How Far To True Interoperability?

Even as clinical IT systems become an integral part of care delivery in the United States, interoperability continues to be a formidable challenge to the collection, sharing and effective use of electronic health information.

Achieving widespread interoperability won't be easy. At the heart of this complex problem is identifying, prioritizing and advancing technical standards to support the secure exchange of health information.

Several industry-wide interoperability initiatives are currently under way to remove obstacles that are preventing providers, payers, public health entities and other stakeholders from securely sending and receiving electronic health information.

For all the attention and agreement on the gravity of the issue, the question remains: How far off is true interoperability?

In late January, the Office of the National Coordinator for Health IT released a draft Interoperability Roadmap. Its plan aims to promote, facilitate and enhance the safe and secure exchange and use of health information nationwide.

The 166-page ONC document proposes "critical actions for both public and private stakeholders that will advance our nation towards an interoperable health IT ecosystem, advance research and ultimately achieve a learning health (system)."

ONC sees interoperability as the ability of two or more systems to exchange and use information without special effort on the part of the user, in essence adopting the definition from IEEE, the New York-based professional association.

"If we think about the definition of interoperability, one component of that is the exchange of information-the movement of information-and then another component [is] the ability to use it, which really gets to a level of semantic interoperability that is key," says Erica Galvez, ONC's interoperability and exchange portfolio manager, who is leading the federal agency's charge to achieve nationwide interoperability to support higher-quality, more affordable care and better health outcomes.

Galvez emphasizes that the roadmap is aimed at nationwide interoperability, regardless of geographic and organizational boundaries. "We're not talking about just pockets of success in a certain number of states or a certain number of networks."



Building blocks

ONC's Interoperability Roadmap details its vision and associated goals that are to be achieved in three-, six-, and 10-year timeframes. In three years, it wants to "be in a place nationwide where the majority of care providers and the majority of individuals should be able to send, receive, find and use a very discrete set of health information that we describe in the roadmap," Galvez says.

ONC's roadmap is organized around five building blocks for a nationwide interoperable health IT infrastructure. They include:

* Core technical standards and functions;

* Certification to optimize health IT products and services;

* Privacy and security;

* Business, clinical, cultural and regulatory environments; and

* Rules of engagement and governance.

ONC is committed to establishing a nationwide framework with a common set of "rules of the road" that will serve as a mechanism for recognizing organizations that comply, while holding organizations accountable for non-compliance, Galvez says. "There's little point in putting forward rules of the road if you don't have a way of recognizing who complies with them. That's part of what brings value to that type of framework."

The governance framework and rules of the road "serve as a set of high-level principles that we think protect the public interest," Galvez says, but she notes that ONC doesn't intend to get "to the really granular details of business practices in that type of framework."

The intricate detail work "should be handled through the industry-led process that we called for in the roadmap," she says. "We think industry should be on the hook to carry out a collaborative process where they make decisions about detailed implementation pieces."



Benefits of a roadmap

The benefit in ONC's developing a long-term framework for interoperability comes through setting a specific direction for which developers and users can plan, experts say.

"It's a great challenge to identify what we will be doing years down the road, but it certainly gives the community of developers and users an opportunity to see what might be part of regulation in the coming years," says Charles Jaffe, M.D., CEO of Health Level Seven International (HL7), an Ann Arbor, Mich.-based standards development organization focused on healthcare information interoperability.

Jaffe applauds the ONC effort to develop a roadmap that he says comprehensively addresses the future state of interoperable health IT. He contends that no single entity or organization will solve the challenges facing interoperability; it will require a broad coalition of public-private partners to achieve it.

It's not just ONC that sees an urgent need for interoperability. Last year, JASON, an independent group of scientists that advises the U.S. government on science and technology, issued a report that decried the lack of interoperability in the current health IT ecosystem. In its report, JASON called for the creation of an open, interoperable health data infrastructure based on the adoption of publicly available application programming interfaces (APIs).

A task force of the Health IT Standards and Policy Committee agreed with the JASON report's assessment that the lack of an architecture supporting standardized APIs is a major impediment to achieving interoperability.

Micky Tripathi, CEO of the Massachusetts eHealth Collaborative and co-chair of the JASON Task Force, believes that ONC's Interoperability Roadmap is closely aligned with the task force recommendations, specifically the "idea of having an evolutionary approach and moving to an open API-based world looking at document-level and data-level interoperability."

Solutions to this dilemma currently exist, many believe. For example, there's significant potential in HL7's Fast Healthcare Interoperability Resources (FHIR), an API that leverages the latest Web standards, says Stanley Huff, M.D., a founding member of Healthcare Services Platform Consortium, a group of providers, IT vendors, system integrators and venture-led firms dedicated to solving interoperability issues.



Standards still lacking

"FHIR is much easier and simpler to implement than a lot of the previous standards we've had," says Huff, who is chief medical informatics officer for Intermountain Healthcare. "There is the opportunity for those FHIR services to be truly interoperable if-and there's a big if in there-we as a country...agree to the information models and terminology that we're going to use for exchanging information."

As manager of HL7's Argonaut Project to accelerate the development and adoption of FHIR, Tripathi says current standards such as the Consolidated-Clinical Document Architecture (C-CDA) are "very cumbersome and unwieldy" because of coding and exchange requirements.

The Argonaut Project seeks to rapidly develop a first-generation FHIR-based API and core data services specification to enable expanded information sharing for electronic health records and other health IT, based on Internet standards and architectural patterns and styles. Tripathi describes the project as a "code documentation sprint."

The project includes major vendors and providers, including athenahealth, Beth Israel Deaconess Medical Center, Cerner, Epic, Intermountain Health, Mayo Clinic, McKesson, MEDITECH, Partners Healthcare System, SMART at Boston Children's Hospital Informatics Program, and The Advisory Board Company.

For now, FHIR might be the frontrunner as an interoperability solution, but "there is no single technical standard that is going to solve all of our interoperability challenges," Galvez says. "There are going to be a number of different technical standards required to support the different needs that we have, and some standards are better suited than others."