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Interoperability: Steady as She Goes

By David Kibbe, MD

The terms “interoperability” and “interoperable health information exchange (HIE)” are used by different people to mean different things. But most of the time the notion is of moving data electronically across the barriers of separate organizations using IT systems from different vendors. It’s important to understand that interoperability is desirable because of the health care context, which has generally made it very difficult for the user of one brand of software, say Epic, to move a patient’s health record to a user of another brand of EHR, say Cerner or athenahealth. Until quite recently, health record exchanges between providers using different EHRs required mail or faxing of the records, a situation that seems both out of date and wasteful in today’s wired business world.

The situation is improving, along several different pathways. First, in some parts of the country, HIEs have established large central databases of patient information, contributed to by many hospitals and practices, which are then available to these providers regardless of their EHR vendors. Second, some EHR vendors have created exchange services that, while primarily serving the exchange needs of their own customer base, now include standards-based exchange technology that permits customers of some other EHRs to connect and exchange with their customers. And third, Direct exchange has grown very rapidly as secure, vendor-agnostic and standards-based technology for “pushing” health data of any kind from any point A to any point B, and which is now available to health care professionals in more than 60,000 health care organizations nationwide. Fast Healthcare Interoperability Resources, or FHIR, is another open standard like Direct that holds promise for “any system to any system” querying and retrieval of health data.

So, as an observer and implementer of interoperable HIE over the past several years, I’d have to say that significant progress is being made toward the goal of making it not just the norm but also the expected behavior that health information will follow patients across the health care systems—both organizations and IT—where they are seen and cared for.

But we still have a long way to go and much work to accomplish. We are not going to get rid of the fax machine or snail mail as routes for sharing health information until we address a number of stubborn business, cultural, and technical issues that stand in the way of advanced electronic interoperability. The primary reason health information sharing is advancing more slowly than many would hope involves a complex combination of inertia, cultural history, and privacy fears. Huge investments in faxing and e-faxing are built into our health systems, and movement away from something old that still works is slow. I’m convinced that many, if not most, provider organizations still feel that the data in their systems are proprietary information, and they do not always want to make it easy for their competitors to access detailed medical records for fear they might lose market share. And the release-of-information processes used by most hospitals remain a cumbersome, paper-based, form-filled labyrinth, a gauntlet of waiting and requesting, resistant to change in large part due to the inappropriate fears that patient access to information is in some way dangerous.

To put this into real-world perspective, my own recent experience is fairly typical. My physician had no trouble sending my clinical summary document from his EHR via Direct to the orthopedic department at Mayo Clinic where I was being referred. But when I needed to get my own operative report from the local hospital, I had to go in person to the hospital’s medical records department, sign a release form, and take the report as paper. Then I had to fax it to Mayo myself. In many hospitals, there is still no electronic connection between the medical records department, the hospital’s EHR system, or the outside world.

It is not easy to measure progress with interoperable HIE, let alone to determine whether the exchange is improving things. Metrics of exchange tell you that electronic standards and systems are in use, but not that the information was delivered in a useful manner or that the quality of care was impacted. I have elsewhere suggested that a first step in such measurement ought to be a decrease in the use of faxes, e-faxes, and mail transactions. We need a baseline of noninteroperable exchanges against which to measure progress in replacement of those with electronic sharing, similar to the standards of measure that were used during the transition from paper prescribing systems to e-prescribing. Then, we need to study the ways in which electronic data sharing relates to and improves actual care delivery and its quality. Are we decreasing delays in medication delivery and improving compliance? Are patients being attended to at the right intervals, and does data sharing help avoid mistakes or duplications in caregiving? Can doctors and nurses in the emergency department work with higher confidence that they know the clinical history of the patient, or can handoffs from hospitals to long term care and postacute facilities be made more efficiently and with less waiting time for patients and clinicians? I have no doubt that we will be seeing these kinds of measurements in the months and years to come.

— David Kibbe, MD, is president and CEO of DirectTrust.