Interoperability – The unofficial guide for all providers

Interoperability is one of those buzz terms that physicians likely hear often but don't fully understand. What does interoperability mean in the context of electronic health records (EHR), and how can it potentially make a difference in patient care?

Joyce Sensmeier, MS, RN-BC, CPHIMS, FHIMSS, FAAN, vice president of informatics at the Healthcare Information and Management Systems Society (HIMSS) shares some insights into interoperability and what it means for today's physician practices.

Ques.: What exactly is interoperability?
Ans.: HIMSS defines interoperability as the "ability of different information technology systems and software applications to communicate, exchange data, and use the information that has been exchanged." In laymen's terms, interoperability means that a clinician (or patient) has access to health information whenever and wherever they need it. Interoperability also denotes that this information will be kept private and secure.

Interoperability doesn't occur automatically even as more practices and hospitals implement EHRs. For example, a patient is discharged after hospitalization to a practice at which he or she will receive follow-up care. The physician at the practice typically cannot access the patient's hospital information even though both settings use EHRs. That's because the technology is generally not interoperable.

The push for interoperability has grown out of a demand for greater continuity of care. Patients don't typically receive all of their care in one setting. It's about creating an ecosystem for each patient and his or her information.

Ques.: What are the different types/levels of interoperability?

Ans.: HIMSS provides the following levels of interoperability:

Foundational: Allows data exchange but doesn't require the ability for the receiving system to interpret the data
Structural: Ensures that data exchange between systems can be interpreted at the data field level
Semantic: Allows two or more systems or elements to exchange information and use the information that has been exchanged

Ques.: Is the goal to eventually achieve semantic interoperability?

Ans.: Yes. We need to structure the data in a standardized way so it has the same meaning regardless of the system in which it resides. There are several national recommended standards that all vendors can use during product development so when clinicians record vital signs, for example, this information can easily be compared across systems.

Ques.: What are the most up-to-date national standards?

Ans.: The ONC is recommending the standards and specifications necessary for interoperable EHRs. According to, these standards include the following:
Standardized healthcare vocabularies, such as SNOMED-CT and LOINC
Secure email protocols
National Institute of Standards and Technology (NIST)-adopted encryption standards
Open and accessible application programming interfaces (API)
These standards should be used to configure EHR technology going forward.

Ques.: So is the challenge that most vendors are not using these standards?

Ans.: Yes. Healthcare is extremely complex. When people complain that we haven't solved the problem of interoperability, it's because there are thousands of diagnoses and descriptions of those diagnoses that clinicians and others must be able to exchange and interpret correctly. When vendors are designing EMRs, decisions must be made about how to structure the data. Now that the ONC has published recommended standards, vendors can leverage these standards to help the industry move forward with interoperability. In addition, the ONC recently published its 2015 Interoperability Standards Advisory that serves as a "best practice" in terms of how to implement interoperable standards.

Ques.: But the standards aren't required, are they?

Ans.: That's correct. EHR vendors are not required to use these standards. A lot of the dialogue at the recent HIMSS national meeting was about interoperability. Are we moving in the right direction, and are vendors on board? Vendors shouldn't be blocking information exchange. Even though the vendor market is highly competitive, vendors need to keep in mind that healthcare doesn't occur in vacuum. Patients can go anywhere they want and receive care from multiple doctors. Accountable Care Organizations will also continue to require greater coordination and collaboration for the best patient outcomes. This should set the stage for vendor adoption of these standards going forward so they can be a part of the new payment and care models that are emerging.

Ques.: How does Meaningful Use relate to interoperability?

Ans.: Various MU standards as well as the EHR certification criteria pertain to interoperability. The proposed MU Stage 3 includes many more opportunities for interoperability. The proposed 2015 certification criteria also include many requirements that will advance interoperability efforts.

Ques.: What level of interoperability currently exists with most EHRs?

Ans.: Most are at the second level—structural interoperability. We had more than 100 vendors participate in the HIMSS Interoperability Showcase™ at our recent annual conference. Vendors are starting to see this as a way to differentiate themselves.

Ques.: Aside from the uniform adoption of interoperability standards, are there any other barriers?

Ans.: Yes. National standards will also help; however, standards are not enough. The next step is for providers to demand interoperability. Providers can include an interoperability requirement in their procurements and upgrades. Vendors will want to meet these demands. In addition to focusing on innovative features and functions, they'll invest in interoperability capabilities to take this to the next level. Patients can demand this as well. It's about our collective voice.

Ques.: Once achieved, how will true interoperability affect physicians directly?

Ans.: True interoperability will enable physicians to obtain a complete picture of the patient's health, including treatment, consults, images, etc. regardless of where that patient received care. Physicians won't need to rely on faxes or logging into multiple systems to obtain this information. It's about convenience, access, patient safety, and accuracy. Interoperability allows physicians to make more informed clinical decisions.

Ques.: How do patients benefit from true interoperability?

Ans.: It's better for patient care and outcomes because it allows physicians to make more informed decisions. It also allows patients to better manage their own health information and potentially make better choices.

Ques.: How do insurers benefit from true interoperability?

Ans.: It reduces the cost from duplication of tests because physicians will be able to see what has already been performed and why.

Ques.: Are there any concerns or challenges with interoperability?

Ans.: Yes, patient matching is a big challenge. We need to ensure that information flows correctly from one system to another. Establishing the correct patient identity and linking information appropriately is critical. Catherine Costa and Adam W. Culbertson, the newest Innovators-in-Residence at HHS are focusing on this very issue—that is, how to advance the implementation of consistent patient data matching in health care.

Ques.: What about patient control over this information? Can—or should—patients be able to control this?

Ans.: This is a good question for which there is no clear answer. Patients have a right to access their own information. But as systems become more interoperable, will providers be prepared to answer potential questions from patients? According to HIPAA, providers disclose only what's necessary for treatment and payment, but how can you monitor what other providers or patients will see?

Ques.: When do you anticipate complete interoperability will occur?

Ans.: 2020 seems to be a realistic goal in light of the ONC's recent draft interoperability roadmap. A final roadmap is expected to be published this summer. This document, along with the standards advisory, puts everyone on the same page for collective movement forward. The foundation is there—we just need to build on it.

Alok Prasad is the President of RevenueXL Inc. which is a leading provider of healthcare solutions, providing ONC-ATCB Certified Electronic Health Records Software to small and mid-sized practices. RevenueXL offers 30-day free EMR trial as well as free EMR in conjunction with its medical billing services.

The views, opinions and positions expressed within these guest posts are those of the author alone and do not represent those of Becker's Hospital Review/Becker's Healthcare. The accuracy, completeness and validity of any statements made within this article are not guaranteed. We accept no liability for any errors, omissions or representations. The copyright of this content belongs to the author and any liability with regards to infringement of intellectual property rights remains with them.

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