December 2016

New Metrics Spotlight Interoperability Progress
By Brian Levy, MD
For The Record
Vol. 28 No. 12 P. 28

Interoperability remains a high-level opportunity and challenge for the health care industry. A focal point of national initiatives for nearly a decade, this ongoing quest to improve health information exchange promises to transform care delivery from both a cost and quality standpoint.

The good news is that there has been significant progress made in recent years. Nonetheless, industry stakeholders acknowledge that a valid method for measuring the maturity and return on investment of its efforts has been lacking. It's not enough to simply rubber stamp the transfer of information from one system to another as "interoperability achieved." The industry needs to validate that the vast resources invested are, in fact, moving the needle on performance.

As such, the Office of the National Coordinator for Health Information Technology (ONC) recently identified two metrics to support specific indicators of "widespread interoperability." The metrics, which were developed in response to directives described by the Medicare Access and CHIP Reauthorization Act of 2015 (MACRA), read as follows:

• Measure 1: Proportion of health care providers who are electronically engaging in the following core domains of interoperable exchange of health information: sending, receiving, finding (querying), and integrating information received from outside sources.

• Measure 2: Proportion of health care providers who report using the information they electronically receive from outside providers and sources for clinical decision-making.

It's important to note that these metrics are separate and distinct from other specifications proposed by Health and Human Services' Quality Payment Program and will require no additional reporting. The data for assessing interoperability maturity come from existing national surveys of hospitals and office-based physicians, including the American Hospital Association's Information Technology Supplement Survey and the Center for Disease Control and Prevention's National Center for Health Statistics' annual National Electronic Health Record Survey of office-based physicians.

On the surface, the new measures appear straightforward, equitable, and aligned to industry goals. Still, achieving a framework to support this level of maturity is anything but simple. While the introduction of standards has enabled easier exchange of information, that critical step forward is just the tip of the iceberg. These measures are specifically designed to gauge the industry's progress with the next level of interoperability, characterized by information exchange that is easily integrated into receiving systems, understandable, and actionable for improving care delivery.

A Deeper Look
To adequately measure progress, health care stakeholders must understand how the industry defines interoperability maturity and success. Some insights can be garnered from the more than 100 comments provided to the ONC following a Request for Information initiated prior to developing the new measures. Specifically, the ONC reported that the following four topics were the focal point of much of the feedback:

• Burden. Do not create significant additional reporting burdens for clinicians and other health care providers.

• Scope. Broaden the scope of measurement to include individuals and providers ineligible for the Medicare and Medicaid EHR incentive programs.

• Outcomes. Identify measures that go beyond exchange of health information. Although measuring the flow of information is important, it is also critical to examine the usage and usefulness of the exchanged information as well as the impact of exchange on health outcomes.

• Complexity. Recognize the complexity of measuring interoperability. Multiple data sources and more discussions are needed to fully measure interoperability.

Specifically, the comments related to outcomes align with other nationally accepted definitions of interoperability. For example, the ONC's interoperability roadmap ("Connecting Health and Care for the Nation: A Shared Nationwide Interoperability Roadmap") calls for measurement and evaluation around the following three domains: the adoption of technology and policy enablers that increase the capability to exchange in an interoperable manner, information flow and usage of interoperable information, and the impact of exchange and interoperability on improved health and health care, and the cost of that care.

HIMSS defines three levels of maturity related to interoperability. "Foundational" speaks to the basic exchange of data minus the ability of receiving systems to interpret data. The second level, "structural," defines the syntax of data exchange or a format that enables uniform movement of health care data from one system to another. As the highest level, "semantic" interoperability enables systems to not only exchange information in a standardized, structured format but also understand and use it in a meaningful way.

Industry initiatives that have introduced specific technologies and standardized clinical vocabularies (eg, SNOMED CT, LOINC, RxNORM) are advancing the goals of foundational interoperability to enable basic data exchange. The new measures introduced under MACRA point to the highest level of maturity, semantic interoperability, where the data exchanged are trustworthy and reliable, are easily integrated across multiple sources, and positively impact outcomes.

Laying a Foundation for Semantic Interoperability
While the industry has made progress with both foundational and structural interoperability, the complexities of aligning the volumes of disparate data with industry standards are notable for all industry stakeholders, including providers, payers, and vendors. Yet data must be normalized around a single source of truth to achieve the goals of semantic interoperability and produce the meaningful information exchange needed to elevate care delivery.

For instance, analyzing a population health cohort for heart failure requires that all representations of the condition (eg, ICD-10-CM, SNOMED, free text) be normalized across a multitude of IT systems within an integrated delivery network. These representations must then be mapped to an appropriate industry standard for clean, accurate capture of data.

Health networks increasingly recognize this challenge. It's why a patient-centered medical home initiative (Vermont Blueprint for Health) and an accountable care organization in Vermont are looking to their statewide health information exchange organization for assistance in aggregating disparate clinical data.

Vermont Information Technology Leaders (VITL), operator of the Vermont Health Information Exchange, is working collaboratively with public and private organizations around the need to prioritize data capture and quality management by addressing data at their source, in the middle of the network, and at the end-point analytics solution. As data move through the system, the organization leverages a number of HIT solutions to measure quality and consistency, implement standards based on structural interoperability, facilitate semantic interoperability terminologies for accurate data capture, and ensure the integrity of its master patient index.

VITL is investigating the degree of data quality maturity, including examining whether Continuity of Care Documents are well-formed and the degree to which standard terminologies are implemented and actually used in these documents. VITL has undertaken a study to determine how data quality maturity, technical maturity, and community clinical activity affect expenditures, utilization, and preventive care in Vermont's health service areas.

The reality is that most health networks manage dozens of clinical, claims, and administrative systems—all with their own inherent clinical language and proprietary codes. Semantic interoperability requires that various terminologies be normalized to an agreeable standard accepted by systems communicating with each other. In light of these complexities, it's easy for many resource-strapped organizations to make the business case for leveraging the expertise of an industry partner and an advanced enterprise terminology management platform.

Advancement of health information exchange will remain a focal point of industry initiatives for the foreseeable future. The recently introduced interoperability metrics demonstrate this reality. As the industry moves closer to full maturity, providers, payers, and vendors must strategically address the next level of interoperability.

— Brian Levy, MD, is the vice president of global clinical operations for Wolters Kluwer, Health Language.