Why your organization can’t afford to skimp on interoperability anymore

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Interoperability is a key enabler for providers and payers to deliver on the promise of health care reform.

Despite increased adoption of electronic medical records (EMRs), only a fraction of providers can demonstrate the routine ability to exchange data efficiently, prompting public criticism of the application software vendors as a barrier to achieving interoperability objectives. Recognizing that interoperability is essential, the Office of the National Coordinator released an interoperability road map intended to drive the market toward a common data set for easier data exchange.

Given this changing landscape, providers must recognize that many interoperability tasks remain undone and the responsibility to interoperate rests on each organization. The following are seven challenges that must be overcome to benefit from interoperability.

1. Interoperability is an additional cost.

Although the incentives are aligned for payers to drive interoperability, the channel for data sharing currently rests with the patient/provider relationship, including the trust that goes with it.

This dynamic imposes a responsibility that provider IT organizations will need to accommodate as meaningful use extends, beyond using an EMR, toward the community using connected EMR's and consumer-oriented patients who interact with their data in increasingly different ways. Although the removal of fees to exchange data between foreign EMRs reduces the cost of interoperability, it is not the only cost to bear. Interoperability will require investment.

Recognition of cost is the first step toward funding the initiative. Interoperability between systems takes years to achieve, and budgets which earmark funds should be put forth as iterative investments over a period of years. Dedicated resources and specific skill sets are required. The highest value-use cases will involve regional interoperability as well as interoperability between the military health system and the private sector. These projects must be prioritized and funded in the coming budget years.

2. Interoperability will expose the duplicates.

Issues of patient identification and disparate provider ID numbers have been a longstanding data quality struggle, and these challenges are magnified when external data is integrated. Absent a national identifier, the ability to create the complete longitudinal patient records will be hampered by records which fail to contain enough key criteria to match the patient. However, many of the records will match. An opportunity is slowly emerging for the patient to validate and connect his or her records through a patient mediated record or correct mistakes in name, address and birthdate through the patient portal.

Recognizing that there will be duplicates in patient identifiers and in clinical records, analysts will need to examine existing system functionality to group the data. To prepare, plan to explore your registration workflows to get a better handle on front-end processes and opportunities to improve or simplify. If your organization has not implemented an enterprise master patient index capability, and you are operating in a best of breed environment, consider interoperability as a means to drive this infrastructure component forward. Staffing dedicated resources to work the queue of duplicate patients may be necessary and like any back-office expense, will reduce the amount of time and attention required by clinical staff to remove duplicate data. Most importantly, managing the duplicates will reduce the organizational risk associated with having multiple records.

3. Interoperability requires advocacy.

Bringing external data from disparate systems together requires leaders who advocate for interoperability. Regional health information exchanges, national lab providers, military health systems, and referral and affiliate providers all represent sources of data that may be absent from any given EMR. Overcoming the technical hurdles of security, identity, performant workflow and physician adjudication will require IT design and collaboration regionally, as well as with EMR vendors.

IT leaders should set interoperability expectations for their organizations, for their EMR vendors, and for their communities, and then actively manage meeting the expectations. Don't go it alone; form a powerful guiding coalition of key stakeholders with positions, power, expertise, credibility and leadership.

4. Interoperability needs a use case.

Any health provider considering a risk arrangement or participating in a pay-for-performance program with a payer can immediately see the value of interoperability. Increasing payment and delivery reforms, including bundled payments and medical homes also help to create a business case for electronic data exchange. Continued affiliations between insurers and providers based on managing populations and risk through the creation of networks assume an ability to interoperate. Consolidation of physician practices, hospitals, skilled nursing facilities and home care providers also creates networks of providers along the continuum of care that are incented to exchange data even though they may never operate the same electronic medical record.

Increasingly, the desire for analytics will remove interoperability barriers. Armed with this information, IT leaders should seek out the risk arrangements its organization is pursuing. Align with quality and pay for performance programs to define valuable missing data. The analytics agenda starts with interoperability, make sure you have this clearly aligned in your strategic information management plans.

5. Interoperability will change workflow.

The shift in care delivery from a role-based, paper-oriented workflow organized around visual signals and outdated communication methods, to the use of computers and smart devices has resulted in drastic transformations within health care delivery organizations.

As described above, complex technical requirements and redundant data are not the only barriers to overcome. Patient consent and related workflow processes will have to change. Many current processes predate electronic medical records. Within health care organizations, interoperability will have to be recognized as crucial to the quality and financial agendas.

Enhancing the utility of health data does not require centralizing all raw data generated by multiple trading partners. Such centralization is costly and hard to scale. Creating use cases organized around roles and workflow and their specific business objectives is the best place to start. Concerns, real or perceived, about cybersecurity risks and patient confidentiality must be explored and resolved. Policies which govern data security and consent may need to be updated and modernized. Roles of care providers may require more granular definition to support protected class information or storage of data which is more sensitive in nature. All of this work requires leadership and funding.

6. Interoperability is a complex use of technology.

Interoperability creates efficiencies. The enriched record when shared between providers is a major step toward holistic patient care, more actionable workflow, and the analysis of populations and outcomes. The ability to analyze patient outcomes, understand behaviors and apply that knowledge to better inform patient decision-making yields the highest patient satisfaction. These are desirable outcomes from the application of technology; specific skills and partnership are required to achieve it.

An inventory of the varying vocabularies operating in your organization must be taken. Collaborative work groups must be formed through existing informatics forums or data governance structures to permit data reconciliation and standardization to occur. Physicians must meet regularly to determine the value of data that is shared and analyze the cost in terms of time and responsibility for them to manage it. Adjacent clinicians will be necessary to prepare the chart for the physician if it is to include external information. Finally, decisions to rationalize multiple health information service providers must be made to enable accurate direct messaging to external providers. All of these system interactions must be monitored and follow strict service-level agreements not unlike the health level 7 integrations of the prior decade. Find this team in your organization; they are already conversant in overcoming interoperability challenges.

7. Interoperability must include the patient.

The primary vehicle for interoperability is the patient. The implementation of EMRs in the last few years, including patient portals, has begun to change the willingness of patients to follow archaic processes designed to protect them from their medical records. Empowered with their computers, a larger share of wallet in the payment for health care services, caretaker roles and an increasingly sophisticated consumer experience in other industries, patients are using their health information more often, asking for electronic copies of their data and offering to electronically submit data to providers.

It remains a challenge to bridge the gap between what providers should do in terms of sharing electronic data and what they actually do. Absent an interoperability program that supports broad data exchange, many clinicians and staff receives patient requests for data without a means to fulfill them. Directing patients to a portal is a fine start, but data trapped in the portal of an EMR is still trapped data. Interoperability is defined by data exchange, not data at rest. Patients who desire to direct data to their providers are often served a fax number or asked to print the information so that it can be scanned. Leveraging the patient and his or her data is critical to creating information which drives clinical decision support and results in lower cost and better outcomes. It's a circle, so plan to iterate.

Interoperability starts with you.

As electronic medical records continue to be installed, collaboration across systems will mature. The organization of medical subject areas will continue to normalize and increase the success of data sharing. Identity challenges will become secondary as providers and patients begin to share and use more data.

Data exchange is getting better and there are campaigns like www.getmyhealthdata.org to advance the cause. It is going to be a process to translate everyone's rights under the Health Insurance Portability & Accountability Act to "what happens when you actually ask for your records," but the desire of the patient is there and discomfort with using technology is no longer the obstacle.

This will all occur because medicine is, and has always been, a patient-provider relationship which depends on collaboration and the exchange of information. The disruptive opportunity presents when two forces merge: provider organizations are capable of accepting external data and patients begin to organize their longitudinal records around their care providers.

Interoperability represents the last frontier to achieve truly connected medicine and realize value from the significant IT investments which have occurred. Health care is desperate for interoperability advocates; it all starts with you.

The views expressed herein are those of the authors and do not necessarily reflect the views of Ernst & Young LLP.

Lisa Khorey is an executive director in the Health Care Advisory practice at EY. Before joining EY, she served as vice president of enterprise systems & data management and director of interoperability at the University of Pittsburgh Medical Center. Lisa can be reached at Lisa.Khorey@ey.com.

The views, opinions and positions expressed within these guest posts are those of the author alone and do not represent those of Becker's Hospital Review/Becker's Healthcare. The accuracy, completeness and validity of any statements made within this article are not guaranteed. We accept no liability for any errors, omissions or representations. The copyright of this content belongs to the author and any liability with regards to infringement of intellectual property rights remains with them.

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