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The Interoperability Evolution

Posted by Arien Malec - Vice President, Strategy and Product Marketing on April 8, 2016

Interoperability , HITECH Act , EHR , CommonWell , FHIR , person-centered interoperability

The current state of interoperability is not unlike Charles Dickens' A Tale of Two Cities: "It was the best of times, it was the worst of times." In the history of clinical medicine, we have more interoperability than ever before — more electronic data is flowing in more places for more purposes. Yet, there's also more frustration about the state of interoperability leading to more attention across our industry and our country than ever before.

Earlier this year, I had the great privilege of participating in a Bipartisan Policy Center meeting regarding the current state of interoperability. Attending were Andy Slavitt (Administrator of CMS), Karen DeSalvo (National Coordinator for Health Information Technology and the Acting Assistant Secretary of HHS), two sitting U.S. senators and a former U.S. senator. Also among us were a panel of senior leaders drawn from provider organizations, medical specialties, and health information technology. Interoperability is clearly capturing the attention of our nation's government at its highest levels.

The Interoperability Trajectory

So where are we now with the state of interoperability?

  • The HITECH Act had a huge impact on EHR adoption. According to the ONC Quick Stats Dashboard updated 2/29/16, physician practice EHR adoption has increased from 20% in 2004 to 82% in 20141 , and 97% hospitals now possess a certified EHR technology vs. 9% who had a basic EHR in 20082. 3
  • The use of electronic prescriptions, lab results and claims is nearing full penetration by providers and clinicians and we have increasing transfer of clinical context on transitions of care
  • Medications, problems, procedures, immunizations, and lab results are using a more consistent set of vocabularies.
  • We've resolved many administrative pain points and business operations challenges.

While we acknowledge these positive trends, we also recognize that we have yet to achieve universal person-centered interoperability that informs care, drives fully formed decision-making and continues improvement in health care.

What is Person-Centered Interoperability?

  • Person-centered interoperability means all health information is available electronically for every patient no matter the location, no matter the platform, and no matter the technology.
  • Clinicians need to be able to provide care based on a complete patient record relevant to patient status and condition.
  • Providers seek systemic improvements to quality of care as measured by both the health of a single patient and the overall health of its population.
  • Patients understandably desire access to their complete records via a range of apps and tools on devices of their choosing.

Across the healthcare spectrum, these unmet needs create unmet expectations. We have yet to achieve the level of data liquidity and saturation necessary to achieve complete improvements to quality care and clinical outcomes.

Why Aren't We There Yet?

  • Technology and Standards Limitations: Interoperability core standards and workflow were developed in the early 2000s and (in the case of HL7 V2, even earlier) and were based on technology that was pre-iPhone and pre-Internet. The channels routinely used to send data today, between apps and with social media like Twitter, didn't exist.
  • Missing Use Cases: Many of those standards were developed when we had less than 20% of providers in the country digitized with EHR adoption. Accordingly, many use cases simply weren't designed for person-centered interoperability. For example, HL7 V2 was primarily designed for inter-departmental use-cases, meaning the exchange between two departments of a hospital.
  • Untested Experience: In cases where use cases were designed for person-centered interoperability, we only now finding how the standards and EHR flows work, both for clinicians and operationally. For example, now that clinical documents are available to clinicians, we are learning what clinicians actually want out of interoperability. Likewise, we are learning that being able to open interfaces is very different from being able to do so cheaply, quickly, and reliably.
  • Ecosystem Effects: In some cases, the presence of large actors (e.g., dominant large health systems, or large technology vendors) encourages a "go it alone" approach, where those actors concentrate more on connecting within the system first. However, as persons, we receive care in ways that aren't bound within the system, and we are learning that local connectivity is insufficient to deliver true person-centered care.

What needs to happen?

Let's take an example from outside health care.

WI-FI: In industries where interoperability has evolved, there is either a single driving force in the market (the 800-lb. gorilla) or a consortia of companies that aggregate supply and demand to drive it. With the evolution of the wireless internet, for example, originally a consumer was forced to purchase a base device and a laptop card from the same vendor. Over time, companies came together, created the Wi-Fi Alliance®, agreed upon standards, conformance guidance, and testing labs, and the Wi-Fi Certified™ Program was born. Wi-Fi became a commodity and companies focused their efforts on distinguishing their technology via more value-added services, such as performance. Today, Wi-Fi is built into every aspect of the technology space, and the creators of apps just assume wireless technology as a base component.

What changes are needed?

Some trust the ONC is going to boost healthcare interoperability via a certification program. However, certification programs are floor-based, and by definition, they have to use standards and criteria already developed and in use in the industry, making it an unlikely driver of innovation and next-generation models.

Interested in hearing more? You can hear directly from Arien Malec on this topic in his most recent HIMSS webinar: Healthcare Interoperability: An Ecosystem Perspective.

To achieve true person-centered interoperability, we need to raise the ceiling, as well as raise the floor. Following the Wi-Fi Alliance model, innovation to drive person-centered interoperability likely only happens when key actors (health IT developers, provider organizations, etc.) band together to deliberately commoditize interoperability and build it into the the technology they develop. Additionally, we need a new generation of standards that are Internet-based, and work for the mobile app and cloud economy.

Encouraging Developments:

In our interoperability journey, we've witnessed numerous key milestones: The HITECH Act, The Direct Project and CommonWell Health Alliance® formation, HL7 FHIR®, The JASON Report, and the creation of the Argonauts. In concert, these industry achievements move us towards the system we envision: patient-centered interoperability informed by a unified view that patients are useful for improving health care quality and outcomes, as well as the drive toward initiatives like precision medicine and learning health systems.

  • CommonWell: The adoption of broad interoperability networks, like CommonWell, which is inclusive of a multitude of health information vendor organizations and serves to drive patient identity, patient linking and data exchange on a nationwide basis.
  • HL7 FHIR: With FHIR's launch in 2012, interoperability and interoperability standards were reconsidered in the context of our new technology era. Conceived as a more resource-oriented, modular approach, FHIR is responsive to the Internet world and is focused around implementers.
  • Modulation: Moving from Integrated to Modular Architectures: The Innovator's Solution by Christensen and Raynor centers on innovation framework from the standpoint of integrated architecture moving to modular architecture and underlines that in times of disruptive innovation, we tend to see a classic ecosystem. What consumers have and what consumers want increase every year because what consumers are used to changes over time. When you have a modular world, you tend to have developed higher-order systems, along with the innovation that comes with higher-order systems. EHRs are moving toward a more modular architecture.

The Wi-Fi example is a useful way to view interoperability in other industries because it underlines that we in healthcare are not alone. The way interoperability plays out in other industries is very predictable, and interoperability is an ecosystem model, such that even if it may be slow, we're still moving in the right direction.


Today, we have a world with higher EHR adoption; we have more nodes in the network and more total value. However, interoperability is not just a technology problem; it's a people, process, and workflow challenge. What more will be required?

  • Clinical Workflow: Orchestrating transition of care changes to reconcile the data in transitional care and incorporate that information into the EHR
  • Job descriptions: New descriptions to address workflow and to implement transitions of care
  • Time Frame: Changes need to be mapped out and implemented now to solve for business models to create value-based care and precision medicine

The good news is that by doing the hard work as an industry, we'll discover what changes to the clinical workflow are needed, where the standards need to be amended and what UI will be essential. I see a lot of hope and progress on the horizon as business models start to align to move interoperability. We all just need to roll up our sleeves and dig ditches, because only together can we get this done.


Arien Malec is vice president, Data Platform Solutions, RelayHealth. He has a more than 20-year career in healthcare and life sciences. In his current role, Arien addresses improved care and health as well as cost containment through the use of clinical data. Prior to this role, he was a staffer at the Office of the National Coordinator (ONC) as the coordinator for the standards and interoperability framework. Arien currently sits on the Health IT Standards Committee, a Federal Advisory Committee that advises the National Coordinator for Health IT.

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