Advanced interoperability will play a crucial role in bringing about improvements in healthcare delivery and advancing healthcare reform, as well as enabling healthcare information technology to deliver on its promise in the years ahead.

That is the expectation of a just-released discussion paper by the National Academy of Medicine (NAM) that focuses on interoperability, but also lays out a roadmap for delivering a return on the nation’s healthcare IT investment over the last decade.

The paper’s topic is one of 19 priority areas of focus covered in NAM’s series entitled “Vital Directions for Health and Health Care” initiative, intended to provide guidance to the next administration on how to achieve progress in healthcare delivery and improve the health of the nation.

Jonathan Perlin, MD
Jonathan Perlin, MD

A panel of healthcare information technology luminaries participated in the interoperability research, including:

• Dixie Baker, security expert with Martin, Blanck and Associates

• David J. Brailer, MD, president of Health Evolution Partners and the first national coordinator of the Office of the National Coordinator for Health Information Technology

• Douglas Fridsma, MD, president of the American Medical Informatics Association

• Mark Frisse, MD, Accenture Professor of Biomedical Informatics and Vice Chair of Business Development, Vanderbilt University

• John Halamka, MD, CIO at Beth Israel Deaconess Medical Center

• Jeffrey Levi, Professor of Health Management and Policy , The George Washington University

• Kenneth Mandl, MD, Professor of Biomedical Informatics and Pediatrics, Harvard Medical School and Boston Children’s Hospital

• Janet Marchibroda, director of the Health Innovation Initiative at Bipartisan Policy Center

• Jonathan Perlin, MD, president of clinical services and chief medical officer, HCA

• Richard Platt, MD, Professor and Chair of the Department of Population Medicine, Harvard Medical School

• Paul Tang, MD, chief health transformation officer, IBM Watson Health

It’s an appropriate time to evaluate the progress made so far with healthcare IT and assess steps for the future, says Perlin, who led the initiative. EHRs have largely been implemented by almost all of the nation’s hospitals and most of its physician practices, so it’s an appropriate time to determine how to maximize benefits from this infrastructure, he adds.

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To make progress, achieving significant levels of interoperability is crucial, contends Perlin. “To have a learning health system, we use the experience of past care to inform and improve future care,” he says. “When you couple that with the promise of electronic health records and the digital dividend of meaningful use, we have a new opportunity.”

The paper outlines three areas of focus—technical underpinnings, use cases and enablers—to achieve and capitalize on interoperability.

Progress relies on the development of data standards to achieve interoperability at scale, the paper notes. Rather than taking a narrow view of interoperability—agreeing on a set of technical standards, for example—the system needs deep interoperability to support the exchange of information for various purposes and to various audiences, Perlin says.

“Data standards are necessary but not sufficient for interoperability,” the paper notes. “Supporting infrastructure, policies and incentives to share data are the rate-limiting elements.”

Notions of interoperability also need to be expanded to incorporate patient-generated data and patient reported outcomes, Perlin says. That will mean expanding the scope of interoperability to include feeds from medical devices and other technologies that may lie outside the four walls of a hospital.

A crucial issue in advancing interoperability is improving patient identification and matching to support interoperability. “Actions under way in the private sector can assist in migrating toward a national strategy, but federal action is needed to facilitate accurate identification and matching of patient data to support widespread information sharing and interoperability,” the paper asserts.

“That’s the longest shot in the whole paper,” Perlin adds, noting that, “It would be a great facilitator” advancing interoperability and making better use of records systems.

The NAM paper also highlights the need to tie together a wide range of devices and audiences to medical information, and it supports the use of service-oriented architectures and web-based services to do so, particularly to enable clinical decision support (CDS), “which separates CDS rules from the EHR itself and allows recommendations or rules to be added, deleted or updated through a Web-based service.”

In examining use cases, the paper outlines the potential for interoperability in three areas:

• Enfranchising vulnerable populations and improving care for chronic diseases

• Distributing and using health data to support public health

• Accelerating the use of aggregated health information in research

In order to take full advantage of interoperability, the nation’s clinical workforce needs to be educated in informatics, and that was a focus of the contributions of AMIA’s Fridsma. He’s particularly concerned about training all those dealing with data to use it, and to push the envelope for interoperability as data needs evolve over time.

“Interoperability isn’t a sort of magical moment that occurs and then you have it, and you’re done,” he says. “Healthcare information technology advances as you go along, and data standards need to be updated and changed as that occurs. So the question becomes how do we maintain and sustain the workforce to get us to the interoperability that we need?”

Finally, interoperability will only be meaningful if all clinicians and patients believe that privacy and security is a priority. The nation needs to do a better job of sharing information about cyber threats and fostering accepted standards for identity management and encryption, Perlin says.

The interoperability report will be synthesized with the other documents from NAM task forces to influence new directions for health policy, Perlin says.

“This is a good time for us to take a look at what’s been accomplished, what challenges remain and how can we accomplish that,” Fridsma says. “Since meaningful use got underway in 2009, we have new efforts such as the Precision Medicine Initiative and the Cancer Moonshot, and those will require significant investments. We need to examine whether we are on the right track or what kinds of course corrections are needed.”

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