When most think of Interoperability we think of physicians instantly having the necessary data to treat a patient regardless of where that data was initially documented. For a clinician to use the data it also must be trustworthy, accurate, up-to-date and readily accessible within the clinician’s own EHR, ideally in the specific section of the system where a particular type of data would be found. The data should be coded so that it is both human- and machine-readable, allowing for the flow of understandable data across diverse health information technology (HIT) systems.
In addition to this scenario, many other healthcare constituents likewise require accurate and easily accessible data, such as to ensure payment or prior authorization, or to assess population health. Healthcare consumers also need their data to manage their health and wellness and want to use the applications of their choice to aggregate and distribute their information.
Achieving true national interoperability requires not only broad adoption; it also requires that all constituents who require data for an appropriate purpose of use have access to information that is trustworthy and accurate and presented in a way that is usable and actionable.
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Today the healthcare industry is moving into a new era that supports the intelligent sharing of health data that is usable to clinicians, healthcare consumers and all other constituents who have legitimate authorization and need. As interoperability advances, user adoption will inevitably grow as clinicians and other constituents recognize that they can quickly and easily access the data they need for point-of-care decision making, for managing their care, or for other use cases.
So, “Are we there yet?”
Using our road trip analogy, let’s start with the highways, or the HIT infrastructure, and the rules of the road for getting from one point to another.
Moving toward a single overarching interoperability framework
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TEFCA
The Trusted Exchange Framework and Common Agreement (TEFCA) was created as part of the 2016 21st Century Cures Act.
TEFCA is designed to be the onramp for the healthcare interoperability highway. Through the work by the Office of the National Coordinator (ONC), Sequoia, the Recognized Coordinating Entity (RCE) of TEFCA, many industry expert volunteers, and the public, a set of regulations were developed. These regulations were designed to improve healthcare interoperability by establishing standards and infrastructure to ease data exchange among key stakeholders, including providers, consumers, payers, and their information technology partners.
The Common Agreement is a set of principles, terms and conditions to enable nationwide exchange of health information across RCE-tested and designated Qualified Health Information Networks (QHINs).
QHINs
QHINs are a centerpiece of TEFCA and designed to become the “on ramp” for all electronically accessible health information without requiring special effort on the part of the user. The intent of TEFCA is to serve as the internet for healthcare data by having all healthcare stakeholders connect to the QHIN of their choice and seamlessly share data. All QHINs will connect with each other, enabling information to flow from any end point on any QHIN to any destination endpoint connected to any other QHIN.
TEFCA enhances secure and appropriate access to health information through the QHINs. The following purposes of use are currently supported:
- treatment,
- individual access services,
- public health,
- government benefits determination,
- a subset of the HIPAA-defined payment activities (utilization review), and
- a subset of the HIPAA-defined health care operations (quality assessment and improvement, business planning and development).
Additional purposes of use may be added through the Framework Governance as TEFCA evolves. Of note, the Framework Governance is designed to include representation from the QHINs and their participants.
Pushing and pulling data
Under TEFCA, QHINs can perform both “push” and “pull” use cases. Push use cases are particularly useful for transitions of care. For example, when a provider refers a patient to another provider or transfers a patient to another facility, they can ensure that the appropriate patient information is “pushed” to the receiving provider.
An example of a pull use case would be a query of a patient’s data to ensure a provider has critical information when a patient visits the emergency department or has an upcoming scheduled appointment.
Data usability
In addition to our healthcare data superhighway and the rules of the road, we also need advances in data usability to drive broad adoption.
To improve data usability, Sequoia has convened a work group to focus on several key enhancements to ensure:
- Data is accurately coded with designated standardized codes and readable by humans as well as machines, which facilitates the flow of understandable data across diverse HIT systems.
- Data is trustworthy, which includes making sure the data is for the correct patient and is accurate, up to date and readily accessible within the clinician’s EHR – and ideally in the specific section of the system where similar data is stored.
- Data does not include duplicate information.
- There is clarity about the source of data elements, called “provenance”, as well as the source of any modifications of the data element (e.g., the original prescriber of a medication and the clinician who changed the dose and refilled the medication.)
- The data is tagged so that the recipient can search for specific types of clinical data, encounter types, narrative text, or document types, or search by roles of the individual who performed the documentation.
As an internist myself, I fully understand that clinicians lack both the time and cognitive bandwidth to parse through massive amounts of documentation to pinpoint the information they need. Indeed, that is why it is so critical that we enhance data usability and get it right.
For interoperability to be truly adopted and embraced, organizations must work with their EHR vendor to define optimal interoperability role-based workflows, whether they are sending, receiving, processing or reconciling data. Team members must then be thoroughly trained, screen-by-screen, on the workflows, as well as educated on how interoperability will enhance their efficiency and job performance.
To finally “get there” requires patience. The rollout and adoption of TEFCA will take time, but I believe we are buckled in and on the right road.
Photo credit: Flickr user Luis Marina
Holly Miller
Holly Miller, MD, MBA, FHIMSS is an internist and Chief Medical Officer for MedAllies, a company that operates multiple networks in support of interoperability. Dr. Miller provides operational, tactical, and strategic collaborative leadership for MedAllies and is also currently a Chair, Co-Chair, or member of several HIT interoperability-related committees and workgroups engaged in enhancing healthcare value.
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