningful ways will of course require training our healthcare workforce to a higher level of quantitative literacy.”

Priorities and collaboration

Advancing interoperability is a complex topic that will require prioritization, said Erica Galvez, manager of the ONC’s interoperability and exchange portfolio. She presented during a joint meeting of the Health IT Policy and Standards Committees last fall. “We really have to think about technology and interoperability of information at points of decision making beyond the doctor’s office, the emergency room and the public health department.”

Galvez outlined a plan that incrementally builds interoperability over time. “There is lots of room for improvement but we’re not starting from zero. We’re focusing nationally on establishing a best minimum possible—a floor of interoperability across which all key players can participate and innovation can flourish.”

Building the interoperability roadmap will require unprecedented collaboration, she said, and the process must describe who should do what by when to make sure interoperability expectations are met.

Catalyze, monitor and guide

Micky Tripathi, president and CEO of the Massachusetts eHealth Collaborative and chair of the Interoperability and Health Information Exchange Work Group, during one meeting reviewed the JASON Task Force and Governance subgroup materials to show how they could be incorporated into the interoperability roadmap.

The JASON Task Force recommended that the federal government focus on an escalating series of actions to catalyze market development of interoperability coordination structures and processes. “First and foremost, we want a set of recommendations that establishes government participation as engaged and vocal market participants, conducting active monitoring, convening, offering guidance and aligning incentive programs,” said Tripathi. The group said the government exerting direct authority to dictate terms of interoperability (requirements, monitoring, compliance, enforcement) should only be a last resort and only used to resolve gaps identified through active monitoring that the market seems unable to address on its own.

Tripathi outlined several key questions, such as whether the goals are meaningful to healthcare outcomes and are they attainable by industry. “We’ve seen that we can only go so far so fast. We want to make sure the goals are something organizations could actually see meaning in.”

Each roadmap building block has draft milestones and actions, he explained. Again, the work group considered several key questions, such as whether the milestones are attainable, are the proposed actions aligned with milestones, are they appropriate to current and expected industry dynamics and focused enough to drive resource allocation and decision-making.

After defining specific goals and monitoring mechanisms, Tripathi said the next step is explicit endorsement of coordinated architecture based on public APIs as the nationwide technological architecture for interoperability to support a learning healthcare system. Third is establishing processes such as determining priority functions and associated minimum set of common interoperability standards.

Desalvo said she wants to be sure the roadmap “is raising the floor but staying out of the way of innovation.” She also noted that there are still areas without internet access and she does not want to exacerbate the digital divide. She supported the concept of leaving room for changes in the market that are difficult to anticipate at this point.

“We have to be really thoughtful of the societal good of the data with respect to public health and advancing science. Remember that as we’re thinking of the foundation of governance, we want to make sure we’re considering potential use cases that might not have clear financial models at this point.”

The Health IT Policy Committee and the Standards Committee formally approved a set of recommendations from the JASON Task Force that calls for the establishment of an orchestrated architecture based on public APIs as the foundation of interoperability.

Private sector steps up

Meanwhile, Health Level Seven (HL7) created the Argonaut Project, a group of private sector stakeholders including athenahealth, Beth Israel Deaconess Medical Center, Cerner, Epic, Intermountain Health, Mayo Clinic, McKesson, MEDITECH and Partners HealthCare, that is working to accelerate the development and adoption of HL7’s standards framework, FHIR--Fast Healthcare Interoperability Resources.

“It’s a perfect storm for innovation when stakeholders, resources and political will align,” wrote John Halamka, MD, CIO of Beth Israel Deaconess Medical Center in Boston, in his blog, Life as a Healthcare CIO. “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.”

The group released its charter in which each of the participants has agreed that all specifications and artifacts developed during the course of the project will be made available to the entire community via an Open Content License.

The group is working on the following three deliverables:

FHIR Data Query Profiles. A set of FHIR resources and accompanying profiles that enables query/response of the discrete data elements contained in the Meaningful Use Common Data Set. The work will be completed for inclusion in the May 2015 HL7 FHIR Draft Standard for Trial Use revision 2 ballot.

FHIR Document Query Profile. A FHIR resource and profile that enables query/response of IHE X* metadata resources, and specifically, transition of care and patient summary CCDAs. The work will be completed for inclusion in the May 2015 HL7 FHIR Draft Standard for Trial Use revision 2 ballot.

Security Implementation Guide. Based on the SMART OAuth 2.0 and OpenID Connect profiles, a final guide will be completed the week of April 1, 2015. The Security Implementation Guide will eventually be incorporated in the HL7 balloting process, but for this project will be developed in parallel to accompany the FHIR Data Query and Document Query Profiles and Implementation Guides.

The Argonaut project is focusing on success by limiting its timeframe and these three specific products.

The FHIR standards align well with the objectives outlined in the Federal Healthcare IT Strategic Plan and those planned for the interoperability roadmap, Halamka wrote.

“FHIR will not solve every problem and we need to be careful to under promise, but the notion of a learning healthcare system based on the kind of data liquidity we have in other aspects of our lives (social media, electronic banking, smartphone apps) seems like the right trajectory to me.”