HITECH was specifically designed to facilitate better healthcare through EHR interoperability among providers. But, seven years and more than $30 billion in incentives later, meaningful interoperability is still lacking, according to the ONC’s report to Congress in December 2015.
Despite the near universal consensus that continuity of care is critical to better outcomes and reduced costs, effective information exchanges remain elusive. Of the five issues the ONC report cites, two stand out as principal obstacles.
- Complex and changing standards. Albert Einstein once said, “If you can’t explain it simply, you don’t understand it well enough.” With that in mind, how easy is it to explain the difference between CDA, CCR, CCD, Green CDA, CCDA and C32 to the average health professional? It’s extremely difficult to understand how each one fits into the overall picture; worse, implementation of any standard demands specialized knowledge. Further, these standards are brittle, as each vendor may have their own interpretation of the specifications. The result is a time-consuming and difficult integration process, even though sending and receiving systems have been developed from the same specifications.
- Security and privacy considerations. If no harm comes from unauthorized use of the data, the penalties for breach are still severe. Even after a vendor manages to work through a sea of standards and the related maze of specifications, exchanging information in compliance with state and federal regulation remains an issue. Security and privacy demands are very high and require even more specialized knowledge. Things such as VPNs, HISPs, DirectMessaging, SSL certificates, AES-256, encryption at rest and minimum necessary privilege present yet another barrier to the process. The penalties, damage to reputation and specialized skill sets needed for secure transactions discourage organizations from doing anything except meeting the bare interoperability requirements. It’s easy to see why some might find it simply not worth the effort or risk to break new ground.
Most organizations stack new integration efforts behind a crushing backlog of other integration projects already in the queue, which makes it seem as though a staffing shortfall is the primary bottleneck in resolving interoperability—if only we had more people. This is especially true for smaller and rural hospitals trying to build networks; it is even more prevalent among community-based organizations (CBO) attempting to connect hospitals to the multitude of downstream, post-acute care providers. Many simply do not have the staff, budget or sophisticated systems in place to complete these critical integrations, adhere to the standards and maintain HIPAA compliance, all while ensuring data is available at the right time to serve the business needs of the network.
However, limited personnel would be much less of an issue if everyone could agree on one clear standard, and security and privacy did not present such an impediment.
Hope could be on the horizon in the form of Fast Healthcare Interoperability Resources (FHIR), the latest standard offering from HL7. While this is indeed Yet Another Standard (YAS), its simplicity and elegance, coupled with the ability to present and transport information through modern web technologies, make it a compelling offer.
The learning curve with FHIR is relatively small, and the documentation is readily available, comprehensive and easy to digest. Even better, a growing community of FHIR enthusiasts is congregating on the FHIR Google Group to provide support. Influential players, such as Cerner and Epic, have provided sandboxes in which developers can readily test their FHIR-powered interoperability offerings.
With new, clearer standards that give technology providers the ability to quickly deliver a wider range of effective interoperability products to market, hospitals, CBOs and their post-acute networks can finally realize the potential of full network data sharing, more efficient care coordination and lower cost care with better outcomes.
For example, five hospitals across two health systems in New England have integrated to identify high-utilizer, at-risk patients; design, manage and measure more effective treatment protocols; and streamline care coordination to ensure patients get the right interventions at the right time, without duplicating services. These new capabilities will enable every participating facility and provider to improve the overall quality of care delivery and improve patient outcomes, which translates directly into improved fiscal health under the new outcomes-based reimbursement models.
We’re seeing similar implementations connecting CBOs, rural provider networks and other organizations, proving successful interoperability is possible. In fact, the resulting better outcomes and lower costs associated with shifting from fee for service to payment for quality makes interoperability across the care continuum inevitable.
This would simply be much easier with less cumbersome standards. Most health systems remain hampered in their efforts to exchange information in a timely and meaningful fashion by a sea of standards, difficult implementations and fear of punitive actions resulting from security issues and data breaches. Fortunately, FHIR is a strong contender for the dominant interoperability standard, thanks to its ease of implementation and modern web architecture.
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