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NOVEMBER 2013
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Everyone claims to want interoperability, so why isn’t it happening? >>
By Paul Cerrato
PLUS Why cloud startups doubt grand data exchange plans >>
To the cloud generation of healthcare tech-nologists, state-based health information exchanges look like a throwback.
The federal government has encouraged the creation of these state and regional data exchanges as part of the evolution toward an infrastructure that allows secure sharing of patient data among healthcare provid-ers. These HIEs are supposed to connect to providers and to other exchanges — though there’s a good argument to be made that HIEs are failing to provide that connectivity.
The Direct Project is one alternative pro-moted by the Office of the National Coordina-tor for Health IT. The idea is to enable secure email between known, trusted participants, each of which has a special email address only available to healthcare providers. Email sent this way can include free-form messages but also patient data in XML — structured data that an electronic health records system on the re-ceiving end can parse and import.
As our cover story notes, the drawback to Direct is that it’s push rather than pull. There’s no centralized repository or index to query —
something HIEs are at least working toward. Di-rect is more of a replacement for faxing records, though at least they’re machine readable.
When I spoke recently with the CEOs of four cloud-based healthcare IT firms, they greeted state HIEs with unanimous skepticism, seeing them as a bureaucracy rather than a workable architecture. Here are their quick takes:
Practice Fusion CEO Ryan Howard: How-ard points out that EHRs seeking Meaningful Use Stage 2 certification have to be able to demonstrate support for sending and re-ceiving messages over the Direct Protocol, which means they have to demonstrate basic interoperability. “That eliminates a lot of the need for an exchange,” he says.
Athenahealth CEO Jonathan Bush: “Health information exchange should be a verb and not a noun. Exchange activity will iterate dra-matically over time,” Bush says, and he is skep-tical that the right structure can be dictated by “some federally sponsored entity.” Athe-nahealth does participate in HIEs anyway be-cause the company wants to be easy to do business with no matter what model wins out.
CareCloud CEO Albert Santalo: “What I am a proponent of is that it should be a national infrastructure,” Santalo says. “I don’t think it makes any sense for every state to be build-ing something.” The Direct approach is “a little better” than navigating the maze of HIEs, but it’s “just email,” he says.
Girish Navani, CEO of eClinicalWorks: The HIE centralized approach makes it too easy to spend time and money trying to build a perfectly secure system. Meanwhile, nothing happens. “The Direct Project is one practical way of sharing data because it’s peer-to-peer,” simplifying the security challenge, Navani says. But he thinks the better alternative will be for patients to provide access to their own data — using a phone or a QR code to unlock a health record in the cloud, much as they ac-cess their money with an ATM card.
One way or the other, health information exchange cries out for simplification.
David Carr is editor of InformationWeek Healthcare. Discuss this and other articles by David at informationweek.com/davidfcarr, or write him at [email protected].
Health Information Exchange Needs A Simpler Model
Critical InsightD AV I D F. C A R R
@davidfcarr
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November 2013 2informationweek.com/healthcare
Want To Write For Us?We want health IT leaders to telltheir own stories on Information-Week Healthcare’s site. Do youhave a distinct or even contrarianpoint of view on an importanthealth IT problem, or lessonslearned you’d like to sharewith your peers? Contact editorDavid F. Carr.
November 2013 3
Everyone claims to want interoperability, so why isn’t
it happening?
Seamless interoperability. It’s part of the dream for how electronic health records will improve healthcare, since it would let caregivers know a patient’s history wherever
that person is treated. In reality, what many CIOs, clinicians and patients deal with is a patchwork of data standards, vendor con-flicts, state laws and federal regulations that sharply limit data sharing.
In practical terms, lack of interoperability means it’s some-times difficult for Mrs. Jones’ digital records to move from her doctor’s office-based EHR to a nearby hospital when she’s ad-mitted for gallbladder surgery.
Among the obstacles preventing true interoperability: lack of
By Paul Cerrato
[COVER STORY]
@plcerrato
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November 2013 4
cooperation among EHR vendors, state laws that block access to patient data and finan-cially unstable health information exchanges. Clearing these hurdles is going to require some creative thinking, vendor cooperation and the political willpower to put patients’ needs ahead of vested interests.
Is The Standards Stalemate Over?“Different vendors adhere to different
standards for each clinical domain: medica-tions, allergies, medical problems,” says Dr. Rasu Shrestha, medical director, interopera-bility and imaging informatics at UPMC. That differing vocabulary can sometimes present problems as clinicians try to share patient records. The federal government has made major progress to help resolve the problem by adding interoperability requirements to Meaningful Use regulations that govern federal subsidies for EHR implementation, but moving clinical data within a large
health system remains difficult. When the Office of the National Coordina-
tor for Health IT released its Stage 2 final rule in August 2012, the ONC director at the time, Dr. Farzad Mostashari, emphasized that, in order to demonstrate compliance, providers must be able to show evidence of at least one successful transmission of patient data from their EHR to one from another vendor. The point is to demonstrate a core capabil-ity: the ability for providers to exchange an electronic summary of care, with all the clini-cal data elements, between different EHRs. The MU Stage 2 document warns: “If we do not see sufficient progress or that continued impediments exist such that our policy goals for standards-based exchange are not be-ing met, we will revisit these more specific measurement limitations and consider other policies to strengthen the interoperability requirements…”
The message was clear: If EHR vendors don’t
offer a better way to talk to one another, regu-lators would become more prescriptive in terms of data standards. Vendors are only slowly getting the message.
Epic, for instance, uses the NDC standard to code medication data in its EHR system, despite the fact that RxNorm is more widely accepted as a national standard. While Epic is in no hurry to embrace RxNorm inside its software, it has created what it calls an “NDC-to-RxNorm walk,” which is essentially a bridge to convert from one language to the other. It’s a start. “A few years ago, many vendors had the ‘my way or the highway’ attitude,” says Shrestha. “Now they realize they can’t play that game anymore.”
Vendors may see interoperability as a threat — after all, some providers choose an “all-Epic” implementation, for example, to lessen integration problems. But as patients demand more data sharing across providers, that strat-egy won’t be enough. “To be competitive in
[COVER STORY]HIE BARRIERS
Why Health IT Must Work More Like Amazon
Healthcare providers must look beyond Meaningful Use regula-tions and start asking: Is my site as useful as Amazon?
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the future, vendors are going to have to open their systems,” says Pam Matthews, senior director of informatics for HIMSS, the profes-sional organization for hospital information managers. HIMSS is helping frame the dis-cussion and making it easier for vendors to cooperate by recently publishing a definition of interoperability and creating a resource library on the topic.
Really, the industry needs a definition of
interoperability? It’s true that stakeholders sometimes disagree on such basics, and so the HIMSS definition helps everyone shoot for the same targets. HIMSS defines interoper-ability as the “ability of different information technology systems and software applica-tions to communicate, exchange data and use the information that has been exchanged.” Data exchange is supposed to let clinicians, labs, hospitals, pharmacies and patients share data “regardless of the application or applica-tion vendor.”
Such interoperability should be both syn-tactic and semantic. Syntactic means separate systems can exchange data, using languages like XML and SQL. Semantic means the sys-tems have the ability to transmit data with “unambiguous, shared meaning.”
Stage 2: A Game ChangerWhy should we hope for better data shar-
ing when it’s been so difficult to date? One big reason is the standards certification pro-cess now being incorporated into Stage 2 Meaningful Use. Stage 2 is the more de-manding set of goals for EHR usage that the federal government is telling providers to meet in the coming year. As HIMSS explains it, the certification process ensures that all
approved EHR products “maintain data con-fidentiality, ensure interoperability to share information and can execute a series of well-defined functions.” ONC has appointed a small group of independent testing and cer-tification bodies to carry out this evaluation process.
The MU Stage 2 regulations also require that providers improve the transition of care for patients as they move from one setting to another. For example, hospitals are penal-ized for certain levels of readmissions. Such improvement requires accurate information to move with that patient, and that drives the need for a standardized clinical care docu-ment that can move from facility to facility. The means to accomplish that transfer of data is called the Consolidated Clinical Docu-ment Architecture. CCDA, set up by Health Level Seven International, is a markup lan-guage based on XML.
Specifically, the CCDA document includes both human readable text and optional struc-tured data for automated processing. CCDA builds on established coding systems such as SNOMED and LOINC to provide a common language for clinical concepts.
The CCDA standard is the backbone for the continuity of care documents that provider
informationweek.com/healthcare November 2013 5
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[COVER STORY]HIE BARRIERS
informationweek.com/healthcare
organizations are supposed to be sharing as patients move from hospital to home to nursing home.
Politics Vs. TechnologyDr. John Halamka, CIO at Beth Israel Deaconess
Medical Center in Boston and co-chair of the ONC’s Health Information Technology Standards Commit-tee, contends that the problem of data standards has mostly been solved for providers looking to share data outside their organizations.
“The barriers to health data exchange overall are political and organizational, not technical,” says Halamka. “Data standards are no longer a barrier.” Not everyone agrees, of course. Epic CEO Judy Faulkner, at the Digital Healthcare 2013 event this summer, said that existing data standards describe “a very, very small subset of the data that’s really there.”
Meaningful Use Stage 2, which will take effect in 2014, lays out a set of certification requirements that include vocabulary standards, content standards and a transport mechanism. In practical terms, the vo-cabulary standards are supposed to create an agreed upon way to represent medication, lab and allergy information, for example. The content standard is the CCDA, which allows providers to deliver a package of data summarizing the patient’s condition when he’s transferred from the hospital to the nursing home, for example. Stage 2 transport requires the Direct
[COVER STORY]HIE BARRIERS
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informationweek.com/healthcare November 2013 7informationweek.com
Protocol, which includes SMTP/SMIME or XDR.During Stage 1, providers only had to test
some of these standards, showing they are capable of moving a clinical document from point A to point B. Stage 2 requires them to actually use all these standards in patient care. And while data standards may remain a prob-lem within some large health systems that use EHR products from multiple vendors, Halamka points out that any Stage 2-certified products will have to use the data, content and trans-port standards to share clinical content out-side their walls.
While technical barriers are coming down, political and regulatory barriers remain to impede the transfer of patient data. In New Hampshire, for instance, it’s illegal to share a patient’s immunization status with state gov-ernment, so doctors can’t send vaccination data to the public health department.
In Massachusetts, health information ex-change is less restricted, but there too policy barriers exist. Halamka points to the law about sharing HIV data: “Not only does a patient have to consent to disclose their data, but a doctor who wants to view their data has to obtain consent at every episode of care.” That requirement holds even after HIV-infected pa-tients have given permission to share the data
[COVER STORY]HIE BARRIERS
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Most of the energy around interop-erability challenges has gone to-ward solving problems such as
electronic health record compatibility and health information exchange that involve sharing between separate providers. Debra Wolf, associate professor at Chatham Univer-sity, has been concentrating on internal bar-riers. And a big concern internally is the abil-ity of nurses and doctors to assess whether the data they’re getting at the point of care is worth using.
“There’s a concern that clinicians may not be knowledgeable enough to question one, whether the data makes sense; two, how up to date and accurate it is; and three, what security is in place to make sure it’s transmit-ted accurately and safely,” Wolf says.
So for example, if a patient walks into the emergency room, a clinician may be able to call up patient data from three separate databases: the hospital’s EHR, the EHR from the private practice that cares for the patient and a third database provided by a neigh-
boring health system that the patient dealt with in the past. What happens when these sources don’t agree?
One solution, says Wolf, involves bringing point-of-care clinicians into the process of designing the user interfaces needed to integrate these diverse data streams and asking them what criteria should be used to evaluate contradictions among the data streams. Sometimes providing simple data points at a glance, like the date on which the patient provided a symptom history, would let clinicians make a judgment call on its value.
But Wolf emphasizes that patients them-selves must be an important part of the so-lution to data inconsistencies. She’s a strong believer in consumer education to convince patients to take ownership of their medical data and track it in a personal health record that can feed into EHRs. If patients take re-sponsibility for the data, they are more likely to detect contradictions and inaccuracies.
— Paul Cerrato
Once Data Is Shared, Is It Any Good?DATA QUALITY
with their doctors. That kind of rule creates a speed bump slowing the process of health information ex-change. Given that every state has its own laws about data sharing that pre-empt the Health Insurance Por-tability and Accountability Act, those speed bumps can turn into a monstrous traffic jam.
Preparing For Medicine’s FutureThe consolidation of healthcare provider organiza-
tions occurring nationwide is going to require a way to clear these traffic jams. As large hospitals buy up smaller hospitals and nearby medical practices, and as individual practitioners give up solo practices to join more profitable multispecialty group practices, clinicians must merge patient data from diverse health information systems that were never de-signed to work together.
In this environment, “connectiveness is everything,” says John Bosco, CIO at North Shore-LIJ Health Sys-tem in New York. “We see a huge consolidation over the next five to 10 years of the number of health sys-tems in the country. The number [of providers] could go down to single digits in New York state.”
Bosco also envisions major alliances eventually among large health systems, creating regional and mega health systems, with each organization re-maining a separate entity. Seamless data exchange will be critical in such a situation.
Even within North Shore-LIJ, Bosco expects growth
[COVER STORY]HIE BARRIERS
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November 2013 9
in its ambulatory centers. It has 400 ambula-tory centers employing about 3,000 physi-cians serving 16 hospitals. And that doesn’t even include the 7,500 docs who have admit-ting privileges to their hospitals but are not employees.
North Shore uses Allscripts’ EHR products for both its inpatient and ambulatory needs, but affiliated physicians can use whatever EHR vendor they want. A few years back, the health system offered to give these inde-pendent clinicians the ambulatory Allscripts product for free but only managed to sign up about 500 of the 7,500 doctors.
Even having inpatient and ambulatory tools from the same vendor didn’t solve the interop-erability problem, since the Allscripts inpa-tient and outpatient products are separate sys-tems. “It’s not one integrated product like Epic, though they are certainly trying to get to that point and making a lot of progress,” says Bosco. With the help of additional software programs, including InterSystems’ integration platform, North Shore can share patient data between hospitals and its own ambulatory clinicians that are using the two Allscripts products.
The InterSystems HealthShare platform will be especially useful, says Bosco, as North Shore tries to integrate data from those 7,000
docs — who continue to use their own EHRs — with North Shore’s Allscripts EHRs. That ef-fort is a work in progress.
But sharing data between independent pro-viders isn’t the only big problem.
Even within a single provider group it can be difficult to get health information systems to communicate with one another. One reason is that inside a single organization there’s a lot more data being shared than there is among independent providers — financial data, scheduling, claims data and so on, explains Micky Tripathi, founding president and CEO of the Massachusetts eHealth Collaborative. That amount and variety of data makes interopera-bility difficult and leads some providers to opt for a single EHR vendor. At Partners Health-Care in Boston, says Tripathi, the solution was to say: “We can’t deal with all these different systems. We are going to take more than $1 billion, wipe the slate clear and replace it all with one system.” The new system, called Part-ners eCare, includes software from Epic and others, as well as additional IS infrastructure.
HIE StewBosco, like most IT leaders, is aware of the
need to share data with the rest of the world, and with that in mind, North Shore has put a
great deal of resources into regional health information organizations. New York state de-cided to take over the operation of its RHIOs, creating a quasi-public organization called the New York e-Health Collaborative (NYeC).
NYeC joins a plethora of HIEs that are help-ing hospitals, practices and health systems share data. HIEs include state, regional and private data exchange organizations, as well as the federally initiated Nationwide Health Information Network, now called the eHealth Exchange.
This HIE stew gets even more confusing when one stirs in all the other players. For instance, there’s the Certification Commis-sion for Health IT, a nonprofit organization that is trying to certify HIEs for their ability to provide connectivity with each other and with EHRs. It will offer this certification un-der a contract with the EHR | HIE Interoper-ability Workgroup — a consortium of several States, EHR vendors and HIE vendors —and the eHealth Exchange.
There’s also Healtheway, a nonprofit com-pany that manages the federal eHealth Ex-change. It launched a collaboration with the Care Connectivity Consortium, which was founded by Kaiser Permanente, Geisinger Health System, Group Health Cooperative,
[COVER STORY]HIE BARRIERS
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November 2013 10
Intermountain Healthcare and Mayo Clinic. Through this partnership, CCC plans to do R&D for the eHealth Exchange and give its members access to advanced services in areas such as patient matching, consent manage-ment and, eventually, population care.
Providers also have the option of using Di-rect Project, a set of standards and protocols intended to let them securely message one another. Its benefits include the ability to send encrypted email and attachments, and it’s rela-tively simple to implement. The downside is it’s a push rather than a pull technology, so an ER doc who needs quick access to a patient’s aller-gies as recorded in a doctor’s ambulatory EHR doesn’t have the ability to pull that data out.
What obstacles do all these HIEs and other data-sharing cooperatives face? HIEs have long faced two major barriers: competition among providers who use the HIEs, and finan-cial sustainability for the HIE.
Some providers have shied away from join-ing large HIEs because they fear that sharing their data may give the hospital down the street access to sensitive information on their patient panel. Letting your neighbor know that you have a big push to attract type 1 diabetics or CPOD patients, for instance, may reveal a marketing strategy that you rather
keep confidential. Or more simply, easier data sharing might make it easier for a patient to go outside a hospital system for a given big-ticket procedure.
Competition could become less of an ob-stacle as patients demand interoperability, and technology evolves to protect data control. “I just don’t know how big a problem competi-tiveness really is,” says Tripathi. “That would de-
pend on the architecture of the HIE.” The Mas-sachusetts statewide HIE, for instance, doesn’t have a repository of data that member organi-zations can tap into. The technology is set up to allow an ER doc to query a doctor’s office about a patient who has just shown up. “In that case, there would be no competitive issues,” he says. But an HIE that does include a shared repository of data may raise such issues.
But competition is only one of many con-
cerns. HIEs also must convince providers that they can meet the privacy, security and operat-ing standards providers have internally. Tripa-thi asks us to imagine a large health system that employs 300 IT staffers suddenly faced with the prospect of sharing its data with a state-run nonprofit HIE run by six people. CIOs will no doubt be asking, “How do I know you guys actually know what you’re doing?”
Financial sustainability also remains a huge problem, according to a recent analysis spon-sored by Robert Wood Johnson (RWJ) Foun-dation, Harvard School of Public Health and Mathematica Policy Research. About three out of four respondents say establishing a sustainable business model is the biggest barrier to HIE development; 66% cite lack of funding as the second biggest concern.
Many stakeholders don’t want to foot the huge bill required to set up the technical in-frastructure and policies because they aren’t sure what kind of return on investment they will see. The result is “a stalemate, with pro-viders who feel that they are being asked to shoulder the majority of the cost and payers and patients who are perceived as reaping the benefits from reduced redundancy and improved quality,” the RWJ report finds .
On a more positive note, the analysis found
[COVER STORY]HIE BARRIERS
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About three-fourths of healthcare
pros think establishing a
sustainable business model is
the biggest barrier to HIE
development, a recent study finds.
November 2013 11
that the number of functioning HIEs is grow-ing, as is their geographic reach. But once the financial support provided through the federal government’s HITECH Act runs out, there’s trouble ahead for many.
The RWJ report suggests part of the solu-tion: “It will be critical to ensure that Stage 3 MU substantially increases the requirements for HIE in order to bolster provider demand for and participation in exchange efforts. This, in turn, should make stakeholders more willing to pay for HIE.”
The Interoperable FutureOnce again, it seems the federal govern-
ment through its Meaningful Use program is calling most of the shots and will do the most to break down the barriers to interoperability in the healthcare industry.
Tripathi says the same pattern played out in other industries. In retail, for example, stan-dardization of certain sales data happened
when big players like Wal-Mart and Target used their buying power to tell consumer goods makers: Get it down now.
That’s the role the federal Centers For Medi-care & Medicaid Services is playing in health-care, since Medicare and Medicaid are the biggest payers for healthcare services. The Stage 1 and 2 regulations that CMS put in place are establishing the standards that providers and vendors will have adhere to, and over time that adherence will transform the healthcare industry just like big retailers transformed their industry.
Already, the EHR incentive program has had a profound effect on providers. In 2012, 53% of hospitals achieved Stage 1 Meaning-ful Use. By July 2013, two-thirds of hospitals had. There’s also early evidence to suggest that health systems are adopting Stage 2 certified technology, which should improve interoperability even further. About 68% of hospitals have bought software tools
that meet the 2014 certification criteria, ac-cording to a recent HIMSS Analytics report. MU Stage 3 will likely take us further down the road.
Some EHR vendors are starting to work to-gether as well. In March, five major EHR ven-dors — Allscripts, Athenahealth, Cerner, Gre-enway and McKesson — created an alliance, called CommonWell, with the goal of improv-ing interoperability. Market share leader Epic, however, hasn’t joined the alliance.
Interoperability still faces many obstacles, obstacles that the healthcare industry is chip-ping away at. How fast it progresses will de-pend in part on whether both patients and payers, led by the federal government, keep on the pressure to demand simpler and more effective data sharing.
Paul Cerrato is a healthcare writer and editor. Discuss his articles at informationweek.com/paulcerrato, or write to us at [email protected].
[COVER STORY]HIE BARRIERS
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