Once seen as elusive, cumbersome and even impossible, electronic data exchange is finally coming into its own—and showing a lot of potential. Hospitals are still finding the road to interoperability a bumpy one, but they’re eager to venture down it as it begins to smooth out.
Value-based purchasing, coordinated care and population health have increased hospitals’ demand for interoperability. Moreover, the ability to exchange electronic data is improving.
But as the industry accepts the need and desirability of data exchange, they’re finding that the challenge is no longer simply the technology’s inability to share data but that some of the pitfalls have been unmasked by the increased interoperability, such as the difficulty of complying with different state privacy laws when doing so, says Micky Tripathi, president and CEO of the Massachusetts eHealth Collaborative.
21st Century Cures provisions take shape
Hospitals have increasingly embraced interoperability as part of their workflow. An Office of the National Coordinator for Health IT report to Congress, issued in November 2016, found that 82% of nonfederal acute care hospitals electronically exchanged clinical information with ambulatory care providers or hospitals outside their organization. That was up from 41% in 2008.
Much of this uptick in activity is due to the Meaningful Use program, created in 2009, which initially focused on rewarding providers for EHR adoption but in the current Stage 2 requires some data exchange and the use of Direct Messaging, a standard that allows for secure data exchange through the DirectTrust network. Stage 3 of the program and the corresponding Medicare Access and CHIP Reauthorization Act, which applies to physicians, require more robust data exchange.
One big roadblock, however, is that few vendors have finished updating their systems to support Stage 3 and the MACRA requirements, says Tripathi.
“The infrastructure isn’t in place,” he says.
Several organizations—including the American Hospital Association—have called for the Department of Health and Human Services (HHS) to delay or cancel Stage 3. Last year, the Centers for Medicare and Medicaid Services (CMS) issued a rule delaying Stage 3 and 2015 EHR certification until 2019.
Meanwhile, the 21st Century Cures Act, signed in December 2016, has been the legislative driver behind federal interoperability efforts. Despite some initial uncertainty about exactly how Cures would be implemented, officials with ONC and CMS have refined their approach recent months, launching several key initiatives to address data exchange. Earlier this year, ONC issued a draft version of the Trusted Exchange Framework and Common Agreement (TEFCA) designed to provide “a single on-ramp” to ease barriers to data sharing between healthcare organizations. The agency is expected to release rulemaking in April that includes its definition of data blocking.
This month, CMS also announced several new initiatives aimed at putting health data in the hands of patients, including Blue Button 2.0, which allows app developers to access Medicare claims data.
ONC officials have said meeting the requirements of 21st Century Cures continues to be the agency’s chief priority. But there are still some questions about how TEFCA, open APIs and data blocking enforcement will be executed long-term.
“We all expect Cures to be the game plan for the next two years, but we don’t know how [HHS] will operationalize the game plan,” said David Kibbe, M.D., president and CEO of DirectTrust.
At the same time, newer technology and standards not required by specific law, such as Fast Healthcare Interoperability Resources (FHIR), are also spurring interoperability by making it faster and easier and enabling patients and others to use apps to share information.
“This is a whole new dimension of interoperability and brings in new developers who in the past stood outside the doors of healthcare. We’ll see rapid growth in two to five years in FHIR,” says Tripathi.
Moreover, more private stakeholder efforts are underway. For example, the two national data exchange initiatives previously seen as competitors, Carequality and CommonWell Health Alliance are scheduled to connect their networks this summer.
Together the two entities represent more than 90% of the acute EHR market and nearly 60% of the ambulatory EHR market. “This is one of the biggest developments. Thousands of providers will be exchanging documents,” Tripathi says. “By the end of the year the siloes won’t be siloes anymore.”
That partnership could also allow the government to play a bigger interoperability support role, such as making provider addresses available online or offering record location services from claims data.
“Government played a huge role in kick-starting this. The government can back off now and let the market develop innovation,” says Tripathi.
To some extent this is already happening. While still heavily involved in certification of EHR products, ONC is been more collaborative when it comes to interoperability, supporting pilot programs and fostering innovation with competitions and prizes, says Steven Posnack, ONC's director of standards and technology. The agency held its first “interoperability in action” day in last year to showcase apps and other pilot programs that facilitate data sharing.
ONC also softened EHR certification criteria in September 2017, allowing vendors to self-declare certification and step back from random surveillance auditing.
“Some interoperability will be driven by statutory mission requirements, but there’s a desire for ONC and the industry to pull momentum together like [Carequality] and CommonWell,” says Posnack.
Barriers to interoperability persist
Data exchange may be getting better, but it’s not without hitches. It’s still exceedingly complex, with differing nomenclature, nonstandard functionalities that can render the data unreadable, and inadequate patient matching. The industry also needs additional standardization and consistency to improve workflow and usability, as well as more thorough testing, says Posnack.
The technology itself still needs refinement, as well. For example, some data received still need a human step to reconcile information into SSM’s EHR, especially with allergy and medication data, says Richard Vaughn, M.D., system vice president and chief medical information officer of SSM Health, a Catholic not-for-profit health system with 24 hospitals in Illinois, Missouri, Oklahoma and Wisconsin.
“So it’s less seamless than you’d like,” he says.
Some vendors and providers continue to be overly protective of their data and unwilling to share with each other or allow patients access to their own records, despite the fact that both the Meaningful Use program and the Cures Act have taken steps to penalize those who engage in information blocking.
“I’m hoping that national network connections will help that,” says Mike Seda, director of regional operations at The Tiger Institute for Health Innovation, a private-public partnership between the University of Missouri and Cerner Corporation.
And while not a barrier per se, data exchange also increases the risk that data could be exposed by hacking or other cyberthreats, so stakeholders need to remain vigilant on cybersecurity and protect patient information, says Posnack.
On Vaughn’s wish list? “I’d love to see some national [action], like a national patient identifier, so we don’t have to worry about patient matching,” he says. Consensus on what constitutes consent would also help; the definition currently varies because states have different consent laws, he adds.
Are HIEs still integral to interoperability?
Health information exchanges (HIEs), which enable a provider to query a database to obtain information about a patient, have met with varying levels of success. Beginning in 2010, ONC meted out 56 awards totaling millions of dollars to state and other public HIEs throughout the country to quickly build this data exchange capability.
However, these HIEs use different business and governance models and have run into some issues with privacy and security. Some of these public HIEs have struggled to sustain themselves, especially as the grants ended; a few have already closed shop.
“We are witnessing the maturation of a lot of HIEs. Many started with a particular set of business lines in mind that were desired at the time,” Posnack says. “As we’ve seen a move to value-based care it’s reshaping business opportunities for HIEs and seeing them adapt to new payment models.”
Some HIEs have been successful, though. For example, a recent study found that hospital emergency departments that accessed patient records through New York’s HIE improved quality and efficiency. But some public HIEs are also facing competition from private HIEs launched by insurers and/or health systems.
“Where there is an EHR developer or other collaborative network, we’re seeing the business case for the [public] HIE subside,” Posnack says.
Moreover, once the Carequality/CommonWell network is live, providers will be able to query other systems from their own EHRs and will no longer need an HIE to do so. The query function has been a core value for many HIEs.
“If an HIE can’t pivot to provide something value-added it may see its demise,” Tripathi says.