What are the four levels of interoperability in healthcare?
Before we answer why, let’s talk about what. The well-known and influential organization, Healthcare Information and Management Systems Society (HIMSS) has developed a definition of interoperability, which is accepted and understood by most healthcare stakeholders. They describe interoperability as “the ability of different information technology systems and software applications to communicate, exchange data, and use the information that has been exchanged.”
HIMSS asserts that data exchange schema and standards should allow for the sharing of data among healthcare community participants irrespective of which applications or vendors they use. Interoperability, according to HIMSS, enables HIT systems to transcend organizational boundaries and promote effective healthcare delivery.
The magic question … “is our healthcare system “interoperable”?” is not straightforward to answer. This is because interoperability, as a whole, is too complex. To make it a bit more digestible, HIMSS has broken it into 4 levels which we will briefly review before looking deeper at the layer of semantic interoperability and the barriers experienced in that layer.
1. Foundational interoperability
In this layer, interoperability lets the data transmitted by one HIT system be received by another. I call this, ‘opening the pipes’ for the data to flow through. This was the focus of Meaningful Use Stage 1, creating the ability to exchange data between systems.
2. Structural interoperability
The next layer, structural interoperability, defines the format of the data exchange that takes place between systems. Also known as syntactic or technical interoperability, this layer structures the data for exchange. One informaticist that I have worked with called this “putting the words into sentences”, thus adding context to the data (or “words” being exchanged.
3. Semantic interoperability
This level of interoperability adds a layer of understanding ensuring that the sending and receiving systems are using the same language in that sentence that is being shared. In healthcare that means that the structured message contains standardized, codified data. This capability aims to create a common vocabulary that enables accurate and reliable, machine-to-machine communication, thus ensuring reliable data and optimizing patient and organizational outcomes.
Scattered, isolated HIT systems that have evolved over the years and employ a range of medical terminologies and nonstandard ways of documenting important clinical detail has led to significant barriers in this layer of interoperability. It is essential then to “normalize” or codify the data being exchanged wherever possible while retaining important clinical details. To create actionable, usable data, it needs to be optimized through reliable technology and subject matter experts who are grounded in know-how and will drive transformation that is clean, clear, and precise. This cannot be left up to untrained IT systems or non-clinical personnel. A data normalization solution allows for apples-to-apples comparisons and aggregation of information from different systems by 1) standardizing local content to common terminology standards and 2) semantically translating data between standards (concept mapping) to eliminate any ambiguity of meaning.
4. Organizational Interoperability
This fourth level of interoperability is a relatively new add by the HIMSS organization and identifies the importance of bringing all the levels together. This level includes governance, standard operating procedures, policies, and social and legal considerations that are important to be able to ensure data governance and data privacy across an organization. This layer brings in some of the concepts that we are hearing about today with the trusted exchange framework as outlined in the 21st-Century Cures Act, and focuses on the trust factor in data exchange. Data governance is key to achieving organizational interoperability and the path to accelerating outcomes.
Why is interoperability important in healthcare?
I still remember the story of Hurricane Katrina and the many displaced families that made new homes in other states after that disaster in 2005. At that time few hospitals in that region were using electronic health record (EHR) systems, meaning that a lot of personal health histories including vaccination records, important diagnostic information, and medication data were completely lost with paper records being swept away by flood waters. Imagine trying to manage your diabetes with no record of the long road to finding the right level/type of insulin for you or enrolling your child in a new school with no access to their vaccination history. That was challenging even for those remaining in the same geographical area and nearly impossible for those that were displaced.
Compare that to Hurricane Harvey in 2017 when most Houston area hospitals were successfully utilizing an EHR System. That was good news for those who stayed in the area and could continue to access care at the health system that held their records. For those who were displaced and needed that information shared with a new health system, that was more difficult. In 2017, approximately 75% of providers stored data electronically but the ability to share important health data like immunization records, allergies, medications, and diagnostic imaging was not mature. Minimally, the information could be retrieved, printed or saved on a disc and shared through manual processes, a step in the right direction for sure.
Today, Interoperability is not a choice but a requirement for many reasons but these three top the list for me. Note that regulation while mentioned is not the reason for interoperability, merely a means to get there.
- Interoperability speeds patient care
It is imperative that when a provider is first seeing a patient whether it be in a medical emergency, a natural disaster, or simply because the patient is changing providers, they have access to the patient’s history, current conditions, treatments, and allergies. The data being presented at the point of care must be optimized and reliable. It must be semantically interoperable, fully auditable, and managed with robust data governance practices in place.
- Interoperability enables clinicians and patients to manage chronic conditions
According to the World Health Organization (WHO), 60% of all deaths worldwide can be attributed to chronic diseases. According to the Centers for Disease Control (CDC), 90% of the nation’s annual healthcare spending is for people living with chronic and mental health conditions. They go on to say that there are proven interventions that can be cost-effective and increase the quality and longevity of life for those suffering from chronic disease. Take diabetes as an example, a person with diabetes is often monitored by more than one specialist, their A1C is tracked regularly, and they must follow a healthy diet and exercise routine. Success in managing this chronic condition requires a team approach where all members of the care team, including the payer organization, have access to important medical and patient-generated information. For patient data to be actionable in population health analytics, it also must be reliable and optimized for clinical outcomes.
- Interoperability reduces physician burden
Have you ever had care delayed because of prior authorization or medical necessity requirements? I certainly have. The burden to providers of documentation and provider-to-payer communication has been well documented and is a top priority for the Department of Health and Human Services. In fact. recent legislation by both CMS and the ONC has advanced the notion of data sharing between payers and providers, specifically in the arena of prior authorization, historically an area of much frustration, and contributor to physician burden. The HL7 accelerator group, DaVinci has been hard at work on developing implementation guides based on the HL7 FHIR standard to promote data sharing between payers and providers for specific use cases with the explicit goal of reducing physician burden in the pre-authorization workflow.
Achieving interoperability in healthcare: Are we there yet?
Interoperability in healthcare has been a long road thus far, so, are we there yet? It’s a great question to ask. We have made great strides in all levels of interoperability since the days when Congress authorized the use of approximately $36 billion dollars in incentives to adopt Health Information Technology. That was in 2009 and payments to providers began in 2011. This has been a long road and to answer the question - no, we are not there yet. Meaningful Use, now Promoting Interoperability, and the 21st Century Cures Act, have led to new regulations regarding data sharing using the content standard of HL7 FHIR.
We are in a new era of interoperability where data quality is becoming the focus of conversation and industry collaboratives. Take the Sequoia Project and its Interoperability MATTERS initiative. You probably know that this group is the TEFCA recognized coordinating entity or RCE. As such they are leading the charge on establishing the network of Qualified Health Information Networks or QHINS focused on the establishment of a Trusted Exchange Framework and Common Agreement (TEFCA).
One of the workgroups the Sequoia Project is currently sponsoring is the Data Usability workgroup. This group is tasked with creating implementation guidance specifically targeted at improving semantic interoperability. They are tasked with improving the usability of the data being exchanged. If you are interested int his important topic, I encourage you to take read through their Implementation Guide. In it you will find reference to the importance of exchanging data using recognized standard terminologies and some of the challenges that have been identified in doing that very thing.
Health Language is passionate about interoperability in healthcare. We focus specifically around that semantic layer. Our solutions are designed to support providers, payers, and HIT vendors ensure that the data they are leveraging is “translated” into the same language, which we believe transforms data into information that can be used to accelerate both organizational and patient outcomes. We enable you to get the most out of your enterprise data with specialized training and tools in an end-to-end data management portfolio of products.
If your team needs support with clinical data governance and normalization, we’d love to help support you! Please reach out – we’d love to connect.
