Health data is notoriously difficult to share. Due to its sensitive nature, it requires more privacy and security than any other data. However, the inability to access it on time can cause significant harm. In a world with high healthcare interoperability, doctors can aggregate patient data from various care facilities with a few mouse clicks and view it on their computer screen, including the complex medical imaging files. This will supply clinicians with a comprehensive overview of a patient’s medical history, allow them to access any recent test results, instead of having to repeat the same tests, and will eliminate redundant entries. In their pursuit of interoperability, medical facilities turn to healthcare software development vendors. But they are met with various challenges, including technicalities, such as which standard to choose, privacy concerns, and reluctance towards data sharing. So, how to improve interoperability in healthcare? And is it worth the investment?What is Interoperability in Healthcare, and How it Benefits Your Organization?According to the Healthcare Information and Management Systems Society (HIMSS), interoperability is the ability of distinct devices and applications to access, integrate, and exchange data in a coordinated manner within and across organizational and national boundaries. As the first step towards healthcare interoperability, medical facilities need to adopt electronic health records (EHR), as paper-based records can’t be safely and effectively shared and used by people across organizations. Already by 2017, 94% of US hospitals used EHR systems. Another survey conducted in 2019 showed that almost 90% of office-based physicians use EHR as well. Michael Restuccia, Senior Vice President and Chief Information Offices at Penn Medicine, emphasizes the importance of EHR in healthcare interoperability, “For us, the foundation that makes the required level of interoperability possible is our common, integrated electronic health record." Why is interoperability important in healthcare? Different medical software vendors develop their products in silos, which makes it challenging for medical systems to communicate. Interoperability aims to solve this problem and offer a holistic view of patients independently of the technology used. The US government supports interoperability in healthcare. In 2016, President Obama signed the 21st Century Cures Act that enforces EHR systems to offer a patient-facing API in order to obtain or maintain their federal certification. Later in 2020, the Department of Health and Human Services published the rules on interoperability and information blocking, including compliance deadlines. Healthcare interoperability plays a vital role outside the US as well. For example, the Australian Digital Health Agency teamed up with Deloitte to build a health data gateway, which is a nationwide effort to increase interoperability. This gateway is based on modern standards, such as Fast Healthcare Interoperability Resource (FHIR), and can interact with data exchange technologies used by the Australian healthcare sector.Levels of Healthcare InteroperabilityHere are four levels of interoperability arranged from the basic to the most advanced.Foundational level: when one information system or device can exchange data with another. The received information can only be interpreted by the user, and it is not machine-readable. One example of this interoperability level is sending a pdf file containing a patient’s history through the hospital portal. The responsible nurse will open the file and enter the data manually into their EHR system.Structural level: at this healthcare interoperability level, data is standardized, and the exchanging systems and devices can comprehend it at the field level. Standards, such as FHIR and Health Level 7 (HL7) provide structural interoperability.Semantic level: allows systems with different data structures to exchange information seamlessly. Let’s take medical imaging as an example. There are several Digital Imaging and Communications in Medicine (DICOM) and non-DICOM imaging formats. With semantic interoperability, systems can transfer and receive images in different formats, interpret them, and incorporate them into the receiving end.Organizational level: facilities with different requirements and goals can exchange medical data. This level is integrated within organizational workflows, and it relies on governance, policy, and technological advances to ensure consent and security.Example of Interoperability in HealthcareA large healthcare organization recently turned to ITRex to develop a healthcare interoperability solution. The organization acquired several dispersed clinics with heterogenous EMR/EHR systems that can’t communicate together. They wanted to be able to share information about patients and were interested in integration procedures. Our team proposed two options to solve this problem: Healthcare interoperability solution 1: establish a relationship between different EHR systems where data interpretation is built separately for every EHR system pair. One clinic is directly connected to another. Advantages:EHR systems are independent. One malfunctioning will affect only one pair of clinics and will not spread to the whole systemSome well-known EHR systems with widespread usage might already have a built-in communication protocol minimizing the amount of workDisadvantages:Takes time and effort to implement a protocol for every pair of EHR systemsCost-intensive as hiring developers for every EHR system is expensiveHealthcare interoperability solution 2: provide an intermediate layer and link all the EHR systems to it instead of connecting them to each other. We suggested REDOX, which offers an FHIR-based EHR integration API. It also supports HL7v2, CDA documents and even can handle custom EHR APIs. Advantages:REDOX is secure and compliant by defaultSome EHR systems, such as EPIC EHR, have built-in integration modules with REDOX. In the absence of such a module, they will need to build a custom integrationREDOX offers a consistent user interface, which does not change depending on the EHR systemDisadvantages:All EHR systems rely on REDOX, which presents a single point of failure. If anything changes there, it will affect the overall interoperabilityThe client opted for an intermediate interoperability layer with REDOX as a more suitable solution, and the project is currently in progress.Benefits of Interoperability in HealthcareImproving the quality of care: with healthcare data interoperability, patients can receive care from independent practitioners, hospitals, and other healthcare clinics, and every facility could access patient data from other parties. This allows medical practitioners to get the complete picture of patient history and make informed decisions. Additionally, it will enable aggregating real-time data from different care models, including telehealth.Maximizing efficiency: healthcare interoperability decreases the administrative burden, allowing physicians to cut down on repetitive tasks and focus on patient care instead. Also, when physicians have access to data residing in other clinics, they don’t need to waste time repeating the same test that the patient already performed elsewhere.Avoiding penalties: some programs enforce or incentivize healthcare organizations to improve their level of interoperability. For example, the Centers for Medicare and Medicaid Services (CMS) put forward its EHR incentive program, Meaningful Use. In the beginning, CMS offered financial incentives to medical centers that adopted EHR and met the program’s requirements. Since 2017, CMS has penalized physicians who don’t comply.Facilitating collaboration: doctors from different practices can work together to treat a patient. They can access each other’s findings safely.Enhancing patient experience: people could access their own medical history at any time and take an active and awareness-based approach to their health. Also, they will not need to fill in papers repeatedly at every medical facility.Reducing errors: medical errors cost around $40 billion per year and can have dire consequences on patients’ health. Healthcare data interoperability empowers physicians to view patient data from distinct locations and avoid manually re-entering fields that already exist in a patient’s medical history. This is especially useful considering a common belief that manual data entry has an error rate of 1%.Healthcare Interoperability StandardsInteroperability standards provide a common language and set of expectations to enable hospitals, practitioners, and patients to share data regardless of applications and devices they are using. There are over 40 different standard development organizations accredited by the American National Standard Institute. Some of these entities create standards, while others connect existing standards and describe how they can work together to support information exchange. Here are four of the more popular healthcare interoperability standards:HL7Health Level 7 (HL7 ) is a set of international healthcare standards that guide data sharing between distinct healthcare providers. HL7 was developed by Health Level 7 International, and it is used in over 50 countries. HL7 v2 was released in 1989. It is a messaging standard for exchanging clinical information among different systems. It can support a central patient care system and a distributed environment. It can be viewed as a database query language that providers can use to access health data. HL7 v3 includes some additional capabilities, for example, it supports government reporting. HL7 standards rely on ASCII text-based messages to communicate between different systems, such as EHR and laboratory information systems. HL7 v2 employs Consolidated Clinical Document format, which is similar to pdf files, making it hard to extract information.FHIRFast Healthcare Interoperability Resource (FHIR) was released in 2014 by HL7 as an alternative to HL7 v2. It relies on RESTful web services and open web technologies for communication, which can enhance interactions among legacy healthcare systems. Additionally, RESTful API provides a one-to-many interface, accelerating new data partners onboarding. FHIR’s interoperability merits are not limited to EHR and similar systems but extend to mobile devices and wearables.DICOMDigital Imaging and Communications in Medicine (DICOM) is a standard for communicating and managing medical images and related data. The National Electrical Manufacturer’s Association developed this standard. DICOM can integrate medical imaging devices produced by different manufacturers by providing a standardized image format. It allows healthcare practitioners to access and share DICOM-compliant images even if they are using different devices for image capturing. At ITRex, we had a large project involving the DICOM standard and medical imaging interoperability. A medical imaging solutions company teamed with ITRex to enable all associated clinics and authorized individual providers to view DICOM-compliant medical images from their own station through a web browser. Medical images, such as CT scans, are challenging to handle due to their large size. Therefore, physicians had to go to the internal server room every time they needed to access an image. The client wanted to build a system that would integrate different DICOM images and make them available through the web in doctor’s office. Our team built a cloud-based DICOM-compliant solution that enables clinicians to upload, access, and manipulate medical images. Doctors could, for example, increase an image’s resolution or accurately measure different aspects of the image. The solution includes one database for all participants and allows various clinics to share images. It also performs automatic backups and software updates.C-CADSeveral entities took part in developing Consolidated Clinical Document Architecture ( C-CDA), including the aforementioned HL7 and Integrating the Healthcare Environment (IHE) initiative. C-CDA allows creating clinical documents that are readable for humans and machines, as they contain Extensible Markup Language (XML) tags. This healthcare interoperability standard provides CDA templates for several structured document types and one unstructured type. It specifies the syntax and semantics of clinical documents. Practitioners can use C-CDA to compose and exchange diagnostic imaging reports, procedure notes, and continuity of care documents, among others.Healthcare Interoperability ChallengesHere are five of the main challenges of interoperability in healthcare:Legacy systems Legacy systems are still widespread in healthcare. There is evidence that 70% of Windows-based medical legacy devices are not even supported by Microsoft as of January 2020. Many legacy systems were designed in the era of minimal network connectivity. Consequently, they lack modern security features and are hard to maintain. They require modernization to meet current interoperability standards. As an intermediate solution, healthcare organizations can deploy a hybrid cloud to extract data from legacy systems and make it available to modern applications. Also, some healthcare interoperability standards are more adapted to legacy systems than others. For example, FHIR offers well-documented mappings for legacy standards.Reluctance towards data sharing Some players in the healthcare sector are not keen on sharing patient data in their possession. For example, hospitals tend to compete with urgent care clinics for patients, and when such a clinic sends a patient data request, hospitals aren’t motivated to oblige. A similar situation prevails when it comes to sharing health data for research purposes. A team of scientists from different Switzerland universities reported difficulties accessing relevant medical data for research purposes due to competition among institutes and some legal uncertainties. Healthcare facilities that want to achieve the organizational level of interoperability in healthcare will have to change their mindset and make data available to authorized parties, hoping that they will reciprocate. One can also expect new governmental policies supporting health data sharing. For example, Pew Charitable Trusts called on the Biden administration to address data exchange practices. Pew also suggested that “The federal government can help make data-sharing among healthcare providers and public health agencies more seamless through its rules related to electronic health records (EHRs).”Absence of a standardized way to patient identification Many medical facilities identify their patients using a name, birthdate, and social security number. But there is no unified format for this combination, not to mention that not all clinics are using this as an identifier. And if there is no acceptable agreed-upon way to refer to a patient, there is no interoperability. Many believe the universal patient identifier (UPI) offers a solution. UPI is a unique medical identification number, which is only valid in the context of healthcare data. So, if someone obtains a person’s UPI, they will not be able to access their financial information.Approval of patient information sharing requests Patient data safety and security are a priority for healthcare organizations. Hence, the process of request validation and approval needs to be regulated. Keep in mind that information ownership belongs to patients themselves. Make sure you have a solid consent management strategy in place and include situations where consent is obtained from someone responsible for the patient, such as parents giving consent on behalf of their children.Diversity of existing standards There is no unified healthcare interoperability standard that the healthcare community can rely upon. It is unfortunate that the same tool that is supposed to streamline the process is hindering it. Michael Gagnon, Executive Director of HealtHIE Nevada, observes that there can be discrepancies even within the same standard, “If I see two C-CDAs from two different vendors, they look very different. It creates complexity. As an HIE, we have to figure out every single vendor’s differences and try to make something useful out of the information we can collect from that.” Gagnon noted that interoperability of electronic health records is also compromised, which poses a problem, “The EHR vendors don’t really want to come together and form one way of doing anything. That places burden on them to develop everything in a single way. They’d have to all agree on a standard, and what happens when you try to do that in healthcare is that you end up with something that’s really watered down.”5 Tips for Improving Interoperability in HealthcareITRex co-founder and CEO, Vitali Likhadzed, has provided five tips for healthcare organizations looking to enhance data interoperability.1. Ensure anonymityPatient privacy is a priority for healthcare organizations. So, make sure no unauthorized third party can view patient information without complete anonymization. This applies to external vendors who help you develop and maintain applications, researchers who analyze data to study diseases, and anyone who isn’t directly involved in a particular patient’s care. When it comes to business applications, collect only the essential data for each business case.2. Establish a reliable patient consent processTo improve interoperability in healthcare, develop a transparent and straightforward consent protocol that will encourage user participation. Make sure you include policies that prohibit data access and transmission in ways that patients did not agree upon. This consent protocol is expected to span across your entire ecosystem. Some users might be hesitant to give consent because they aren’t sure how their data will be used within ten years, given medical technology advances. To encourage them, you can explain how their information can help develop innovative treatments and save lives. You can also partner with trusted organizations known for their patient advocating work.3. Manage IT integrationWhen building a data ecosystem, organizations need to focus on two aspects:A data layer that provides APIs enabling your partners to integrate their data repositories. Make sure it’s compliant with the most common healthcare interoperability standards, such as the ones mentioned above, as they address security and compliance issues for you.A data management strategy that will ensure consistency and privacy. As you arrange your data for interoperability purposes, you can also consider other applications of data in healthcare that you can tap into after investing in data organization.4. Use health information exchange (HIE) servicesHIE allows to electronically move clinical data among diverse health information systems while maintaining its meaning. You can connect to such a service if it is available for you. For example, New York has its own HIE tool, the Statewide Health Information Network for New York (SHIN-NY). All the city hospitals and many independent practitioners are connected. SHIN-NY continues to expand up to this day and improve patient care. Mitchell Adler, MD, Chief Medical Informatics Officer at Northwell Health Physician Partners expresses his satisfaction with the SHIN-NY, “HIE is a fundamental tool that I, as a provider, have directly observed positively impact patient care and outcomes. Real time access to patient information when I need it is vital to my clinical decision-making and presents clear value to the healthcare system.”5. Move your data to the cloud if you haven’t yetHealthcare organizations are turning to the cloud for their data storage. Studies show that 82% of small practices located in urban areas have already adopted cloud-based EHRs, with 81% reporting their satisfaction with the system. Adopting the cloud has many benefits for the healthcare sector. Improving interoperability in healthcare is one of them.Do you want to integrate disparate EHR systems or otherwise increase healthcare data interoperability? Get in touch with ITRex! Company has experience working with several interoperability standards and will craft a tailored solution for you.
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