• On the (Bumpy) Road to Interoperability

    By Karen Wagner Nov 21, 2017

    Nationwide provider-to-provider interoperability may be a reality in the not-too-distant future. But is that enough?

    The ability for any provider to electronically exchange information about the medical history of any patient may once have seemed like a worthwhile but distant goal. Today, that capability is almost here.

    Technology, including electronic health records (EHRs) and health information exchange (HIE), is being used to send data electronically and securely among healthcare organizations. But availability doesn’t equal acceptance. Barriers persist in the form of budgetary and time constraints, privacy concerns, and issues with data quality.

    Indeed, there is not even agreement on what interoperability entails. One view holds that for the industry to truly benefit from interoperability, there needs to be secure, automatic data exchange not just between providers but between providers and health plans, providers and patients, and health plans and patients—and none of that is happening enough.

    National Interoperability

    Micky Tripathi, president and CEO of the Massachusetts eHealth Collaborative, a nonprofit professional services firm that provides consultation on EHRs and HIE, says the industry’s interoperability capabilities are maturing.

    Interoperability Feature_Micky Tripathi“We are literally 1 to 1 ½ years away from being able to say we have nationwide interoperability capability for basic medical records,” Tripathi (pictured at right) says.

    Many EHR vendors are part of collaborations that support common data standards and other components of a common interoperability framework, Tripathi says. By connecting disparate networks, such a framework enables data exchange for users of the EHR systems. Noting that these EHR vendors represent 85 percent of the national market and are beginning to make the functionality part of their systems (rather than a custom add-on), Tripathi says most of the market will be able to exchange healthcare data electronically.

    “In a very real way, that is nationwide interoperability,” he says.

    High-Level Users

    Reliant Medical Group (RMG), a multispecialty practice based in Worcester, Mass., has had interoperability capability since 1993, when it began exchanging data with a local hospital and area health plan, says Larry Garber, MD, medical director for informatics and associate director of research. Today, RMG uses its EHR functionality to exchange patient medical records with organizations in nearly every state.

    The practice, which has 25 sites and 300,000 patients in central Massachusetts, also exchanges data through the state HIE, called the Massachusetts Health Information Highway.

    Interoperability Feature_Lawrence Garber“Our connections are such that when one of our patients shows up in the emergency rooms of any local hospital, our electronic health record automatically sends a summary document securely, using direct messaging, to that ER on that patient, telling the doctors that these are the meds the patient is on, these are the allergies, the medical problems, recent test results,” Garber (pictured at right) says. “And it all happens within 90 seconds of them registering in the ER.”

    Through its EHR vendor’s interoperability platform, the practice can also query other organizations—with patient consent—for specific patient health data, Garber says.

    The practice also receives claims data from its contracted health plans through secure interfaces. The data enable RMG physicians to see the treatment that patients have received from provider facilities to which the practice is not linked through its EHR or the HIE.

    “I think we really are among the best in the country in terms of interoperability,” Garber says.

    Independence Blue Cross, a Philadelphia-based health plan, was a founding member of HealthShare Exchange, the HIE serving southeastern Pennsylvania and the greater Delaware Valley, including southern New Jersey. HSX has 130 subscribers—including hospitals and health systems, medical groups, independent physicians, health plans, accountable care organizations, and behavioral health and post-acute-care entities—with a clinical data repository that already includes more than 6 million patients (click on the exhibit below for more information).

    Interoperability Feature_Exhibit

    Over the past year, providers have exchanged more than 300,000 direct secure messages via HSX, mostly between different health systems, notes Greg Barnowsky, chief enterprise architect for Independence. Every month, the HIE sends his health plan real-time notifications of thousands of admission, discharge, and transfer (ADT) events for its members that may trigger care management steps, Barnowsky says.

    “We have the ability to recognize that a member has been admitted to an individual hospital with a tool called an automated care team finder,” he says. The tool also notifies the patient’s primary care physician of the admission.

    “We’ve been very lucky to be [part of] one of the very few plan/provider collaboratives for sharing electronic health records” data, Barnowsky says.

    Non-Users

    Although the technical means exist, not all providers are using interoperability functionality. Several issues pose daunting barriers.

    Resources. Certainly, healthcare organizations are faced with competing priorities that squeeze already limited financial resources and manpower. Interoperability requires some amount of funding and internal expertise, depending on the provider’s desired level of functionality. RMG, for instance, has four clinical FTEs dedicated to healthcare IT work, Garber says.

    Interoperability Feature_Greg BarnowskyConnecting to HealthShare Exchange is relatively uncomplicated. Small or solo practices with limited resources can use standard, secure email messaging to receive basic patient history data, Barnowsky (pictured at right) of Independence says. However, participants that want additional functionality, such as the ability to query other EHRs, require internal technical expertise.

    For a health system, the cost to join the HIE is not considerable, Barnowsky says. Payers help to cover the cost of operating HealthShare Exchange, and provider funding for joining HIEs is available from the Centers for Medicare & Medicaid Services.

    But many health systems are directing resources into their EHRs and trying to address regulatory pressures, such as government mandates relating to meaningful use. “That’s all competing with the ability to share information,” Barnowsky says.

    Health information exchange functionality, such as Carequality and CommonWell network capability, is increasingly being built into the core EHR product, meaning there are no up-front costs for development or implementation. Nor are most vendors charging a separate fee for this capability, Tripathi says.

    Liability. Providers are concerned over how to manage the potential legal consequences if data is used inappropriately, Barnowsky says.

    “One of the biggest challenges we’ve had is the understanding of where you are from a liability standpoint if your individual electronic health record is lost or used in the wrong way,” Barnowsky says.

    Some EHR systems are coming out with functionality that enables providers to self-enroll in data-sharing networks by clicking on a link to a contract and agreeing to terms. These are standard contracts that define the “rules of the road” of the network and essentially state that providers are responsible for what they do on the network, including getting appropriate permissions from patients, Tripathi says.

    Another big challenge is the incongruency of state privacy laws that govern patient data. Again, Tripathi says this is a manageable issue. The potential solution is similar to the approach used by Amazon in dealing with varying state tax laws that relate to online sales. “Computers are very good at managing [variation],” Tripathi says, and the greater penetration of networks such as Carequality and CommonWell will pressure states to align policies with nationwide standards.

    On the other hand, a federal law preventing federally funded substance abuse clinics from releasing data on patients without separate consent is a more challenging barrier, Tripathi says.

    Data quality. Continuity-of-care documents—the electronic vehicle for exchanging bulk data—are standardized to an extent but still allow for local customization that clinicians find frustrating

    “The quality of those is just really bad. They’re really bloated. They have way too much information in them. They’re inconsistent,” Tripathi says.

    For example, determining whether a patient is allergic to penicillin may require sifting through a large electronic document, making it easier to telephone for the answer, Tripathi says.

    The solution lies in increasing the number of users and the amount of data being exchanged. If users, rather than software engineers, specify what does and does not work in interoperability functionality, vendors will respond over time and make appropriate changes.

    But users have to be motivated to exchange data, and that may present the greatest obstacle to date.

    Incentives. RMG has such strong interoperability capability, Garber says, in part because it engages in risk-based contracting, which offers incentives for lower-cost, high-quality care. But many physicians still practice under the fee-for-service model, which incents volume.

    RMG uses claims data for clinical analytics to better predict and manage patient health, and for business analytics to assess the acuity level of their patients when determining financial risk.

    Garber says if other physicians were similarly incentivized, they, too, would improve their interoperability capabilities.

    “It’s not the technology that holds you back,” Garber says. “It’s the individual organizations and whether they’re motivated to turn on the [interoperability] functionality to make it happen.”

    More Players Emerging

    Even as barriers are overcome and EHR vendors make interoperability for basic medical information more readily available, provider-to-provider data exchange by itself may be insufficient.

    “I would argue that without plans and patients and providers all working cohesively—all engaged—you will not have a successful system,” Barnowsky says.

    Health plans can incent physicians to provide better care by linking payment to care and can motivate members to engage in wellness programs in return for lower premiums. All of this is what drives down overall costs and improves quality, Barnowsky says. This approach requires not simply data but the ability for data exchange among all three groups of stakeholders.

    Linking data from personal health-tracking devices to individual patient care plans can help with population health management initiatives. In a program at RMG, for example, several hundred patients with both diabetes and hypertension have home blood pressure monitors that can download readings to the practice’s EHR, which analyzes the data and issues alerts when problems arise, Garber says. “The computer lets us know when there’s something significant to see,” he says.

    “If you discount the patient or plan out of that model, providers may still have ways to exchange information, but you may not be able to get the results or sustainability needed to improve population health,” Barnowsky says.

    However, neither EHRs, which are used by providers only, nor HIEs, which some experts say lack scalability for national reach, appear to be a true solution for such three-way data exchange functionality.

    One promising solution is Fast Healthcare Interoperability Resources (FHIR), a new standard for health data exchange that is said to be more flexible and simple to use across disparate organizations.

    Independence Blue Cross adopted the FHIR standard as part of its member health and wellness portal, allowing member information to be more easily exchanged with vendors of health and wellness programs.

    The standard has real-time data exchange capabilities, Barnowsky says, unlike the typical file transfer method, which requires several hours. “That will drive a whole new ecosystem of health and wellness in the future,” he says.

    Tripathi agrees that three-way data exchange is necessary and that FHIR may provide a viable answer. Despite existing barriers, he believes that the quality of clinical care documents will improve, and he is optimistic about where healthcare interoperability is going.

    “I would say that we are on the cusp of having the version 1.0 of real nationwide interoperability, which is a significant milestone for the industry,” he says. “And it’s just going to get better and better over time.”


    Karen Wagner is a freelance healthcare writer based in Forest Lake, Ill., and a frequent contributor to HFMA publications.

    Interviewed for this article: Greg Barnowsky, chief enterprise architect, Independence Blue Cross, Philadelphia; Lawrence Garber, MD, medical director for informatics and associate director of research, Reliant Medical Group, Worcester, Mass.; Micky Tripathi, president and CEO, Massachusetts eHealth Collaborative, Waltham, Mass.

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