Why there’s reason for cautious optimism with interoperability
Recently, I’ve found myself cautiously optimistic about the progress of data and document exchange among physicians and health systems. Perhaps the cause of optimism is my recent return from two conferences focusing on the future of interoperability.
These conferences, the Strategic Health Information Exchange Collaborative (SHIEC) and the Office of the National Coordinator (ONC) Interoperability Forum, highlighted the state of the union for local and national data exchange.
Perhaps my optimism is an outcome of the actual work happening in the trenches of standards development, network proliferation and patient access. Or maybe it is because the interoperability product I’ve worked on at NextGen recently passed a five-year anniversary.
Regardless of the cause, when it comes to clinical data exchange between disparate electronic health record systems, optimism is rarely validated by the facts. Just in the last five years published research, private studies, and journal articles have found the following.
Most EHR vendors lack a basic understanding of user-centered design, thus delivering clinically frustrating workflows that rarely allow for successful data entry or exchange, according to research published in the Journal of the American Medical Informatics Association.
Interoperability stubbornly remained the No. 1 answer among physicians when asked what changes they’d make to deliver better care. Some 62 percent of physician respondents to the Deloitte Physician Survey answered, “Make the current system more interoperable.”
Only 14 percent of providers reported that they’re able to locate, access and use clinical data exchanged with a provider on a different HER, according to KLAS Research.
Despite these harsh statistics, real steps are underway to directly address concerns regarding interoperability. In the first half of this year, the industry has responded with tangible evidence that data sharing is accelerating in nearly every aspect of healthcare delivery from national network initiatives, the rollout of superior interoperability standards, proposed regulations which penalize data blocking and increased payer involvement.
National network initiatives provide a single connection path which enables access and exchange with practically every healthcare system. Publicly available APIs are now providing patients with direct access to their healthcare through smart phone apps that enable patient-initiated data sharing.
This year, we’ve seen secure provider-to-provider messaging surpass one billion transactions using Direct Trust, with the fastest increase of message exchange occurring in the most recent quarter. Direct messaging continues to be the most plausible approach to finally eliminate faxing from clinical workflows. This news will be welcomed by medical schools that may, one day, be able to eliminate faxing from new hire training.
Also, 2019 has been a significant year for the continued growth of Carequality. EHR vendors, HIEs, payers, and providers are consolidating on the Carequality Interoperability Framework as the preferred method to support query and retrieval of medical records. Carequality publishes a Fast Healthcare Interoperability Resources (FHIR) directory of connected endpoints, which provides the rules of the road for secure document exchange across networks and enables the participation of Record Locator Services that enable providers to discover where patient records reside. With the activation of CommonWell on the Carequality network, this cross-network functionality now is available to 600,000 providers across 40,000 clinics and 1,700 hospitals.
With the success of these national frameworks, there is an emerging understanding that we now have a consensus for how to exchange C-CDAs and some images and notes (most systems support the sending and receiving of images and notes using Direct messaging, but Carequality participants are mostly sharing only C-CDAs).
Providers and technologists know that it isn’t always prudent to exchange a multi-page document with dozens of data categories if the recipient only needs to know the most recent problem list. In fact, the frequent exchange of these documents may contribute to provider burnout when automated through EHR messages that proliferate a provider’s EHR Inbox.
With the advent of HL7’s FHIR specification and the proliferation of EHR vendor APIs, organizations are finding a greater ability to target specific types of data exchange for specific use-cases. The shift from exchanging heavy documents for every use case to exchanging the minimum necessary using an API-based approach opens the doors to supporting new use cases.
For example, EHR vendors can now integrate with vendor-agnostic clinical decision support at the point of care through CDS Hooks—enabling providers to choose the CDS system which works best for their patients and specialty.
Regulations often have the double-edged sword of incentivizing the wrong activities. Ten years and $36 billion is the amount of time and money ostensibly spent on the “unholy mess” of government incentives for EHR adoption according to Fortune Magazine’s and Kaiser Health News’ 9,000-word exposé of the EHR industry. It makes a compelling argument against regulatory action in the EHR space and that past mistakes failed to incentivize the actual sharing of clinical data.
However, newly announced regulations, and corresponding sub-regulatory guidance, including the 21st Century Cures Act, the Trusted Exchange Framework and Common Agreement, and the CMS Promoting Interoperability program seek to correct the industry’s course.
These initiatives will not only provide more mechanisms for data exchange (e.g., publicly-available APIs) and on-boarding, but also introduce new financial penalties for those vendors and healthcare delivery organizations who stand in the way of data sharing. Going forward under the new rules of the 21st Century Cures Information Blocking provisions, data must be shared unless one of a few exceptions apply.
These activities are also beginning to translate into actual clinical benefits for patients. A recent study published in Health Affairs found that HIE participation among Florida hospitals was associated with a decrease in the probability of unplanned 30-day readmissions for acute myocardial infarction that was 1.3 percentage points greater than that seen at nonparticipating hospitals.
With the advent of value-based care and the emergence of new payment models, there is also evidence that paying for quality is also driving the increased usage of data exchange. A recent study in the American Journal of Managed Care found that alternative payment model participation “was associated with greater HIE diversity, breadth, and depth suggests that value-based payment may be spurring improvements in HIE infrastructure.”
The rest of this year will prove whether these recent gains are sustainable. One metric is the Patient Record Scorecard. It names and shames organizations that fail to provide patients with timely access to their records in accordance with HIPAA’s Right of Access provisions.
The real goals of interoperability will be achieved when we no longer require patients to carry their medical records from one office to another; when providers have full usable access to every patient’s medical history; and when the topic interoperability fades into the background as something that is taken for granted and that “just works.”