The Health Information Technology for Economic and Clinical Health Act (HITECH Act) requires that the U.S. Department of Health and Human Services (HHS), in implementing the electronic medical records “meaningful use” incentive program, focus on the secure exchange of health information to improve individual and population health. Exchange requirements were fairly minimal, however, in the first stage of the program. Stage 2 began for early adopters this year, and concerns are being raised about the inability of program participants to meet exchange objectives, including:
- Exchanging information with other healthcare providers to support transitions in care.
- Sharing data with patients through portals and secure e-mail.
Lack of Interoperability Interferes with Sharing
Lack of “interoperability” is commonly perceived to be the main obstacle to sharing data. From a technical standpoint, interoperability is “the ability of two or more systems or components to exchange information and to use the information that has been exchanged.” (IEEE Standard Computer Dictionary, 1990) In the context of health IT, interoperability is more broadly understood to refer to the ability of disparate entities to access and share health information that can be easily utilized to inform decision-making by providers and patients and provide the foundation for improvements in individual and population health.
Pockets of interoperability exist today. The more robust interoperability needed to fully leverage the promise of health IT, however, has not yet been realized.
At the August Health IT Policy Committee, the HHS presented a summary of survey research on health information exchange activity between physicians and hospitals, as well as between providers and patients. Prior to Stage 2 of meaningful use, exchange among providers – particularly exchange with external providers – remained fairly limited, although it had increased since 2008. Early Stage 2 data shows there still is only a limited exchange of data to support transitions in care, and a significant number of patients continue to report gaps in information-sharing.
The HHS summary reinforced key themes that emerged from “listening sessions” conducted by the Health IT Policy Committee’s Information Exchange workgroup and reported to the Policy Committee at its April 2014 meeting. Those sessions revealed that providers participating in the meaningful use program were undergoing significant challenges in meeting both of the Stage 2 exchange goals—supporting transitions in care and implementing data sharing with patients through secure portals and e-mail.
New Focus on a Solution
In the past, solving obstacles to exchange was seen as having at least two major dimensions:
- Technical barriers (specifically, the inability of different electronic medical record (EMR) systems to be able to send, receive and “consume” relevant clinical information about a patient), and
- Lack of incentives to share information in fee-for-service payment models.
With payment reform—including Accountable Care Organizations (ACOs), medical homes, and bundled and value-based payments—gaining a greater foothold in the industry, the demand from providers to share data with one another is growing. In addition, HHS now seems more focused on finding answers to the remaining technical and policy obstacles to exchange.
The latest effort to overcome challenges to interoperability began in March 2013, when the Centers for Medicare and Medicaid Services (CMS) and the Office of the National Coordinator (ONC) sent out a request for feedback from the public on “Advancing Interoperability and Health Information Exchange.” Several months later, the agencies jointly issued a report summarizing the public’s comments and identifying a number of principles and strategies for accelerating HIE.
On June 5, 2014, ONC, under new leadership, issued a “10-Year Vision to Achieve an Interoperable Health IT Infrastructure” that includes a short list of overarching guiding principles, broad goals and representative “use cases” that illustrate those goals to be met within three, six and 10 years. The agenda for achieving the vision, which is intended to engage all aspects of the federal government, focuses on five “building blocks”:
- Core technical standards and functions
- Certification to support adoption and optimization of health IT products and services
- Privacy and security protections for health information
- Supportive business, clinical, cultural and regulatory environments
- Rules of engagement and governance
A National Interoperability Roadmap to Achieve the 10-Year Vision
At the August 2014 meeting of the Health IT Policy Committee, Erica Galvez, the Interoperability Portfolio Manager for ONC, presented ONC’s efforts to develop a national interoperability roadmap to achieve its 10-year vision. The roadmap is expected to address three key questions:
- What are the critical technologies and policies (including governance) required to achieve the vision?
- Who needs to do what and by when (including government, technology developers and technology users)?
- How will the roadmap be updated over time and at what frequency?
The roadmap is currently in development, informed by both an online community forum and the federal Health IT Policy and Standards Committees. The work is being augmented by research and analysis that both staff and consultants are actively performing.
The initial draft is expected to be released in October, in time for a joint meeting of the Health IT Policy and Standards Committees scheduled for October 15. The draft will be subject to comment from the Committees and their working groups, as well as from the public. The final roadmap is expected to be released in March 2015.
Efforts Informing the Roadmap’s Development
A number of developments could inform the roadmap’s development, including:
- In March 2014, the GAO issued a report criticizing HHS for its exchange strategy. The report urged the Department to develop specific actions to advance health information exchange and to set milestones with timeframes for the actions to gauge progress more accurately.
- In April 2014, the Agency for Healthcare Research and Quality released the JASON report prepared by Mitre Corporation, on “A Robust Health Data Infrastructure.” The report includes recommendations for developing a health information-sharing software infrastructure within the next 12 months, based on published application programming interfaces (APIs). Patients would control the sharing of their health data through expressed privacy preferences. The Health IT Policy and Standards Committees have established a joint workgroup to evaluate this report and provide feedback.
- In June 2014, an article published in JAMIA by the SMART (Substitutable Medical Applications and Reusable Technology) C-CDA Collaborative identified issues with interoperability for C-CDAs, the standard for document exchange to support transitions of care for Stage 2 of meaningful use. The article suggested practical opportunities to improve C-CDA exchange capabilities in the coming years.
- The U.S. Senate included language in the draft HHS appropriations bill directing the federal Health IT Policy Committee to submit a report on the technical, operational and financial barriers to electronic health records interoperability.
- The private sector also is launching efforts to advance interoperability, including Healtheway’s Carequality initiative and the eHealth Initiative’s 2020 Roadmap.
The onset of Stage 2 has placed long-standing obstacles to exchange in sharper relief, and the recent spate of activity presents a critical opportunity for HHS to use its policy levers to build a firmer foundation for advancing interoperability. The success of this intensive effort, however, will depend as well on the willingness of the industry and other stakeholders to participate—and to embrace and support the changes that may be necessary to achieve interoperability.