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Disconnected: How stalled interoperability hurts patient care


Interoperability may be a noble goal, but health care providers are still a long way from reaching it.

Internist Edward Gold, MD, of Emerson, New Jersey, doesn’t believe that the efforts of the government to promote electronic health data exchange have been successful. “I don’t think we’re more interoperable than we were three or four years ago,” he says. He still can’t exchange secure messages with most other doctors, he notes, and a local health information exchange (HIE) initiative has come to naught so far.

In contrast, Edward Rippel, MD, an internist in Hamden, Connecticut, believes there has been some progress in interoperability over the past year or two. “There has been an increase in electronic communication of clinical information among community-based providers, whether they use disparate EHRs or the same EHR,” he says. “It has grown because of greater provider awareness of its existence and an increased push for the criteria associated with meaningful use.”  

Rippel, however, admits that his ability to exchange data with other doctors and his hospital remains very limited. He has not been able to receive any secure messages from physicians who use different EHRs, and the statewide HIE in Connecticut was terminated last year, after spending $4.3 million in federal funds. (A new law requires the state to try again, however.)

Related:The debate over healthcare interoperability

Looking at the national picture, Nathan McCarthy, MHA, a senior manager at ECG Management Consultants in St. Louis, Missouri, says that interoperability “has been more promise than action for most of the providers we’re working with.”

Some physicians are easily able to obtain summaries of care, known as continuity of care documents (CCDs) or consolidated clinical document architecture documents (CCDAs), from their colleagues, he notes. But for the most part, the doctors who have this connectivity either work for healthcare systems and are on the same EHR or belong to “a small subset of independent larger practices” in the area, he says.

A host of factors continue to impede interoperability, despite some well-publicized efforts by the government and the private sector. McCarthy says employed physicians have greater access to external data than do their private practice colleagues. But for the majority of physicians, interoperability still seems like a mirage, forever receding into the distance.

Next: Mixed picture


Mixed picture

The Office of the National Coordinator for Health IT (ONC), which has given more than $500 million to statewide HIEs, paints a rosy picture of interoperability in a recent report, citing data from an American Hospital Association survey. Among other things, the ONC data brief finds that in 2014, 69% of hospitals exchanged data electronically with other hospitals, and 62% of them exchanged information with ambulatory care providers outside their enterprises.

But other studies have gotten very different results. A 2014 study published in Health Affairs found that health information exchange was still quite low, despite the rapid increase in the percentages of providers who had adopted EHRs. Only 14% of physicians, for example, shared information with providers outside their organizations in 2014.

Related:Health information exchange: State anaylsis finds no 'one size fits all' solution

Similarly, a 2013 study showed that only 10% of physicians and 30% of hospitals used public HIEs to exchange data. The researchers recently did a second survey, asking the same questions. Julia Adler-Milstein, Ph.D., a coauthor and an assistant professor at the University of Michigan, told Medical Economics that those percentages haven’t changed in the past two years.

Why does hospital interoperability look so much better in the ONC report? One reason is that many hospitals use Direct secure messaging or private HIEs rather than statewide or regional HIEs that receive public funds.

In addition, the survey didn’t ask how many providers the hospitals had exchanged information with or whether they used different EHRs. To meet the meaningful use Stage 2 requirements, a hospital must transmit electronic care summaries in 10% of transitions of care, but it must send just one of those from its EHR to an EHR from a different vendor. Even if a hospital transmitted only enough CCDs to satisfy these criteria, it could have claimed it was interoperable in the survey data used by ONC.

Next: Direct messaging


Direct messaging

Direct messaging is ONC’s great hope for leveraging the HER incentive program to promote interoperability. Certified EHRs must include Direct capability, although Direct is not the only acceptable way for eligible providers to exchange information.

Two-thirds of “health information organizations” have deployed Direct messaging, according to a recent study by the Health Information Management and Systems Society (HIMSS). The fairly small sample in this survey included physician practices, hospitals, healthcare systems, accountable care organizations, HIEs, and health information service providers (HISPs).

Among the respondents using Direct, the top benefits included faster information access, reduced paper handling, and more accurate and complete patient information. Major challenges included high cost, changing workflows, and other providers not willing to communicate via Direct.

Related: How to get started with Direct messaging

The most common uses of Direct were exchanging care summaries at transitions of care, notification of admissions, discharges, and transfers (ADTs), patient communication, and secure email for communication only. Slightly below that were physician referrals and other kinds of peer-to-peer collaboration.

There is evidence that the use of Direct messaging is growing. The leading HISPs-which convey Direct messages among providers--are seeing a strong increase in the number of providers using their services, says David Kibbe, MD, CEO of DirectTrust, a trade association for HISPs.

The 34 HISPs belonging to DirectTrust also have begun sharing their directories of Direct addresses, he notes. This makes it easier for physicians who use different HISPs to locate one another on the Direct network.

Federal agencies are increasingly using Direct in their healthcare operations, Kibbe adds. For example, the Centers for Medicare and Medicaid Services (CMS) plans to use Direct in its Electronic Submission of Medical Documentation (ESMD) program. ESMD enables providers to send documentation electronically in response to requests from Medicare auditors.

Next: Direct challenges


Direct challenges

While some EHR vendors have embraced Direct, other developers “have not put in the features and functions that make their Direct capabilities usable by providers,” Kibbe says. For example, there may be no Direct inbox or no easy way to compose a Direct message in the EHR.

That is not a problem in Gold’s EHR, but he has trouble finding the Direct addresses of the specialists to whom he refers patients. In many cases, they don’t have Direct addresses, perhaps because they don’t want to pay the fees for HISP service, he says. Many other doctors use different HISPs than his, so he can’t locate their addresses. Despite what Kibbe says about HISPs sharing directories, the only one Gold can access is that of Surescripts, he says.

Surescripts says it’s in the process of sharing directory information with other HISPs. It plans to share its Direct addresses with every other HISP with which it has a trust relationship through DirectTrust, a spokeswoman says.

Related:EHR vendors are holding patient data 'hostage,' text expert says

Gold finds the whole process of exchanging care summaries via Direct messaging “clunky.” There should be an easier way than creating messages, searching for addresses, uploading and downloading CCDs, and reviewing their contents for the desired information, he says. He would like to have the data go into his EHR fields, instead of coming in as a PDF document.

Rippel’s EHR vendor, eClinicalWorks, provides “peer-to-peer” secure messaging for free, he says. If a colleague is on the eClinicalWorks network, whether or not he or she has the same EHR, Rippel can send the person a referral message, attaching a care summary and other documents. Then the other doctor can import the CCD or print and scan it, depending on the system.

Rippel has received secure messages from other physicians who use eClinicalWorks, but not from practices that have different EHRs. eClinicalWorks has told him that to get Direct messaging, which provides a higher level of interoperability, he’d have to pay the vendor an additional monthly fee.

An eClinicalWorks spokeswoman confirms that customers must pay an additional fee for Direct messaging. But she says that practices should be able to exchange messages with disparate EHRs through the vendor’s proprietary system.

Next: Health information exchanges


McCarthy has seen other problems with Direct messaging. “Providers want to obtain data across the care continuum, but they’re able to get only some of that data, or they’re getting it in a non-consumable format. It’s a CCD document that’s not discretely digestible by their EHR.”

He adds, however, that most of the challenges doctors encounter are related to the process, not to the technology. For example, if a physician has to go to a portal to get Direct messages, instead of receiving them in his or her EHR, the physician may become frustrated when visiting the portal and doesn’t find the information he or she is seeking. And with so many doctors not using Direct, a physician who does may not receive referral data electronically and may have to request that information be sent via fax.

Nevertheless, McCarthy stresses, “The physicians we work with see Direct as a much bigger value over fax. It saves their staff a lot of time and there’s a recordable record that it was sent over in a much more reliable fashion than a fax machine.”

Health information exchanges

As noted earlier, a small minority of physicians use statewide or regional health information exchanges (HIEs). While there are vigorous, successful HIEs in some states, such as New York, Indiana, Michigan, and California, these organizations are not widespread, and efforts to start more of them have met with significant challenges.

In northern New Jersey, for instance, Edward Gold’s practice has been waiting for the formation of an HIE that promised to provide interoperability with the local hospitals and an ACO in which Gold is the medical director. Unfortunately, he says, “The HIE hasn’t come to fruition, and I doubt they will. They talk a good game, but they haven’t produced.”

Summarizing her team’s national research on HIEs, Adler-Milstein says, “We’re not seeing a massive dying off [of HIEs]. But we’re not seeing a large number of new efforts or a big increase in the number of engaged providers. It doesn’t seem there’s rapid growth, and that HIEs have reached a tipping point and that they’re robust and widespread. The challenges remain the same, but the exchanges continue to exist, so they’re filling some need.”

Related:EHR best practices: Making the system work for your practice

The surviving HIEs are moving to support new care delivery models, including ACOs, Adler-Milstein says. Among those that responded to her team’s survey, 80% said they’re building capabilities for quality reporting and population health management.

Little data exists on the number and prevalence of privately-funded HIEs. But McCarthy has observed that private HIEs are continuing to grow faster than public HIEs, which are still somewhat dependent on the willingness of individual states to fund them. (ONC recently made some HIE grants available, but most of the federal money available for that purpose has already been spent.)

Next: Interoperability: Three levels


Larger healthcare organizations and ACOs have formed most of the private HIEs. In many cases, these are open only to providers who are affiliated with these enterprises. For example, McCarthy cites a group of providers in Montana who have formed an HIE specifically to connect the members of their ACO.

Overall, Adler-Milstein predicts ACOs will promote public HIE formation going forward. But she admits that that might depend on whether an ACO can motivate patients to seek care within the ACO’s network. “If you think you can, then the right solution is to get real connectivity with your ACO partners,” she says. “If you think you can’t, you need to know when your patients are being treated elsewhere, and some level of connectivity [with external providers] is needed for that.”

Interoperability: Three levels

According to the Healthcare Information and Management Systems Society (HIMSS), interoperability is defined as the extent to which systems and devices can exchange data, and interpret that shared data. For two systems to be interoperable, they must be able to exchange data and subsequently present that data such that it can be understood by a user.

HIMSS’ definition of interoperability includes three levels: foundational, structural and semantic.


Interoperability that allows data exchange from one information technology system to be received by another and does not require the ability for the receiving information technology system to interpret the data.


An intermediate level of interoperability that defines the structure or format of data exchange where there is uniform movement of healthcare data from one system to another such that the clinical or operational purpose and meaning of the data is preserved and unaltered.

Next: Barriers remain



Interoperability at the highest level, which is the ability of two or more systems or elements to exchange information and to use the information that has been exchanged. This level of interoperability supports the electronic exchange of patient summary information among caregivers and other authorized parties via potentially disparate electronic health record (EHR) systems and other systems to improve quality, safety, efficiency, and efficacy of healthcare delivery.

Source: HIMSS

Interoperability barriers remain

Several barriers continue to inhibit nationwide interoperability and must be overcome rapidly. These barriers include:

Electronic health information is not sufficiently structured or standardized and as a result is not fully computable when it is accessed or received. That is, a receiver’s system cannot entirely process, parse and/or present data for the user in meaningful and usable ways. It is also difficult for users to know the origin (provenance) of electronic health information received from external sources. Workflow difficulties also exist in automating the presentation of externally derived electronic health information in meaningful and appropriately non-disruptive ways.

Even when technology allows electronic health information to be shared across geographic, organizational and health IT developer boundaries, a lack of financial motives, misinterpretation of existing laws governing health information sharing and differences in relevant statutes, regulations and organizational policies often inhibit electronic health information sharing.

While existing electronic health information sharing arrangements and networks often enable interoperability across a select set of participants, there is no reliable and systematic method to establish and scale trust across disparate networks nationwide according to individual preferences.

Source: ONC

Next: Are vendors 'information blocking?'


Stalling Interoperability: Are vendors ‘Information Blocking?’

By Ken Terry

There has been a lot of discussion about “information blocking,” in Congress and elsewhere, since ONC released its report about it last spring. ONC said it had anecdotal evidence that some vendors were engaging in this practice, which included such tactics as charging high fees for interfaces with other EHRs and high data transmission fees. Soon after the report came out, Epic Systems, the largest ambulatory care vendor, said it would no longer charge fees for sending or receiving clinical messages.

The ONC report also cited evidence showing that some providers were erecting barriers to the free flow of information. In some cases, healthcare systems were said to be making it difficult to exchange data with other organizations in order to protect referrals of patients to their own hospitals.

A Senate committee recently held hearings about information blocking, and witnesses testified that the practice continues to be a problem. A provision in the 21st Century Cures Act, which recently passed in the House of Representatives, aims to make that more difficult. But University of Michigan School of Public Health assistant professor Julia Adler-Milstein, Ph.D., says that information blocking is likely to continue because “it’s legal, and it’s profitable.”

For example, she says, “EHR vendors can make a lot of money building complex interfaces. Even though their systems could enable exchange in a lower cost way, that option is not described to customers as something that’s available. They’re told that paying for an interface is their only choice.”

Large healthcare organizations may also engage in information blocking by telling their staff physicians that the best way for them to exchange information with the hospital is by switching to the same EHR that the hospital uses. Internist Edward Rippel, MD, has encountered that with his own hospital. While the facility offers to provide some connectivity to independent practices for a fee, it has strongly urged the private practice doctors to adopt its EHR.

Rippel, a solo practitioner, can’t see why he should, since he likes his current EHR. “Why would I switch to a system that’s cumbersome, not modifiable, and doesn’t reside on my premises, and I don’t control it? I have a lot of issues with that.”

On the other hand, he doesn’t think the government-mandated approach of meaningful use is the key to improving interoperability. “Something needs to be done about interoperability,” he says. “But it needs to be done in a way that’s a minimal interruption for practices and providers, because what’s happening now is getting us no place.”

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