Healthcare Interoperability 101

What is Healthcare Interoperability?

Interoperability in Healthcare is the ability for various healthcare information technology (HIT) to exchange, interpret and use data cohesively.

Interoperability is the ability of different information systems, devices and applications to access, exchange, integrate and use data in a coordinated manner, within and across organizational, regional and national boundaries, to provide timely and seamless portability of information and optimize the health of individuals and populations globally.

Without proper interoperability standards in place, quality of care for patients will be adversely affected. HIMSS goes on to define 4 stages of interoperability

1. Foundational interoperability provides with basic inter-connectivity requirements. This will allow one system to receive data from another and does not require the receiving system to interpret the data.
2. Structural interoperability defines the structure or format of the data exchange, i.e., it defines the format, syntax, and organization of data exchange.
3. Semantic interoperability enables two or more systems to exchange and use information. This brings in the concepts of codification of data, e.g., ICD-9, ICD-10, SNOMED, etc. Semantic interoperability provides shared understanding and meaning to the user
4. Organization interoperability is a “new” level that includes, governance, policy, social, legal and organizational considerations to facilitate the secure, seamless and timely communication and use of data both within and between organizations, entities and individuals.

How does Interoperability Improve Healthcare?

The primary objective of Interoperability is to improve quality of patient care. Exchange of information between various Healthcare Systems is critical in achieving this. This is where Interoperability comes into picture. [1]

Quality of Care

Patients receive care from various sources and having access to their medical history is essential to improving the level of interactions between Physicians and Patients. This improves Patient Safety as Physicians can make well-informed decisions based on the medical history of the patient, which is now accessible to them.

Financial Incentives

Meaningful Use (ARRA 2009) offered incentives to practices that adopted Electronic Health Records (EHR). This spurred the adoption of EHR/EMRs and as a result brought about a lot of attention to the need for interoperability between systems and its alignment with financial incentives.

Privacy & Security

With Interoperability comes improves security and privacy for patients. When Personal Health Information (PHI) is entered into secure, interoperable systems, organizations can gain a better idea of where their data is located and who has access to it, helping them secure patient data and protect privacy. Health Insurance Portability and Accountability Act (HIPAA) not only protects PHI from misuse, but also enables that PHI to be accessed, used, or disclosed interoperably, when and where it is needed for patient care.

Reduced Healthcare Costs

A paper released by the West Health Institute (WHI) before the House Energy and Commerce Subcommittee on Health estimates that medical device interoperability could be a source of more than $30 billion a year in savings and improve patient care and safety.

Standards in Interoperability

This section covers some of the means of achieving interoperability at a high-level. Each of these would be covered in detail in subsequent posts.

Standardization can be achieved at various levels:

Content Standardization

• HL7v2 is a widely implemented messaging standard that allows the exchange of clinical data between systems. It is designed to support a central patient care system as well as a more distributed environment where data resides in departmental systems. There are various versions of HL7v2 that have been released over the years. Till recently, access to the HL7 standards required a membership on their website. This has been opened up to all now to spur improved adoption. A sample HL7 message is shown below. As you can see, HL7’s Messaging Standard provides structured interoperability by placing each data item in a specific line (segment) as well as a defined location within that segment by dividing it using pipe characters (|). A receiving system should be able to understand this structure since it is a well defined standard. 

• CDA is an XML-based document markup standard that specifies the structure and semantics of clinical documents for the purpose of exchange between healthcare providers and patients. It defines a document as having six characteristics: 1) Persistence, 2) Stewardship, 3) Potential for authentication, 4) Context, 5) Wholeness and Human readability. An example CDA message is shown below.

• CCDA harmonizes previous efforts from HL7, Integrating the Healthcare Enterprise (IHE), and Health Information Technology Standards Panel (HITSP). It represents harmonization of the HL7 Health Story guides, HITSP C32, related components of IHE Patient Care Coordination (IHE PCC), and Continuity of Care (CCD).

Transport Standardization

• HL7 provides a number of standards that serve as the basis for many exchange standards currently used in health IT. HL7 standards serve as the underlying standards for FHIR and IHE. MLLP (Minimum Lower Layer Protocol) is an example of a simple transport protocol for HL7. The purpose of the MLLP Protocol is to provide both a minimalistic Open Systems Interconnection (OSI)-session layer framing protocol as well as a minimalistic reliable transport protocol. If security is an issue, additional protocols or technologies will have to be layered on top of MLLP to achieve these goals.
• DICOM (Digital Imaging and Communications in Medicine) is a standard for the communication and management of medical imaging information. DICOM enables the transfer of medical images across systems and facilitates the development and expansion of Picture Archiving and Communication Systems (PACS).

• IHE (Integrating the Healthcare Enterprise) provides a number of specifications that can be used in the exchange of health information. A full list of IHE Profiles can be found on the IHE Wiki page. XDS.b is one such IHE profile.

• DIRECT defines a set of standards and protocols to allow participants to send authenticated, encrypted health information directly to known, trusted recipients over the Internet. Two primary specifications are the Applicability Statement for Secure Health Transport v1.2 and the XDR and XDM for Direct Messaging.
• FHIR (Fast Healthcare Interoperable Resources) is an HL7 standard for exchanging healthcare information electronically using RESTful APIs. Think of this as the next-gen HL7 that has adopted an API based exchange of information. FHIR adoption is on the rise. With Cloud adoption on the rise in Healthcare, Azure and AWS now provide FHIR APIs making it much easier for Application Developers to provide interoperability services in their applications.

Terminology Standards

This provides the ability to represent concepts in an unambiguous manner between a sender and receiver of information. This improves the effectiveness of information exchanges. Some of the popular standards are LOINC, SNOMED CT, RxNorm, ICD-10, CPT, etc.

Popular Tools

With all the standards in place, we still need to ensure that the adoption and deployment of Healthcare IT systems can be fast with high quality interfaces. The data flowing between systems in a Healthcare environment typically flows via Integration Engines Corepoint Health captures the role of an Integration Engine aptly. Some of the key highlights are:

1. Migrate EHRs and incorporate new applications efficiently. IT teams need to easily be able to connect new EHRs or incorporating new applications into their infrastructure.
2. Deploy quickly with confidence. Deliver tested, ready-to-deploy interfaces in minutes or hours rather than days, weeks or months.
3. Maintain native high availability and disaster recovery. Ensure that data continues to be processed during downtime or unplanned emergencies.
4. Exchange data with web APIs and HL7 FHIR. Securely and efficiently exchange data using the most modern data exchange standards.
5. Easily monitor the status of every interface. Easily know the status of every interface in the enterprise.

Some popular Integration Engines include:

• Corepoint Integration Engine (Ranked #1 by KLAS)
• Rhapsody
• Mirth Connect (now NextGen Connect)
• Redox
• Cloverleaf
• PilotFish
• Ensemble            

We will get into more details about each aspect of Healthcare Interoperability in subsequent posts.

This article has been published on my personal blog as well - Healthcare Interoperability 101.