National Coordinator for Health IT Karen DeSalvo, M.D., has laid out her office’s 2016 goals which include connecting health information exchanges across the “entire country within a year,” as part of the agency’s big push towards interoperability on a national level.  

In a Dec. 8 speech before the Bipartisan Policy Center in Washington, D.C., DeSalvo observed that some communities such as Maryland are “already connected across state lines” and that ONC’s ultimate objective is to achieve nationwide HIE in 2016. However, three prominent interoperability experts dismiss the realistic chance of this goal being met.

Also See: ONC Wants Connected HIEs Nationwide in a Year

Chartese Day, an ONC spokesperson, said that DeSalvo’s remarks are consistent with ONC’s Shared Nationwide Interoperability Roadmap, which lays out high-level goals for health IT interoperability required to achieve a learning health system by 2024. However, nowhere in the roadmap does it specifically address complete HIE connectivity by the end of 2016. “This iteration of the Roadmap focuses primarily on actions that will enable a majority of individuals and providers across the care continuum to send, receive, find and use priority data domains at the nationwide level by the end of 2017,” states the document.

Health Data Management reached out to industry stakeholders to get comment and a reality check on this ambitious ONC goal to connect the nation’s HIEs exchanges—both public and private—by the end of next year. While most praised ONC’s zeal in making interoperability a high priority over the next 12 months, the proposal was met with a healthy dose of skepticism from respondents, who do not see it as very practical—especially in the absence of details on how the agency intends to proceed.

Here are some of the responses:     

John Halamka, M.D., CIO of Boston’s Beth Israel Deaconess Medical Center

It’s a noble goal. However, we must develop enabling infrastructure (such as provider and patient directories), consistent policies/governance, and aligned incentives before declaring any nationwide effort. Otherwise we’re mandating cars before we build roads. 

David Kibbe, M.D., president and CEO of DirectTrust

This is quite confusing to me, as I’m not sure what the notion of “connecting all of the nation’s HIEs” actually means.  It sounds grand, but it’s really vague.  As John Halamka has ably pointed out, talking about “APIs” in the absence of any specified standards and no practical experience in the field, is assuming things are farther along than they are. There are huge problems associated with patient indexing and matching, and with authorizations, permissions, and consent that have to be worked out before inter-organizational use of FHIR will be practical, and that would include inter-HIE or inter-HIN queries using FHIR.  In my opinion, this is not a good time to continue to raise people’s expectations or engage in magical thinking about interoperability of health IT.  

Micky Tripathi, president and CEO of the Massachusetts eHealth Collaborative

This is an ambitious goal and it’s great to see ONC providing some enthusiastic encouragement to the market. While truly rapid progress is being made through private sector initiatives such as the Argonaut Project, Carequality, Epic’s Care Everywhere, CommonWell, Surescripts, DirectTrust, and selected “public HIEs”, it’s not realistic to expect that nationwide interoperability driven by FHIR-based APIs can be accomplished in a year.

A challenging but achievable goal for 2016 would be to focus solely on nationwide interoperability of Direct-based transactions.  DirectTrust has done an admirable job providing a policy and technical foundation for bridging “push” networks.  MU Stage 2 interoperability requirements will only really kick in this year, which will give a boost to demand for this type of interoperability.  We still need better provider directory interoperability, and providers still have to contend with the fact that CCDAs are not fully compatible across systems and EHRs cannot consume “alerts” or “event notifications” for which there are no nationwide standards.  However, Direct-based interoperability at least enables records and messages to be sent and received, and it’s reasonable to expect that the content delivered will improve rapidly over time.  Focused leadership and encouragement from ONC, further advancement in the diffusion of value-based purchasing by CMS, and active engagement of government provider organizations such as DoD and the VA will be especially helpful to meeting such a goal in the coming year.

Finally, it’s important to distinguish nationwide availability from ubiquitous use.  Cell phones are available almost everywhere, but not everyone has a cell phone let alone a smart phone.  If we are able to get to the point where we can connect Direct-based networks to the point that most providers with a certified EHR have a reasonable expectation that they can routinely, reliably, and securely send a record or message to the providers who they share most of their patients with, we will have taken an important step forward.

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