Is interoperability the new meaningful use?

Some see the ONC's Interoperability Roadmap as a daunting proposition —166 pages packed with information that will likely lead to more rules, which may make meaningful use seem like a mere warm-up.

Many physicians and hospital administrators struggle with the dead ends of an IT system that is not interoperable. Some hospitals or networks have multiple systems to serve different needs, frustrating clinicians and getting in the way of care. Others give up on communicating with other hospitals with different systems, faxing or calling over records when they need to exchange information.

Medical professionals, legislators and federal regulators have debated the subject, calling for vendors to produce platforms that can operate with other systems. When the ONC introduced its National Interoperability Roadmap in January, it included a list of suggested standards that will be released in stages over the next two years to help reach complete national interoperability by 2017.

However, Matt Patterson, MD, saw a problem. The president of AirStrip, a mobile interoperability technology company based in San Antonio, Texas, Dr. Patterson deals with the tangles of interoperable systems on a daily basis. To him, the ONC's goal of basic interoperability seemed elementary — the vendors would simply fulfill the bare minimum checklist and be done without delivering what health systems actually need.

Dr. Patterson says he had two initial reactions to the announcement of the 2017 deadline.

"One is that we saw this coming from the very beginning with the HITECH Act," Dr. Patterson says. "Interoperability was not specifically incentivized and therefore would come to roost at some point.…The second thing is that [most healthcare professionals'] reaction is that here's one more thing that just got added to my already busy schedule of healthcare IT initiatives that I have to do, so what's the minimum number of things I can do to comply?"

Where are the flaws?
The ONC included a list of 10 standards as well as a set of 19 data points to be included in all patient records. The Interoperability Roadmap claims this will make HIEs function much more efficiently if the software knows what to include. However, Dan Golder, DDS, a principal at Naperville, Ill.-based healthcare technology consulting firm Impact Advisors, specializing in strategic advisory, implementation and optimization services, has heard providers express frustration with the current interoperability standards in place for Meaningful Use. In this context, many providers feel MU’s “Summary of Care” standard does not add value beyond the information they already receive from their EHRs’ “Discharge Summary”, diluting any potential benefits for clinicians. As the Interoperability Roadmap’s “common clinical dataset” is very similar to the Summary of Care, Dr. Golder wonders if it will be met with similar antipathy.

"I think the litmus test for the Interoperability Roadmap will be to see whether this minimum data set is ultimately viewed as useful or not for clinicians and patients," Dr. Golder says

Instead of setting specific clinical values that all vendors must be able to provide, Dr. Patterson says it would be more effective to specify vocabularies, document types, and transport mechanisms to be used when sending or receiving data. In addition, the industry needs a more fluid review system led by health systems and not by vendors, enforced as needed by regulatory bodies to ensure compliance with these communication standards. Currently, providers do not have enough input on how vendors communicate with each other and most experience shows that vendors cannot be trusted to do this reliably or effectively on their own, he says.

Providers are not terribly optimistic about interoperability, according to the 2014 KLAS Research EMR Interoperability survey. Less than half of providers say their system works well with other vendors, and only one-fifth were confident about collaborative interoperability industry initiatives. Approximately 82 percent of respondents said they felt successful about achieving interoperability, but only 6 percent reported being at an advanced stage. Essentially, providers think interoperability is possible, but if asked to have it tomorrow, they would not be able to meet the requirements.

Creating a stronger dialogue among vendors, regulators and providers could help achieve the interoperability the ONC aims for, Dr. Patterson says. Both Dr. Patterson and Dr. Golder agreed that the timeline is aggressive and would take significant industry acrobatics to achieve.

What are the obstacles?
Twenty years ago, interoperability in the medical industry was a distant goal, according to Brian Goad, the vice president of engineering services for Healthslide, a Knoxville, Tenn.-based interoperability IT company that helps organizations implement HIEs and builds interfaces. When he started in the healthcare IT business, it was difficult to communicate the possibilities to both consumers and vendors. Today, people are more familiar with interoperability and are willing to work with the company and update parts of their systems to be interoperable.

However, Mr. Goad does not think the ONC 2017 deadline is feasible simply because of the infrastructure overhaul it requires. Many facilities already have interoperability in place within their own systems but not with others, and creating that would require an organization to rewrite every one of its interfaces, he said. Mr. Goad, who has worked for General Electric and McKesson, says there is a significant charge per interface, and the cost to redesign them all within a hospital would be inhibitive.

Additionally, there may be little reason for vendors to strive for interoperability with others, Dr. Patterson says. Their own systems can communicate, but connecting them would not drive business to any one particular vendor, and so the industry will not strive for interoperability without regulation from the government or pressure from health systems, physician groups and consumers.

However, Dr. Golder disagreed, saying interoperability is in the best interest of vendors and he has seen effort from companies such as Epic and Cerner to implement it.

Cerner, Allscripts, athenahealth and McKesson formed the CommonWell Health Alliance to promote interoperability. However, as shown by the KLAS Research survey — which included systems from these major vendors — interoperability lags. Politico Pro published a Q&A with Epic CEO Judy Faulkner, in which she responded to criticism of Epic's lack of information sharing, saying the criticisms stemmed from other companies' frustration at being unable to access Epic's data. Afterward, CommonWell responded to her statements, saying "We know that to make interoperability work requires technical resources — both talent and dollars. We recognize that the current members cannot do this alone."

"I think the vendors really do want interoperability," Dr. Golder says. "I don't see that as a barrier. I think the vendors are more than willing to adopt new features, including interoperability, that will help their customers. They want to provide the best possible products for clinicians—it’s what sets apart the truly best vendors—and interoperability is a part of that."

Dr. Golder says he has experienced more opposition to interoperability from physicians and payers, who are concerned that interoperability regulations may parallel meaningful use, incurring more burden and cost.

To that extent, he agrees with the physicians and payers: the ONC's Interoperability Roadmap represents a potentially daunting proposition. The document's 166 pages are packed with information, and the roadmap will likely ultimately lead to many new set of rules and standards to support interoperability, he says.

How CIOs should go forward
To prepare, he recommends hospital CIOs become familiar with the document so they can project future actions for their organizations. The first step is to read the document in depth as well as the Federal Health IT Strategic Plan. The second step is to provide feedback on the Interoperability Roadmap, which is open to public comment until April 3.

Finally, he recommends CIOs converse with their vendors about their plans to implement the interoperability standards and how it will affect the hospital.

However, he remains concerned. Should ONC move forward with new interoperability standards as specified in the roadmap, the industry will likely be challenged to implement them in the timeframes specified by ONC. Software developers will need to digest the regulations, and program the standards into their products. These will then need to receive testing & certification from ONC (similar to the EHR certifications in place for Meaningful Use) and then hospitals and providers will need to compete for time slots with vendors to install, implement & retrain staff to use the new software and its features in time to meet the ONC’s deadlines.

"All of the rules and initiatives that are proposed in the roadmap are going to result in additional standards and governance, measurement and oversight from ONC," Dr. Golder says. "This really represents a tremendous amount of new regulations and new standards. It may make meaningful use pale by comparison."

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