ONC Task Force Seeks Answers to Interoperability Challenges

A task force of the Office of the National Coordinator for HIT held a second listening session August 5 with stakeholders to get feedback on a report concluding the lack of interoperability among data resources for electronic health records is a major barrier to information exchange.

An independent group of scientists called JASON, convened by contractor MITRE Corp. to advise the government, published the report which was funded by the Agency for Healthcare Research and Quality. Authors recommend the government establish a “comprehensive, transparent and overarching software architecture” that would create an open, interoperable health data infrastructure. Karen DeSalvo, M.D., national coordinator for HIT, has encouraged stakeholders to take a look at the JASON report's recommendations and to provide their feedback.

Micky Tripathi, co-chair of the JASON Report Task Force created under the auspices of the Health IT Policy and Health IT Standards Committees to analyze report recommendations, spoke with Health Data Management on what the task force heard from stakeholders:

HDM: From your perspective, what were the key takeaways from the August 5 listening session?

Tripathi: This was the second listening session. There was also one last week. In both those sessions, we’d tried to cover a wide variety of perspectives. And, certainly on every issue there was a full spectrum of views. If I were to say that there was one thing that emerged from both sessions, it would be a sense that there are certainly technology issues that the JASON report focuses on but there are complex legal, business and policy issues that are at the heart of a lot of what the report addresses as being real deficiencies in interoperability that are at least as important as technology issues. I think across the board what we heard was that there are real issues and gaps in interoperability that the JASON report appropriately identifies.

And, the second point is that I think what we heard in general was that there’s probably more progress in interoperability on specific fronts than the JASON report seems to identify. That’s probably where we just need to take into account that this is a long process of when the government sought the advice of JASON. They started their work I think like 18 months ago, or even longer than that, and then their report came out a year ago. More importantly, the report came out before Meaningful Use Stage 2 requirements were fully specified. So, a lot of people in the listening sessions had the sense that there’s probably more progress than the report gives credit for.

HDM: The report was very critical of what’s been achieved through the Meaningful Use program.  For instance, they find that the criteria for Stages 1 and 2 "fall short of achieving meaningful use in any practical sense." Had JASON issued their report more recently, would it have made a difference in their findings and recommendations?

Tripathi: I think their criticism seems to be more about the structure of Meaningful Use than about the execution of it.

HDM: When it comes to Stage 3, that’s where JASON recommends that the government "break free from the status quo and embark upon the creation of a truly interoperable health data infrastructure." But, EHR vendors yesterday seemed to say the report’s Stage 3 emphasis on moving from a consolidated clinical document architecture (C-CDA) to discrete data elements involving application programming interfaces (APIs) and the proposed HL7 Fast Healthcare Interoperability Resources (FHIR) standard is too quick.

Tripathi: That’s where we’re going to see some of the tension. What we heard is that it’s very hard to accomplish this in what some might consider artificial timelines. I say artificial because trying to top-down say this needs to be done by this date in a very large, complex, and fragmented industry poses a real challenge. I think that’s what the stakeholders were pointing to: the timelines of the JASON report are probably way too ambitious. It’s hard to imagine being able to accomplish what they are trying to accomplish in 12 months is what we heard from stakeholders. That’s something for the task force to assess.

From a functional perspective, what the JASON authors are pointing out is that you want to be able to get to a granular type of interoperability with data level identification of things important to that atomic data element like providence and privacy, which suggests the Open API kind of concept. The transition from the C-CDA to FHIR could be a vehicle for that to happen but that’s just going to take time. What you end up finding is that you need a whole industry ecosystem to develop around that. These are all industry maturity issues. In the case of FHIR, if we tried to quickly snap our fingers and get every EHR to have it but we still don’t have an industry that is able to use it because there’s not enough infrastructure. Also, it will take time for the users—clinicians—to change their internal workflow processes to be able to use it.

HDM: One stakeholder said that EHR vendors have no desire to interoperate and that it is not reasonable for JASON to think that APIs and an elegant architecture will overcome the economic disincentives to sharing patient data.

Tripathi: The insidious motivation would be that people are hording data because they don’t want others to make money off of that data. The more benign, but I think equally powerful motivation from an influence perspective, is that people focus on things that they have incentives for. The market is starting to demand it and we’re slowly starting to see more and more responsiveness in the provider and vendor communities to achieve it.       

HDM: Patrick Leonard, chief technology officer for consumer health app vendor iTriage, told the task force that he “wholeheartedly agrees with the assertion in the JASON report that patients or healthcare consumers are the ultimate owners of their data.” But, Leonard said that this is an area where the healthcare industry has done a terrible job and the owners of their data need to get access to it. How do you see it?

Tripathi: I didn’t get a chance to talk to Patrick about it, but I guess one question is: are we speaking metaphorically or literally? The reason I say that is because if we are speaking literally that’s just factually not true. I’m not a lawyer but my understanding is that in 49 out of 50 states that is factually not true that the patient owns the data. New Hampshire is the one state that I’m aware of where legally there is a statute that says the patient owns the data. In every other state, that is not true.

If we are speaking metaphorically, I think that everyone would agree with the principle that is being articulated, which is that as a legal matter the patient doesn’t own the data but we want to change habits to put patients at the center so that they have as much access to their data—and control over how their data is used—as is humanly possible. Interoperability right now is focused on provider to provider for the most part. It’s going to take a real change in paradigm for us to move toward that greater concept of something that is more patient-centered.