Tuesday, October 21, 2014

What are Realistic Goals for EHR Interoperability?

Last week, the two major advisory committees of the Office of the National Coordinator for Health IT (ONC) met to hear recommendations from ONC on the critical need to advance electronic health record (EHR) interoperability going forward. The ONC Health IT Policy Committee and the ONC Health IT Standards Committee endorsed a draft roadmap for achieving interoperability over 10 years, with incremental accomplishments at three and six years. The materials from the event are worth perusing.

The ONC has been facing pressure for more action on interoperability. Although great progress has resulted from the HITECH Act in terms of achieving near-universal adoption of EHRs in hospitals (94%) [1] and among three-quarters of physicians [2], the use of health information exchange (HIE), which requires interoperability, is far lower. Recently, about 62% of hospitals report exchanging varying amounts of data with outside organizations [3], with only 38% of physicians exchanging data with outside organizations [4]. A recent update of the annual eHI survey shows there are still considerable technical and financial challenges to HIE organizations that raise questions about their sustainability [5]. The challenges with HIE lagging behind EHR adoption was among the reasons that led ONC to publish a ten-year vision for interoperability in the US healthcare system [6].

The ONC was also pressed into action by a report earlier this year from the JASON group, a group of scientists who advise the government [7]. This led to formation of a JASON Report Task Force (JTF) to respond to the report's recommendations, which would feed into the larger process of developing a ten-year road map for interoperability. The JASON report was critical of the current state of the industry, noting the lack of progress on interoperability as well as criticizing current vendor practices that make exchange of data with outside organizations more difficult. The report called for a unified software architecture and public application programming interfaces (APIs) that would quickly replace existing vendor systems.

The JTF presented its recommendations at the meeting. The task force pushed back some on the JASON Report, embracing the larger vision of the report but advocating a more incremental, market-driven approach to reaching their shared goals. In particular, the JTF put forth six recommendations for advancing the health IT ecosystem, which are (mostly quoting from the report, as follows):
  • Focus on interoperability - ONC and CMS should re-align the Meaningful Use program to shift focus to expanding interoperability, and initiating adoption of public APIs. Requirements for interoperability should be added to Meaningful Use Stage 3 as well as EHR certification.
  • Industry-based ecosystem - A market-based coordinated architecture should be defined to create an ecosystem to support API-based interoperability.
  • Data sharing networks in a coordinated architecture - The architecture should loosely couple market-based data sharing networks (agreements). There should not be through a highly prescribed, top-down, approach.
  • Public API as basic conduit of interoperability - The public API should enable data- and document-level access to clinical and financial systems according to current internet standards. It should be public and secure.
  • Priority API services - Core data services and profiles should define the minimal data and document types supported by public APIs. The initial focus should be on clinician-clinician and consumer use cases.
  • Government as market motivator - ONC should proactively monitor the progress of exchange and implement non-regulatory steps to catalyze the adoption of public APIs.
The two advisory committees then presented their draft roadmap, which will be finalized following public comment in March, 2015. The draft roadmap laid out five core building blocks as well as general goals for three, five, and ten years out. The building blocks fall into the categories of:
  • Core technical standards and functions
  • Certification to support adoption and optimization of health IT products and services
  • Privacy and security protections for health information
  • Supportive business, clinical, cultural, and regulatory environments
  • Rules of engagement and governance
The general goals for 2017 advocate a focus on clinicians and individuals being able to send, receive, find, use a basic set of essential health information. Later goals focus on using expanded sources and users of information, improved quality and reduced cost of care, and Increased automation, ultimately aiming to achieve the vision of the learning health system [8].

The meeting was summarized well (as always) by John Halamka, who also described his view of the emerging core technical standards and functions, which include:
  • RESTful architectures for efficient client-server interaction - the emerging industry standard uniform interface between client and server, which is used by most Web-based software platforms (e.g., Google, Facebook)
  • OAuth2 for Internet-based security - another emerging industry standard that allows distributed secure access across systems on the Internet
  • Standard API for query/retrieval of data using standard data markup languages including eXtensible Markup Language (XML) and Javascript Object Notation (JSON). The emerging standard for a health public API is HL7's Fast Health Interoperability Resources (FHIR). They provide a nice overview aimed at clinicians.
All of the speakers noted a need for these standards to handle both documents and discrete data. While the JASON report and the infamous PCAST report of a few years back called for all data elements to be discrete, the reality is that there will always be a need for documents and the narrative text within to explain the patient's story and provide other nuance that purely discrete data cannot describe.

What solutions would I recommend for technical standards as someone who is more focused on the capture, use, and analysis of data but less expert in the nuances of implementation? I take it from the experts that RESTful architectures with OAuth2 security and FHIR APIs with some specified data standards make the most sense. I will advocate for some basic standards for documents and discrete data that will facilitate use of data. For documents, this is Consolidated Clinical Document Architecture (CCDA) with standard metadata including document and section type names. For discrete data, I advocate the use of mature terminology standards for problems and diagnoses (ICD, SNOMED), tests (LOINC), and medications (RxNorm/RXTerms) as well as the National Library of Medicine Value Set Authority Center (VSAC) for quality and other measures. Combined with public APIs, use of these data standards could vastly simplify interoperability and not require the myriad of system-to-system interfaces that add cost and complexity.

I do recognize that the presence of standardized data alone does not guarantee its provenance. For example, many organizations (and people within them) take different approaches to managing problem lists. Likewise, the mere listing of a drug in a patient record is no guarantee it was actually prescribed, filled at the pharmacy, or taken by the patient. Nonetheless, starting to get data into standardized forms will greatly advance interoperability and, as a result, clinical care and secondary uses of the data.

Certainly there will continue to be challenges around interoperability, data standards, and related areas. But the ONC's plans are a good step in moving us toward the vision of a connected, learning healthcare system. I look forward to adding my comments to the public comment process and seeing an achievable and implementable vision for the future.


A number of other nice postings about this meeting, the JASON Task Force Report, and related topics from:

1. Charles, D, Gabriel, M, et al. (2014). Adoption of Electronic Health Record Systems among U.S. Non-federal Acute Care Hospitals: 2008-2013. Washington, DC, Department of Health and Human Services.
2. Hsiao, CJ and Hing, E (2014). Use and Characteristics of Electronic Health Record Systems Among Office-based Physician Practices: United States, 2001–2013. Hyattsville, MD, National Center for Health Statistics.
3. Swain, M, Charles, D, et al. (2014). Health Information Exchange among U.S. Non-federal Acute Care Hospitals: 2008-2013. Washington, DC, Department of Health and Human Services.
4. Furukawa, MF, King, J, et al. (2014). Despite substantial progress in EHR adoption, health information exchange and patient engagement remain low in office settings. Health Affairs. 33: 1672-1679.
5. Anonymous (2014). 2014 eHI Data Exchange Survey Key Findings. Washington, DC, eHealth Initiative.
6. Anonymous (2014). Connecting Health and Care for the Nation: A 10-Year Vision to Achieve an Interoperable Health IT Infrastructure. Washington, DC, Department of Health and Human Services.
7. Anonymous (2014). A Robust Health Data Infrastructure. McLean, VA, MITRE Corp.
8. Smith, M, Saunders, R, et al. (2012). Best Care at Lower Cost: The Path to Continuously Learning Health Care in America. Washington, DC, National Academies Press.


  1. Really appreciate your insights. great blogpost.

  2. Thanks Bill, It is to bad that we supporting XML which is heavy in comparison to JSON. JSON is also better to integrate with analytics and NoSQL DB. We need to start thinking mobile, less data not more. JSON is also more human readable.