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Are Health Data Interoperability Standards the Same in Theory as Practice?

Health data interoperability standards are actually open to interpretation, requiring the industry to invest in measurement and monitoring.

Health data interoperability standards

Source: Thinkstock

- The idea of developing and implementing shared health data interoperability standards has finally started to catch on the EHR vendor community, which has suffered a number of crushing blows from unhappy consumers and Congressmen concerned about the inability to share patient information seamlessly and reliably.

Consumers are on high alert for purposeful information blocking; enhanced electronic health record certification guidelines are on their way – eventually – with more stringent data sharing provisions; MACRA stresses the key role of data sharing in value-based care; and the 21st Century Cures Act now threatens vendors and providers with worrisome penalties if they are caught keeping their data squirreled away.

But acknowledging the benefits of interoperability standards and putting them into practice in a uniform way across a fragmented and highly competitive industry are two very different things. 

Just like the clinical presentation of a patient, even the most detailed and comprehensive interoperability standard documents can be interpreted in significantly different ways, leaving users confused about why their expensive certified products still don’t talk to each other.

“Experience has shown that just because technology includes ‘standardized’ capabilities, they are not necessarily used to their fullest extent nor are they always implemented in a ‘standardized’ manner,” conceded Steven Posnack, MS, MHS, Director of the ONC’s Office of Standards and Technology in a HealthITBuzz blog post.

READ MORE: Interoperability, Population Health Remain Top EHR Challenges

“When it comes to evaluating interoperability from a technical perspective, one ‘simple’ question to ask is: did the people who developed the health IT in use implement the same standards in the same way to solve the same problem?”

Unfortunately for healthcare providers, the answer is often “no.”

Historically, health IT developers have not had much guidance on how to effectively share data across disparate systems.  The first generation of commercially available EHRs were built simply to document care in a digital format – and perhaps to enable some basic analytics – not to support a value-based reimbursement ecosystem that didn’t yet exist.

Private industry collaborations like CommonWell, Carequality, and The Sequoia Project are relatively recent inventions.  And many, if not most, of the nation’s healthcare organizations are still using EHRs built and purchased before the major health IT vendors agreed that data sharing is not a luxury add-on to their product suites.

Even though the majority of the EHR industry is now working furiously to answer the demands of its unhappy customer base, vendors are still operating without industry-wide metrics that can help them understand whether or not their efforts are effective.

READ MORE: True Interoperability Requires Proof before Mandates, HL7 Says

“For many standards today publicly reported, quantifiable data regarding their implementation and use is often not readily available or regularly tracked,” said Posnack.

“Indeed, measuring for what purposes and to what extent interoperability standards are being implemented and used is of particular importance because it can identify industry trends as well as areas where standardization on its own appears not to be enough to prompt widespread use.”

The ONC’s proposed solution to this conundrum is a health data interoperability standards measurement framework that complements the 2015 Nationwide Interoperability Roadmap.

“The purpose of the Proposed Interoperability Standards Measurement Framework is to determine the nation’s progress in implementing interoperability standards in health IT and the use of the standards as a way to measure progress towards nationwide interoperability,” the document states.

“The potential industry benefits from pursuing this measurement framework would be three-fold: 1) to inform the evolution of the Interoperability Standards Advisory (ISA); 2) to inform updates to the ONC Health IT Certification Program; and 3) to inform stakeholder decision-making.”

READ MORE: Health Data Interoperability Requires Patience, Persistence

The ONC hopes to glean a better understanding of whether interoperability standards are being appropriately deployed in vendor products and how end users are leveraging these capabilities for meaningful data exchange.

Of particular interest is whether or not users are customizing their use of interoperability standards after implementing a product.  Significant changes to out-of-the-box capabilities due to heavy EHR optimization could defeat the purpose of having standards in the first place, the Framework warns.

The document identifies four key problems related to unintentional deviation from ideal interoperability standards, including the architecture of health IT infrastructure, development decisions that alter the level of measurement granularity and comprehensiveness, access to critical measurement data from within the product, and variability in standards implementation that may not be appropriately tracked or compensated for.

“The focus on use will allow the identification of instances where a deployed standard is not being used by end users,” the Framework explains. “This could result from a number of factors, including, but not limited to, insufficient education on how to use the functionality enabled by the standard, difficulty finding or using the functionality, or lack of other users with whom to exchange.”

“Tracking the use of standards will provide a window to where interoperability is and is not occurring and allow stakeholders to investigate the reasons behind the success or failure of using standards.”

Once the industry has developed a better understanding of how to measure the differences in standard implementation and use, organizations will be able to communicate more effectively about how to address data exchange barriers.

Stakeholders will need to commit to a cooperative and blame-free approach to this process if it is to succeed, the ONC says.

“ONC recognizes the critical role that health IT developers, health information exchange organizations, and health care organizations will need to play to develop an agreed upon set of measures to assess the implementation and use of standards.”

“Accurate measurement will require strong support and participation from multiple health IT stakeholders. Ultimately, a finalized measurement framework would enable aggregate, industry-wide statistics that could be used as a resource by all stakeholders to inform business decisions, enrich policy deliberations, and enhance the accuracy of the guidance provided by the Interoperability Standards Advisory (ISA).

To jumpstart the process, the ONC is soliciting public comment on the measurement framework.  Interested parties will be able to share their suggestions until July 31, 2017. 

The document includes a list of ten questions to which the ONC is seeking answers, including:

  • Does the proposed measurement framework include the correct set of objectives, goals, and measurement areas to inform progress on whether the technical requirements are in place to support interoperability?
  • Given that it will likely not be possible to apply the measurement framework to all available standards, what processes should be put in place to determine the standards that should be monitored?
  • Would health IT developers, exchange networks, or other organizations who are data holders be able to monitor the implementation and use of measures outlined in the report? If not, what challenges might they face in developing and reporting on these measures?
  • How should ONC work with data holders to collaborate on the measures and address such questions as: How will standards be selected for measurement? How will measures be specified so that there is a common definition used by all data holders for consistent reporting?

“Stakeholder support and strong participation across the ecosystem will be vital to this measurement framework’s success,” the document reiterates. “ONC will work with stakeholders who are data holders to promote the creation and use of the measures outlined in the framework as well as the public reporting of the results.”

“In three to five years, ONC seeks to coordinate with stakeholders to define uniform electronic measures of the implementation and use of standards that can be built into health IT developers’ products. This approach will provide more accurate information compared to self-reported survey data, and automating the process will ease the burden of capturing and reporting the data.”

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