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| Seonho Kim, VP of Information, Exchange, CIOX Health |
Q. IHE has been around for 17 years, has it been a long slog to get widespread adoption of
IHE profiles, or is it just a difficult task that takes a long time?
You are right, IHE (Integration the Healthcare Enterprise), was found about 20 years ago by HIMSS and RSNA (Radiology Society of North America) and since then the adoption of IHE was pretty slow. I consider it has been a long continuous effort to get widespread adoption of IHE profiles. I don’t believe it is because it is a difficult task that takes a long time. Instead, I believe it is because of various barriers to overcome. Additionally, it is not just with IHE only but same with other health IT standards too.
You know, the healthcare industry, it is not like other industries. For example, In finance more than 30 years ago they started talking about standards such as EDI (Electronic Data Interchange), and nowadays they freely exchange financial information electronically. But in healthcare the biggest challenge is in ensuring patient privacy and interoperable data exchange across communities. A lot of local community hospitals and clinics have been building their own integrated networks basically silos.
Q. What have been the barriers to exchanging patient information across these communities?
I would say, generally speaking, technical, financial and regulatory challenges. HIPAA regulation on patient privacy and security is one and the lack of interoperability is another one I would like to emphasize.
Q. Everyone has to comply with HIPAA regulations, is that making it more difficult to achieve interoperability?
Previously I would have said yes, but nowadays, since the Health Information Technology for Economic and Clinical Health (HITECH) Act as part of the American Recovery and Reinvestment Act (ARRA) of 2009, the CMS and the Office on the National Coordinator of HHS have been working very hard to break down the barriers for information exchanges especially the privacy and security concerns. With the HITECT Act, They strengthened the HIPAA rules and they provided economic incentives to address financial and economic barriers, at the same time, they came out with, especially with Meaningful Use stage 1,2, and 3, clear description of the requirements for interoperability including privacy, security, common vocabularies, interfaces and content type. If regulation was a barrier before, I don't see it as a barrier now any more. On the contrary, HIPAA actually supports and advances interoperability by giving providers permissions and confidence to securely share PHI (protected health information) with other healthcare stakeholders for patient care coordination, care quality enhancement, population health etc.
Q. What about competitive advantage? Has that been a barrier?
Yes. I have seen concerns on “competitive advantage” raised barriers to statewide or regional Health Information Exchange (HIEs) participation, collaboration and data exchange. Specifically, healthcare organizations do not want to share proprietary health information with other competing healthcare organizations mainly due to the fear of possible exploitation of shared health information for a competitive advantage. However, I also have been seeing more and more organizations start focusing on other factors to create a competitive advantage such as reducing cost structure, improving care quality, stronger care provider alignment to name a few.
Q. What about technological issues, what has been the most difficult technological issue?
I would say the lack of interoperability. The technology is there, the problem is interoperability and there are many aspects to consider. First of all, interface. Interface is the way you exchange (information) with a different system. It is also called “foundational and structural interoperability” or “syntactic interoperability.” You can use different services, you can use many different protocols to exchange data between different systems. In terms of interface, even though we can use pre-defined standards or profiles, how we actually implement it makes a difference. The implementation may be different. For example, some of the parameters (of a given profile) are optional, meaning sometimes even though it is not required, some systems may require the parameter and validate on their end. So interface can be a technical challenge because we have to verify what has been actually implemented in different systems. That is the first technical challenge. The second is semantic, what I mean by that is when we exchange any data between different systems, anything, or clinical document, the semantics around payload can be different, using different vocabulary or different terminologies. Sometimes different organizations use different terminology or create their own terminology.
Q. What do you mean by payload?
I mean meaningful data content that is exchanged over communication protocols. For example, providers sends claim messages to payors using a TCP/IP protocol or some other communication protocol. The claim message, which is normally in ASC X12 837 format, is payload. Other examples include payment, clinical documents, lab results, and DICOM images to name a few.
Q. So the difference in the way the content is organized?
Yes the difference in the way the content is organized and content is constructed with the different terminologies and different vocabularies.
Q. Does IHE address that in trying to establish a common set of terms?
Exactly. So IHE and HL7 and Federal Government worked together to address semantic interoperability challenge and created a standard for a clinical document, it is called CDA(Clinical Document Architecture), and now Meaningful Use 2 and 3 requires all EHR technology to be able to produce and share consolidated CDA documents or C-CDA documents.
Q. What are the administrative issues around maintaining, ensuring, documenting privacy that pose challenges to interoperability?
I think the biggest challenge is establishing appropriate administrative, technical, even physical safeguards around authorization. Because before any medical record can be shared or transferred to another system there needs to be proper authorization. That is one of the big difficulties of administration.
Q. What are the risks then of exchanging that information and managing that risk?
I would say ensuring appropriate administrative, physical and technical safeguards. Without proper safeguards in place, we will always face risks of exchanging health information.
Managing that risk is not easy. That is why organizations sometimes hire consultants or use vendors. Most providers have an HIM (Health Information Management) department for managing the sharing of health information within or outside the organization. Generally speaking, HIM is responsible for ensuring the protection of the health information but also the availability and accuracy of it. Unlike larger healthcare organizations, smaller and medium sized organizations cannot afford that level of management internally, so they must be very careful in choosing software solutions or choosing their vendors.
Q. What are some of the solutions available to small and medium-sized providers for managing the exchange of information risks?
Choosing and using a right EHR technology solution is really important. I would say any EHR technology solutions certified through the ONC Health IT Certification Program would work. As far as I know, the majority of small and medium-size providers use a cloud based EHR solution and EHR solutions are equipped with functionalities ensuring proper release or exchange of information. However, (these may) not fully address the risks we just talked about. There are companies that manage release of information or ROI. What we (CIOX Health) do as a company is enabling authorized collection, process, and secure release of medical records. Any time we start the process we need to make sure there is proper authorization from patients, attorneys, or payers – commercial or government payers. There are other HIM or ROI vendors, and all of them focus on how to securely and efficiently manage the authorized release of all medical information.
Q. Are more and more smaller and mid-sized providers turning to companies like yours?
I would say yes but at the same time small and mid-sized organizations are able to purchase EHR solutions or other solutions that have the functionality and capability of doing this and managing that kind of information exchange. They definitely need to be sure that the EHR or health information system, when they purchase it, is compliant with government regulations, especially whether the solution is compliant with Meaningful Use 2 and 3 and HIPAA regulations. By asking the right questions of any vendors they can minimize the risk.
Q. What are the right questions?
The first question would be whether the EHR solution is Meaningful Use certified, how is the solution compliant with HIPAA regulations and thirdly whether the solution supports interoperability or interoperable information exchange.
Q. Where is the US in terms of what percentage of providers have achieved interoperability?
I would say we are at about 40 percent at this moment I mean considering providers have achieved a certain level interoperability. In terms of EHR adoptions, I believe it is around 50 to 60 percent. But using EHRs to communicate or exchange information with other providers is not that high – about 20 to 30 percent I would say. That is why I said we are about 40 percent.
There are a couple things we can take a look at in terms of adoption of IHE interoperability profiles. In terms of IHE profiles or IHE standards, there are four federal agencies, and various non-profit healthcare organizations or EHR vendors and alliances that have adopted IHE profiles. The initiative is called eHealth Exchange. Four different federal government agencies are participating in that, VA, DOD, SSA and CMS. At the same time 50 different state-wide HIE and individual hospitals like Mayo, and as far as I know those cover about 40 percent of US hospitals, and about 14,000 medical groups and 3,000 dialysis centers and around 8,000 pharmacies, covering more than 100 million patients.
At the same time there are other initiatives, one is called CommonWell Health Alliance that has also adopted IHE profiles or standards to develop use cases for the exchange of data between different systems. They include vendors like CERNER, McKesson, Allscripts, Athena Health to name a few. And these EHR vendors are participating and actually exchanging data, so I would say around 30 or 40 percent adoption of IHE profiles.
Q. Are we lagging behind other countries?
Canada, Korea, Netherlands, France, Germany, compared to other countries, the US system is much more complicated. There is no single payer (in the US) and at the same time the hospital systems (in other countries) there is more like a big push from their governments and they are achieving interoperability much sooner easily, but I think the US is getting there because the federal government has been investing in it. The biggest thing the federal government can do is provide more incentives, at the same time providing clear and easy-to-adopt guidelines for interoperability technology. Giving out incentives for providers or organizations or vendors to adopt interoperability standards has actually increased the adoption rate and at the same time broken down some of the barriers.
Q. What is the overarching benefit for achieving interoperability for patients and for provider organizations?
As a patient, I want to see my medical records, right? At the same time, I don't want to pay for the same things over and over again and don’t want to carry around my medical records in paper or CD. Let me share my personal experience, my son broke his arm a couple of times. Every time we visit a different office, even if we brought our x-rays, sometimes they would say they need to take their own x-rays. And I had to fill forms and answer questions regarding medical history over and over again. If we were able to talk to the orthopedic doctors and have them send the medical images and medical information we wouldn't have to pay for another set of x-rays or fill the forms. For patients it would save money, and at the same time, it reduces the harm of exposure to unnecessary x-rays. When we move around the country and have different doctors, our medical records do not follow us, and the new primary care physician does not have the complete picture of the medical history. So I would say continuity of care is one of key benefits for patients.
For providers, first and foremost, I would say improved patient safety. Interoperable health information exchange helps providers to have the complete picture on a patient medical history. With that, providers can reduce the possible medication or medical errors.
Also having the ability for interoperable exchange can save money. Every time there is a request for medical records there are a lot manual processes. The record must be printed out and put in an envelope or saved as a PDF and put on the fax system. Instead if it is done electronically, they can push that information to the requestor and at the same time move that information to another system, that would reduce a lot of the administrative cost by eliminating unnecessary paperwork and handling. At the same time when you exchange the data electronically the risk of security breach is reduced. We can add layers of security so that every time there is a new request, we can make sure only authorized persons or systems can access the information, and thereby prevent unauthorized access. If there is a breach we are automatically notified of the intrusion so action can be taken as soon as possible.
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