A Health Affairs report on health information interoperability by staffers of the Office of the National Coordinator for Health Information Technology (ONC) provides a good enough summary of the situation. But it also is not news, and falls under the Bob Dylan Rule: You don’t need a weatherman to know which way the wind blows. From the article: “In general, limited interoperability across vendors, low motivation to share information in a fee-for-service payment environment, and the high cost of interfaces remain substantial barriers to widespread health information sharing.”
Two difficult but solvable structural problems block our exchange of health care information. The first is the “transport protocol.” Most health care data transport approaches lack the strong privacy and security safeguards that other industries now consider essential. The same industry that is moving toward clinical applications of mobile health, genomics, and nanotechnology still primarily relies on cumbersome, expensive faxes to transmit clinical information between organizations.
The second is the “semantic standard,” which would provide an agreed-upon structure for content. Stage 2 Meaningful Use calls for adoption of The Consolidated Clinical Document Architecture (or CCDA). But health care organizations have settled on different, often incompatible versions of the CCDA, perpetuating the exchange conundrum.
Based in part on the idea that clinical information systems would become interoperable, meaningful use incentives pumped billions of dollars to doctors and hospitals. Much of that money transferred to the Electronic Health Record (EHR) vendors. Even so, vendors and providers have resisted coming to agreement on a workable semantic standard, perhaps because they can better maintain market share by holding customers hostage to proprietary health information technology platforms. Many providers also have been reluctant to share patient data beyond their own organizational affiliations, so they haven’t promoted transport interoperability either.
While these barriers are well understood, we have persisted with policies we know can’t work under the current structure. It has seemed important to do something, anything, except apply substantive solutions that might be detrimental in the short term to powerful special interests.
That said, the rest of us would benefit from the easy and secure exchange of health information. Clinicians would have access to more complete patient information, which would significantly enhance their decision-making about care and its coordination. Purchasers presumably would pay less — on the order of hundreds of billions of dollars annually — because better coordination would result in more effective care, with fewer inappropriate or duplicative services, as well as improved patient safety from fewer errors.
A “Direct” approach. There is a ready solution to the transport protocol problem. Spearheaded by David C. Kibbe MD, a pragmatic longtime champion of seamless clinical data exchange, DirectTrust has developed a consensually agreed-upon security and trust framework for cross-platform, cross-enterprise health information exchange through a set of open specifications known as Direct.
DirectTrust is an independent non-profit trade association created by and for participants in the Direct community, our common goal being to establish and maintain a national Security and Trust Framework in support of Direct exchange. We define the Trust Framework as a set of technical, legal, and business standards, expressed as policies and best practices recommendations, which members of the trust community agree to follow, uphold, and enforce.
Members of DirectTrust now include over 90 representatives from Health Internet Service Providers (HISPs), Health Information Exchanges (HIEs), Certificate Authorities (CAs), consultants, state agencies, and EHR vendors, as well as health care providers and provider organizations who are their purchasers and subscribers. We support both provider-to-provider Direct exchange as well as patient-to-provider Direct exchange.
To its credit, in March, ONC provided DirectTrust support through grant monies and an ONC Cooperative Agreement “to increase interoperability, decrease cost and complexity, and facilitate trust among participants using Direct for health information exchange of personal health information for health care improvements.”
Even a good platform must be coupled with incentives. But even a sensible transport platform like DirectTrust’s won’t get us to full interoperability. There must be the impetus for EHR vendors to standardize the semantic structure as well. Improvements in care and cost are obviously not enough. Providers must have a reason to demand that EHR vendors provide the necessary upgrades to be Direct exchange compliant, and to adhere to the same content structure.
A financial incentive is the simplest answer. In a stroke, CMS could change the dynamics that have impeded interoperability. It could structure Medicare and Medicaid reimbursement to pay providers more if they are compliant with Direct and their vendors are accredited by DirectTrust, and if they structure their content according to a standard.
This approach has been successful before. Using a modest incentive, this strategy dramatically accelerated e-Prescribing adoption between 2008 and 2010, at nominal cost to the government.
The technology is now readily available to facilitate interoperability. Now we need a financial incentive to bring it to fruition in the common interest.