Interoperability – a long-time conundrum – is now in ONC’s sights 

The federal agency is looking to facilitate the free flow of health information by attacking information blocking and setting a strategy for national data exchange.

Interoperability and easy information exchange is a growing imperative sought for healthcare and a key initiative for ONC.

This article is part of the January 2023 COVERstory.

Interoperability has long been understood to be an important deliverable of digital technology in healthcare. Even so, it’s been one of the most difficult capabilities to delivery. 

Because the easy exchange of information is critical to bring efficiency to healthcare and to improve patient care, it has become a key focus for the Office of the National Coordinator for Health Information Technology.

Part of the push comes from the ONC’s charge in the 21st Century Cures Act to use regulatory muscle to prevent information blocking, which interrupts access to patient information – either by patients themselves or healthcare organizations. Meanwhile, the agency is pursuing a standardized approach to formal information exchange through the Trusted Exchange Framework and Common Agreement

The pressure is growing from other federal agencies. For example, in December, the Centers for Medicare & Medicaid Services (CMS) issued a proposed rule that would improve patient and provider access to health information and streamline processes related to prior authorization for medical items and services. 

Both initiatives seek to improve the exchange of information for a variety of purposes in healthcare. And they come in response to years of glacially slow progress on information exchange in the healthcare industry. 

Years of frustration 

The exchange of healthcare information among providers and to consumers had been included among provisions of the Meaningful Use incentive program. However, the lack of standards and competitive factors, among other reasons, have resulted in limited progress in exchanging information. 

Many industry watchers criticize the lack of rigid requirements for interoperability early in the implementation of the Meaningful Use program, saying it is difficult to backfill information exchange. But ONC officials say the lack of emphasis on requirements was calculated, giving standards and technology time to evolve to better enable interoperability now. 

“Some of the things that we hear often is that interoperability should have been done sooner,” says Micky Tripathi, national coordinator for health IT. “But the phasing of the way that the meaningful use program thought about interoperability was a feature, not a bug. It was a deliberate decision to operate before we could interoperate.” 

Tripathi recalls his experience with the Massachusetts Health Data Consortium, an early effort to equip about 600 of the state’s clinicians with medical records systems in the 2000s. “We were talking about (creating) health information exchanges … and what we heard very strongly from the provider was, ‘Do not do that until the dust settles on my EHR within my four walls, so I can be sure the revenue cycle is working.’ In hindsight, you reflect on it and, well, have to get paid. I observed directly on the ground that, if someone’s income gets disrupted, they stop thinking about everything else. So that was our focus – you need to make sure everyone lands safely” with their EHRs. 

Early interoperability might have locked the country into a rigid way to achieve interoperability that may have been difficult to operate or undo, Tripathi contends. “First off, I think it would have created a huge adoption issue that would have put us in a much worse position than we are today, and we may have locked ourselves into old ways of doing things that we would regret now. We would have basically created like the AOL or CompuServe network, and now, we would all be saying, ‘Oh, those idiots!’ “ 

Info exchange on FHIR 

Now, ONC is staking interoperability hopes with the use of the Fast Healthcare Interoperability Resource (FHIR) standard, which, while still early in development for specific use cases, holds the promise of enabling easy and ubiquitous exchange of healthcare information among a variety of healthcare organizations. 

“Now, we have FHIR APIs, and we have much more, much better and more facile ways of being able to use advance interoperability, offering advanced interoperability using modern Internet conventions that just didn’t exist back then,” Tripathi says. “The phasing absolutely made sense when you think about how you have to think about technology trajectories and always preserving your options.” 

Still, interoperability in healthcare remains an unresolved challenge, says John Glaser, longtime CIO at Massachusetts General Hospital and now executive in residence at Harvard Medical School. Settling on standards is important in achieving widespread commitment, he notes. “I get the need for standards, because otherwise, why would I (tackle) this? People will tackle it if there’s motive to tackle it.” 

ONC will try to forge more progress on interoperability, spurred by efforts in other federal agencies, says Lisa Bari, CEO for Civitas Networks for Health, which represents the nation’s health information exchanges. For example, the Centers for Medicare & Medicaid Services in December proposed a rule to expand access to health information and to streamline the typically manual prior authorization process. 

National exchange efforts 

Earlier in 2022, ONC announced the final rules for TEFCA, which will serve as its strategy to achieve nationwide data exchange. The rule is viewed as a large step forward in the implementation of full interoperability. 

The approach hinges on organizations designated as qualified health information networks (QHINs) to perform data exchange, which will serve as the nervous system within the TEFCA ecosystem. They will directly connect to each other and enable their participants to engage in data sharing – they’ll route queries, responses and messages. Each QHIN will voluntarily sign the just-finalized common agreement with the Sequoia Project, the recognized coordinating entity that has responsibility for designating, onboarding and providing oversight of QHINs. 

So far, several organizations have stated they are applying to become QHINs. The Sequoia Project expects to announce decisions on QHINs early in 2023, Tripathi says. 

“We’re hoping that (TEFCA) can help answer industry questions that have been sort of bouncing around for a long time with no clear way to resolve it because of the fragmentation of the industry,” he explains. “TEFCA, for example, can help us settle the question of what is nationwide interoperability governance, and how does that work?" 

“I think we’ve been very clear to say that we’re starting on the path of saying FHIR-enabled interoperability is the future. We know that read-only, one-way FHIR APIs are not the end of that chapter – that’s the beginning. We’re just saying we want to have a FHIR foundation, and we want to keep building on top of that.” 

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