When it comes to nationwide seamless health information interoperability, people may disagree on the exact definition, but they can certainly agree on one thing: We don’t have it now.

There’s been significant progress on certain applications, such as Direct secure messaging, exchanging of continuity of care documents and e-prescribing. And in certain geographic areas, health information exchanges have high participation and advanced capabilities that have been developed over decades.

Vendor-based efforts like Epic Systems Care Everywhere and the multivendor network CommonWell Health Alliance are popular with their customers, although neither claims universality. CommonWell rolled out nationwide in 2015 and claims 5,000 providers in its network, while Epic’s Care Everywhere claims more than 300 participating clients, each representing multiple providers. In April 2015, both networks dropped some of their charges to providers for sharing information, in part a response to a report from the Office of the National Coordinator for Health IT criticizing industry practices that result in “information blocking.”

Micky Tripathi, president and CEO of the Massachusetts eHealth Collaborative.
Micky Tripathi, president and CEO of the Massachusetts eHealth Collaborative.

But for the most part, information sharing among unrelated providers—although increasingly essential in a world moving toward value-based care—is erratic, clunky, inconvenient and not yet ready to have the promised impact on reducing costs and improving quality of care.

“I want to be able to look at a unified diabetes flowsheet with information from everywhere the care was done,” says Danny Sands, MD, a medical informatics expert who also practices internal medicine at Beth Israel Deaconess Medical Center in Boston. “Just flipping screens and looking at information from other places doesn’t solve my problem. If it’s too hard to look at the information, it becomes easier to reorder the tests.” He’s chronically frustrated by the inability of unrelated institutions—even those right across the street from each other in Boston’s hospital-dense Longwood Medical Area—to integrate their information.

“It’s all about the workflow,” says Chuck Christian, vice president of technology and engagement for the Indiana Health Information Exchange. “If you want to have a bad day with physicians, mess up their workflow or make them learn a new one that they think is less efficient.”

From a physician’s point of view, looking at a [Consolidated Care Document] is like rummaging through a “junk drawer” in search of that one elusive item. “They don’t want to hunt for what they want,” Christian says. “They don’t even want to open the drawer.”

Although overall progress has been slow so far, it’s not for lack of time, energy or thought. Multiple public and private entities are chipping away at each of the many obstacles to interoperability.


In November, ONCHIT released the final version of “Connecting Health and Care for the Nation: A Shared Nationwide Interoperability Roadmap,” an agency strategy that lays out an ambitious goal of achieving a completely interoperable national “learning health system” by 2024, and identifies four areas that must be addressed to achieve that goal:

  1. Standards: Improve technical standards and implementation guidance for priority data domains and associated elements.
  2. Financial Incentives: Rapidly shift and align federal, state and commercial payment policies from fee-for-service to value-based models to stimulate the demand for interoperability.
  3. Privacy and Security: Clarify and align federal and state privacy and security requirements that enable interoperability.
  4. Consistent Business Practices: Coordinate among stakeholders to promote and align consistent policies and business practices that support interoperability and address those that impede interoperability.

Since the report was released, a variety of activities in the industry illustrate the interest in and movement making interoperability a reality. They include:

  • In January, the College of Health Information Management Executives (CHIME) launched its National Patient ID Challenge, with $1 million to the first person who figures out how to accurately match patients with all their data without resorting to the most obvious solution, a national patient ID, which federal entities are officially forbidden by Congress from creating. Entries are due by April 8.
  • A survey released in January by Premier, a healthcare alliance of about 3,600 U.S. hospitals and 120,000 other providers, revealed that integrating data from out-of-network providers—a key goal for interoperability efforts—is the top HIT challenge for 80 percent of accountable care organizations.
  • Also in January, DirectTrust (an alliance of participants in the exchange of secure health messages using the Direct protocol) announced that 44 million messages were exchanged among its members in 2015. DirectTrust predicts that this year’s message volume will top 200 million, and 2017’s could quadruple to more than 800 million, if current trends continue. The network now includes more than a million trusted addresses.
  • In December, ONCHIT released its 2016 Interoperability Standards Advisory, which not only catalogs existing and emerging standards to meet specific interoperability needs, but also provides implementation specifications so that vendors and organizations can incorporate the standards into their systems in a consistent way. “It’s a huge contribution, because before, vendors could make their own choices and providers were stuck,” says Joyce Sensmeier, vice president of informatics for HIMSS. “If two vendors have implemented a standard in the same way, the odds [of interoperability] are better.”
  • Also in December, Carequality (a public-private collaboration of vendors, providers, health information exchanges and other interested parties) released its Interoperability Framework, a set of guidelines for creating the business agreements to enable trusted information exchange. In late January, five major HIT vendors were the first to commit to using the framework.
  • HIMSS’s interoperability certification program, ConCERT, launched about a year ago, will announce its first group of certified products at the upcoming HIMSS meeting in Las Vegas. It will be demonstrating its capabilities at the Interoperability Showcase on the exhibit floor. The products must support both Direct secure messaging and query-based exchanges.

“I think a tremendous amount of progress has been made, but it’s been from the bottom up,” says Micky Tripathi, chief executive of the Massachusetts e-Health Collaborative, which helps organizations implement electronic health records and health information exchanges. MAeHC is serving as project manager for The Argonaut Project, a joint effort by vendors and providers to develop FHIR-based application programming interfaces (see sidebar).

Tripathi observes that many great interoperability projects, such as the phone system and the ATM network, grew in local pockets, instigated by market forces that propelled the necessary technological innovations, until the market forces and the technology both reached the critical mass necessary to connect everyone. He acknowledges that the complexities of healthcare pose unique barriers—for starters, there are 50 different state privacy laws.

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The interoperability conversation is going to flip pretty quickly when reimbursement is based on value.

“FHIR is not going to solve that problem,” he says. “The question is what ecosystem you need to support these APIs. A good developer can write a fully functional app within a week, but then they try to plug it in and the system says, “Sorry, we won’t let you in!’ “

HIMSS’ Sensmeier expects the remaining barriers to fall soon. “The interoperability conversation is going to flip pretty quickly when reimbursement is based on value,” she says. “That’s going to require clinical integration like nothing we have today. If you have to demonstrate outcomes from your patient population and show you’re improving them with the care you give, you have to have interoperability in place.”

While the technological obstacles to interoperability are being knocked over one by one, the non-technological barriers are proving more stubborn. Until now, the business case for providers to share information was much less persuasive than the business case for not sharing.

“If we need progress in one area, it should be the incentive and motivation side,” says Julia Adler-Milstein, assistant professor in the School of Information at the University of Michigan, who recently served on an interoperability task force assembled by the ONC’s Health IT Policy Committee.” We need a group of stakeholders saying we need to solve these problems.”

Getting providers to pay for health information exchanges has been one of those problems, but new reimbursement models may nudge providers toward recognizing their value. “The market has been ambivalent about HIE services, so customers haven’t been excited to pay for them,” Adler-Milstein says. Her recent research shows that health information exchanges are looking for ways to provide extra value to their customers, in the form of analytics services and ways to integrate data to support value-based care.

Sometimes the simplest solution is the place to start, and Adler-Milstein sees a lot of near-term promise in vendor-based networks such as Epic’s Care Everywhere. “They made it quite easy for anyone who has Epic to turn on this functionality, and they had a take-it-or-leave-it approach to governance,” she says. “Everyone who’s had the option has said yes.”

However, proprietary solutions won’t solve the long-term problem, and she’d like to see the vendor community try to achieve something close to plug-and-play interoperability. “We could push a lot harder on EHR vendors to work among themselves, if we really wanted to make some quick progress,” she says.

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The market has been ambivalent about HIE services, so customers haven’t been excited to pay for them.

The Michigan Health Information Network (MiHIN), a consortium of Michigan HIEs, has elected to prove its value “one use case at a time,” says executive director Tim Pletcher, MD. “We think that people really only do what they’re paid to do or punished for not doing,” he says. To that end, the organization has chosen specific tasks, like reporting immunization data to the state, which is required by the government’s meaningful use incentive program, and made them easy to do through the HIE. It’s also helping providers share admission, discharge and transfer [ADT] information, and Pletcher says 98 percent of the state’s admissions can be accessed on the network.

Erica Galvez recently left her post as ONC’s interoperability portfolio manager to become the director of health information exchange at Aledade, a company headed by former National Coordinator Farzad Mostashari. Aledade facilitates the development of physician-led accountable care organizations and is currently active in 11 states. In her new capacity, she sees even more clearly the business-related obstacles to full and easy data sharing. She’s currently focused on making sure ADT information flows from hospitals to physicians, so they can manage care transitions.

“The hard thing is brokering the agreement: the terms and conditions, the pricing, and how we’ll get the data up and running,” she says. “Once we can agree, getting the technical nuts and bolts in place is pretty easy. It’s that up-front negotiation around ‘Here’s why you should let your data go, and here’s how you can do it in a HIPAA-compliant manner, and here’s the financial value of that information.’”

Patient matching, essential for making sure providers are retrieving information on the correct patient, remains a formidable challenge, as CHIME has recognized with its $1 million prize. IHIE’s Chuck Christian, who’s also chairman of the CHIME Foundation board, recently got a personal look at the challenge when he and his wife visited the island of St. Lucia to celebrate their 40th wedding anniversary.

They were staying at a resort where guests sign for all their on-site purchases and then settle up when they leave. When he tried to make a purchase in the gift shop, to his astonishment, the salesperson asked him to verify his identity with his passport. “Turns out there was more than one Charles Christian at the resort that week,” he says. “In a resort with only 700 people.”

Every day, 10,000 people in the U.S. turn 65, and some of them inevitably have the same name, observes Dean Sittig, professor of biomedical informatics at the University of Texas Health Science Center at Houston. He has done extensive research on how to prevent errors in medical information, and says misidentification of patients is one of the most common and dangerous errors.

Most identifiers aren’t unique, or even permanent, he says. Most women change their names at least once in their lives, and one in four people change their address in any given year. “Even gender isn’t as permanent as we thought,” he says. “We can’t have interoperability if we can’t match your data when we move it from one place to another.”

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