of any particular subsystem. Many early
clinical interoperability standards, like
Health Level Seven (HL7) messaging, were
created to facilitate this interoperability
between systems within an institution. 2 A
growing number of hospitals avoided this
decision altogether by outsourcing their
financial and clinical systems to companies
like SMS. 3
As clinical systems improved, and the
cost of technology began to decline relative to its performance, more and better
investments were made within hospitals for
their core clinical systems. The Centers for
Medicare & Medicaid Services (CMS) EHR
Incentive Programs have provided Federal
incentives (and in some cases penalties) for
meaningful use of certified EHRs. 4 Mergers and acquisitions have brought a whole
new set of challenges for system integration. But the real change has just started:
more and more the focus is shifting to challenges of interoperability between systems
in different organizations.
ONC’S INTEROPERABILITY ROADMAP
In January 2015 the Office of the National
Coordinator for Health Information Technology (ONC) released the first draft of
their Nationwide Interoperability Roadmap. 5
The vision described in the Roadmap is that
of the “Learning Health System” (LHS)
where, “…individuals, care providers,
communities and researchers should have
an array of interoperable health IT products and services that support continuous
learning and improved health.” 6 Central
to fulfilling this vision is interoperability,
which means that, “…all individuals, their
families and their health care providers
have appropriate access to electronic health
information that facilitates informed decision-making, supports coordinated health
management, allows individuals and caregivers to be active partners and participants
in their health and care and improves the
overall health of the nation’s population.” 7
The Roadmap then goes on to lay out the
principles, requirements, and strategies
for enabling and managing interoperability
within the LHS.
The LHS represents a paradigm shift in
the healthcare ecosystem within which we
all operate. Through shared governance,
the “rules of the road” for data sharing
and data access will be collaboratively
developed and agreed upon. Better, more
comprehensive standards will ensure that
standard terminologies are more perva-
sively used so that the meaning of data
will be maintained from system to system,
setting to setting. The LHS is data driven:
stakeholders (e.g., individuals, care provid-
ers, public health, payers, researchers) both
contribute and access data appropriate to
their role and their “need to know.” For
example, a patient with a rare cancer can
not only direct her health data to whichever
clinicians she chooses to work on her care
team, but may also use the LHS to identify
other patients like her with whom she can
share experiences and strategies. She can
make her health data available for research
– anonymously at first, but with the option
of being contacted without revealing her
identity should a relevant research break-
through take place. Public health agencies
receive required reports of cancer incidence
in the population and can query the LHS for
follow-up information on specific cases or
cohorts. Clinical Decision Support Systems
built on publically-accessible algorithms
and ontologies assist clinicians and payers
to understand the increasing complexity
of medical practice and consider new tech-
niques as they emerge.
This is quite a vision! ONC developed a
concept paper in the spring of 2014 to lay
the groundwork for the Roadmap. 8 Within
this document is a set of guiding principles
(in bold below) which can be used to guide
an approach to interoperability and standards:
1. Build upon the existing IT infrastructure. There is always a tension
between maintaining “the old” and moving to “the new,” with the understanding
that here has to be some balance between
the two. Clinging to existing technologies is
constraining when trying to enable newer
functionality, but embracing the new can
be expensive and disruptive. This is true
not only of technical solutions but of the
underlying standards as well.
2. One size does not fit all. Solutions
must be flexible since the health system
itself is diverse. Different stakeholders are
in different stages of deployment, so this
timing lag inherently leads to a diverse
landscape.
3. Empower individuals. Individuals
are just one component of the ecosystem,
but they are the primary target and subject of the healthcare enterprise (though
at times we may be more concerned with
groups of individuals). Empowerment is
based on having ongoing access to one’s
health information, and not only the portion their provider (or payer) chooses to
share with them. They must be able to
access that information when they want
or need it, and not when a provider deems
it appropriate.
4. Leverage the market. The demand
for data that evolves within the LHS should
be an active driver for change and development. This demand will happen unevenly
across stakeholders and clinical areas; it
is important to identify and build upon
opportunities as they unfold, and to influence stakeholders to consider data interoperability requirements of their initiatives.
5. Simplify. The LHS is complex: while
we need to build upon simpler solutions,
we need to be prepared for more complex
approaches to address the more complex
functionality that will need to be supported
as time goes on.
6. Maintain modularity. As more complex solutions develop they will need to
be modular enough to adjust to change.
This implies that existing infrastructure
that may be less modular will need to be
replaced over time for the long-term good
of the LHS. Service-oriented architectures (SOA) are key to implementing this
modularity successfully. Standard interfaces need to continue to develop and be
deployed with appropriate semantic standards to make them meaningful.
7. Consider the current environment
and support multiple levels of advancement. The LHS will be phased in over time,
and different stakeholders will deploy
participating systems according to different timetables. The desires of stakeholders
will vary in their interest in technology and
their access to electronic information, the
ability to deal with electronic systems, and
