The digitalization of healthcare is primarily associated with electronic health records (EHRs), but today’s healthcare technology is a mix of systems, databases, devices, applications, and processes. Organizations and professionals keep integrating new information technology into care delivery, learning, patient engagement, management, and other processes to improve patient care while maximizing operational efficiencies, lowering costs, and staying competitive.
Patients also expect a seamless customer experience, better security, and more innovative services. In particular, they want their health records at their fingertips and with no need to carry their information from one healthcare provider to another. Remarkably, less thatn one-third of organizations seem to be providing patients with the best-in-class digital experience.
To meet these challenges, hospitals, doctors, insurance agencies, research institutes, and IT providers need to develop new ways to communicate with patients and each other’s computerized systems. This need is reflected by the concept of interoperability in healthcare.
In the US, this issue has been around since the Health Information Technology for Economic and Clinical Health (HITECH) Act was enacted in 2009. The government placed interoperability at the forefront for the emerging healthcare industry and identified health information exchange (HIE) as its critical part.
Complying with interoperability rules means not interfering with patients’ access to, or use of, their electronic health information and refraining from information blocking. The rules are already taking effect and will continue into 2022, posing extra challenges for many already revenue-stressed healthcare organizations. And what for?
This article provides an overview of the benefits of interoperability for patients and healthcare providers and some methods for smooth and effective interoperability implementation. We’ll provide some context first.
Generally, interoperability refers to the ability of disparate hardware, software, applications, databases, and other computer systems, including those coming from different manufacturers and vendors, to connect, communicate, and share each other’s data without any restrictions, to interpret that data similarly so that it becomes information, and to use that information. Interoperability software is any program that meets these criteria.
What is interoperability in healthcare? It may mean the extent to which health information systems, devices, or apps can connect within or outside a healthcare organization and access, securely exchange, and use patient data and other information: admission and discharge records, transfer notifications, lab and examination results, filed claims, and so forth.
It may also mean the ability of patients, clinicians, hospitals, private practices, labs, pharmacies, researchers, and other actors to quickly exchange and use meaningful information across apps, wearables, etc., for effective delivery of healthcare for individuals, communities, and the entire population.
The American Healthcare Information and Management Systems Society (HIMSS) defined the following levels of HIT interoperability:
This is the initial level of data sharing between separate information systems. Foundational interoperability ensures that one system can connect to and share data with another system. The receiving system needn’t interpret the data with extra technologies or user intervention. A 2019 HIMSS survey found 74% of healthcare organizations had passed the foundational level.
This tier is also known as syntactic or technical interoperability. It defines the format and structure of the data to exchange allowing the receiving system to interpret it at the level of data fields, e.g., patient records. This has to do with the standards that govern the format of messages exchanged between systems to preserve the unaltered clinical or operational purpose and meaning of the data.
This is the level of connection to which all should aspire. It ensures that two or more systems or components can share, fully interpret, and immediately use the exchanged information. Semantic interoperability utilizes the structuring and codification of the data to support patient information exchange among authorized parties via potentially disparate EHRs and other systems. It’s vital for eliminating the existing technology and terminology gaps between the numerous software systems and data sources.
This level encompasses social and organizational aspects and data exchange policies necessary for introducing interoperability to entities’ workflows and facilitating smooth and secure data exchange.
Under ideal settings, interoperability facilitates connections and integration across all systems regardless of where the data originates, its target end-user, or the applications used. The data that is being sent should be usable, immediately available to share, and intelligently interpreted and presented to the recipient. The goal isn’t to have one system that does everything but to connect all forms of healthcare to the wealth of information that exists. This approach offers multiple benefits to all parties.
In spring 2020, the US HHS’ Office of the National Coordinator (ONC) for Healthcare IT and the Centers for Medicare & Medicaid Services (CMS) issued their final interoperability rules. The rules cover health systems and all CMS-regulated plan types.
The ONC’s interoperability goals imply:
The lack of HIT interoperability entails inconvenience for the patients at best. Patient records still rely heavily on the forms they fill out. Every time they deal with another entity (primary care, dental, or chiropractic specialists, occupational and physical therapy, etc.), they deal with another form. Not every entity captures the same data, and not all of them will be connected electronically. Moreover, contradicting and even wrong information can be entered. This results in inaccuracies and inconsistencies contaminating EHRs, healthcare providers unable to access patients’ complete information, and a high percentage of patients not matched properly to their records when seeking care. Manual data input errors may even put a patient’s health and safety at risk.
As opposed to that, what is interoperability in healthcare promising to patients and healthcare providers? The benefits they are likely to reap from interoperability as described above include:
Interoperability implies that providers directly put personal health information conveniently in the patients’ hands, e.g., via patient portals. Having proper access to and control over that data via chosen mobile apps and regardless of a health system or type of EHR, patients will be able to make more informed decisions. Quick and easy access to their own treatments, lab results, and other medical records will enable them to better care for themselves without needing to see a doctor in person.
Connected systems that can securely share data will be able to populate a fuller patient record. Having to spend less time searching for patients’ information, every healthcare professional can spend more time on patient care. When all necessary information is readily available and presented in a consistent and well-organized manner, clinicians can evaluate it faster. This speeds up the decision-making, reduces errors, and facilitates treatment tailored to each patient’s genetics, preferences, and health history.
The access to complete patient records will promote the continuity of care, particularly for complex cases. Practitioners can follow up with patients quickly, providing referrals or reinforcing items related to their treatment plan. Interoperability also enables safer transitions of care, resulting in better patient outcomes.
By integrating interoperability software, healthcare providers can streamline some processes, e.g., patient identification and matching their records, reducing manual data entry, minimizing errors, and freeing up time for other office tasks. By better equipping clinical staff and practitioners, interoperability should enhance their productivity and reduce staff burnout and churn.
More efficient information sharing saves time and effort. Being able to share more useful information when it is needed, healthcare providers and patients can reduce the costs associated with paper-based or archaic systems, superfluous lab tests, and more.
With connections to HIEs and EHRs, interoperability capabilities can ensure compliance with pay-for-performance initiatives (MACRA/MIPS), the Cures Act, and other regulations. As long as sensitive data is initially entered correctly via an interoperable network, an entity stands a greater chance of securely storing protected health information (PHI) throughout its life cycle.
Interoperability facilitates a quicker and more precise collection of public health data. In the ideal scenario, every healthcare provider and office would be interoperable, creating a single national or even international network. All data pertaining to patient healthcare would be shareable with any eligible hospital, diagnostic center, laboratory, etc.
For example, integrations between vendors of remote patient monitoring (RPM) and electronic medical records (EMR) can facilitate the exchange of biometric data, patient demographics, and care plan information. The analysis of collected data would empower public health agencies to predict long-term national health trends.
This paves the way to developing patient cohorts and utilizing artificial intelligence (AI) and machine learning (ML) algorithms to discover the most at-risk patient populations that require extra care. It will also be easier to recognize, interpret, track, and predict the spread of contagious diseases, prevent and control outbreaks, and increase the efficacy of treatments.
Knowing these advantages, one may wonder what stops healthcare providers, payers, vendors, and others from embracing interoperability right now. Unfortunately, the task is not straightforward. They say that interoperability is 20% technical and 80% an economic and political issue.
The primary factors that inhibit interoperability are:
This is a major impediment to interoperability in healthcare. Insurers are reluctant to cooperate with healthcare providers and disclose information. EHR vendors often build proprietary communication and language protocols, blocking communication with other EHRs. Some would charge fees for transmitting data outside the system.
Besides different EHR formats, there are many electronic health data standards out there. Standards may pertain to data security, transmission, format, structure, or the meanings of codes or terms. Each standard is meant to match particular organizational needs, so clinical systems and payers use different data-sharing standards that hinder real-time data aggregation and interoperability in a broader sense. Systems have to manipulate and sanitize data before importing it into another system.
The adoption and use of common standards for capturing, transmitting, receiving, storing, and managing patient data are essential to industry-wide interoperability, and necessary steps are being taken. Namely, to enable nationwide sharing of health-related data in the US, all key players will have to implement the following:
1) Fast Healthcare Interoperability Resources (FHIR)
Created by HL7 International, FHIR (pronounced “fire”) is a standardized API setting up a collection of resources that separately or together can satisfy most common data exchange use cases.
FHIR can be used with apps, cloud-based systems, EHR-based data sharing, and server-based communication for structural and even semantic interoperability. It supports four data transfer paradigms, uses HTTP-based RESTful APIs suitable for mobile applications, and allows sharing documents represented in XML, JSON, and RDF format.
ONC proposed to adopt its 4th version as a foundational standard. Starting in 2021, Medicare Advantage, Medicaid, Children’s Health Insurance Program, and the Federally Facilitated Exchanges will have to support this API to help patients access claims and their clinical data via any third-party app. It might also be used to integrate a health plan’s data into a patient’s EHR.
Other use cases include:
2) US Core Data for Interoperability (USCDI)
USCDI is a set of standardized health data classes and constituent elements for nationwide HIE. It basically outlines what pieces of information should be shared at a patient’s request.
Massive transition to USCDI data exchange via FHIR-based APIs will bring closer the moment when patients can shop for healthcare services and insurance on their smartphones.
There is still no consistent way to identify a patient within an EHR system, let alone across a network of providers. In the US, patients are normally identified by their name, date of birth, and Social Security number. However, since different systems store each instance of this information differently, patient identification errors are possible.
A national unique patient identifier that would help recognize a specific patient at every point of care throughout their lifetime might solve the problem, but patient privacy concerns prevail. Thus, data privacy and security represent another barrier.
Entities and individuals may also be confused by the lack of clear interoperability standards in healthcare: without a standardized way to measure the effects of implementation, they can’t improve it. Only the ability to measure issues across the entire healthcare chain will enable them to analyze any problem areas, make changes, and monitor how those changes improve patient care and outcomes.
The Shared Nationwide Interoperability Roadmap and the other continuously changing federal and state regulations can be overwhelming for small and single practices. Even though the technical means exist, they are not using interoperable technology components due to the lack of resources. The management of PHI requires connections and integrations with disparate EHR and HIT systems, but only large enterprises can afford such a level of connectivity.
The final regulations put a heavy financial burden on hospitals, IT providers, and insurers. For example, CMS estimates year-one costs of about $4 million and ongoing annual costs around $800K for each hospital.
Misaligned incentives and other human-centered factors can also jeopardize interoperability projects. The staff may initially meet new technology with apprehension. Clinical staff having to learn another technology can feel frustrated. The learning, double documentation, and operating between cloud-based and local platforms can seem daunting.
The list of obstacles is far from being exhaustive, but the good news is that several solutions to overcome some of the factors that inhibit interoperability are suggested:
Cloud services offer a relatively fast and cost-effective way to create an interoperable infrastructure on top of the existing system. Some of the leading cloud service providers helping achieve HIT interoperability are Azure API for FHIR, IBM FHIR Server, Google Cloud Healthcare API, Oracle Healthcare Data Repository, and Connected Consumer Health platform.
Since ONC’s interoperability goals explicitly listed the use of APIs for promoting patient data access, now we’ll focus on them.
Interoperability is easier to achieve if an entity’s solutions have public or open APIs. These sets of procedures and functions facilitate the development of applications that access data or features of another app or operating service. Developers can use ready-made templates, customize them, and add extra functionality if needed. Put simply, using an API in healthcare is about helping information systems to communicate and exchange healthcare data.
Many big EHR vendors already offer open APIs for creating apps that seamlessly connect and access their EHR data.
These APIs generally work as follows:
The common consumption patterns of APIs include, but are not limited to:
An entity may use an existing open API or opt for custom API development to create a healthcare app that meets its unique needs.
Providers and facilities are generally recommended to take the following steps to meet the new requirements for interoperability in healthcare:
Identify the level of interoperability you want to achieve for your entity and conduct gap analysis to have a clear understanding of where it is now and the distance it needs to cross. Instead of entirely replacing existing infrastructure, it’s reasonable to try to expand the interoperability and squeeze maximum benefits out of it. Conduct a thorough technical review of the existing hardware, software, applications, databases, and other computer systems, as well as the processes, to understand how your data points touch the patient experience and flow into each other.
Your goals should not be limited to formal compliance with the ONC and CMS interoperability rules. It’s wise to think of interoperability as a philosophy and pursuit of leadership in your market. Always keep the patients’ needs and interests at the core of your long-term interoperability strategy.
Identify SMART goals of your interoperability implementation and plan the necessary resources and time-frame accordingly. Your strategy should focus on the benefits of interoperability for the organization and the patients, vendors, and other external parties. Identify and document the short- and long-term expectations, including the return on investment. Be as specific as possible.
Prepare a detailed ‘implementation playbook.’ Identify the steps to be taken, outline and prioritize measurable intermediate goals, and specify how the entity will comply with applicable regulations, what interoperability standard should be adopted, what technology should be used, and any partnerships with external tech vendors or others you need to form to this end.
Scrutinize every type of admission, discharge, or transfer event in your entity and their respective workflows and system interactions, all clinical use cases, types of data to share, and all parties involved in providing patient care. For example, the medical staff typically connects to and requests data from EHRs, billing systems, lab results, and more. IT vendors permit varying patient data elements for exchange, impacting the type and amount of patient information that clinicians can exchange.
This research will help you determine the optimal technical approach to data transmission, e.g., via point-to-point connection or a portal, and how your entity can strategically use the additional data coming from other entities’ systems. Also, try to guess what cases may arise during your healthcare facility’s transition to a patient-centered model and other transformations.
Shape a compliance roadmap with policies including what records are affected by the new rules, how patient identities will be confirmed, how to spot abuse, how to conform to state and federal law, etc.
Interoperability projects usually cut across several networks, involve many stakeholders, and require continuous motivation, top-down leadership, championship, and support at all organization levels. All stakeholders need to be on the same page about the entity’s vision of HIT interoperability, the steps to achieve it, the value expected from the initiative, the necessary resources, and the timeline.
Provide stakeholders with the implementation playbook. Explicitly communicate the current situation, the required changes, what should be achieved, and how the organization should get there. Clearly explain what interoperability means for the patients, doctors, other staff members, and the entire organization.
Standardized data collection and reporting that produce quality data are the keys to successful interoperability implementation. Invest in your entity’s data cleaning to make sure it’s clean, meaningful, intelligible, and will be useful to your patients. This will be beneficial to your ML and other analytics-focused efforts. If you contemplate collaborating with integration vendors, be ready to comply with their data standards, if needed.
Education of the entity’s staff can be combined with HIPAA/HITECH and EMR training.
Healthcare providers, hospitals, and payers also need to educate patients on choosing third-party software to access and aggregate their information, about the benefits and potential risks involved in using such apps, and about the dangers associated with transferring data to an app not covered by HIPAA.
After successful interoperability implementation, publicize the results.
The future of interoperability in healthcare revolves around the standardization of data inputs, whether from software-to-software or hardware platforms like wearable devices. All participants should strive to establish a standard where patient insights are easily extracted through the pool of data, providing organizations with the most relevant and up-to-date information.
Centralizing this information across the healthcare ecosystem is another step to take. Radical interoperability, where every person’s health information will be consolidated and available for research and treatment purposes, may become essential to every modern healthcare organization by 2040.
In the US, the government’s relevant initiatives are intended to facilitate coordination and management, improve the quality of care, enhance patient safety and outcomes, reinforce patient privacy and security, increase staff productivity and operational efficiency, facilitate knowledge sharing and medical research, reduce medical error rates, lower healthcare costs, and ultimately, improve the entire population’s health.
The federal regulations and updates to the goals and interoperability standards in healthcare, AI, growing patient data access opportunities, and other developments will significantly impact the industry in the coming years.
The need for new software systems to communicate with each other will only be growing. Entities that want to satisfy patients’ demand for accessing healthcare records, shift to value-based care, or leverage analytics to maximum capacity will all need interoperability. Interoperability and other innovation in the healthcare industry will be driven by APIs.
If you plan to integrate APIs into your existing network or develop a new one within your organization’s interoperability or innovation strategy, Onix is here to help. Our team is experienced in building medical interfaces and back-ends of different types and complexity using various cutting-edge technologies and flexible development processes.
Many thanks to Volodymyr Katarovskyi, PM at Onix’s healthcare software projects, for assistance with this article!