From Exchange to Interoperability

When National Coordinator Karen DeSalvo said, at HIMSS15 in Chicago, that the nation needed "true interoperability, not just exchange,” I imagined the 45,000 or so attendees crying out in unison, “Just exchange?”

Measured only since George Bush made EMRs a priority in his 2004 State of the Union address, it has taken our country 11 difficult years to get to a point where 75-80 percent of U.S. hospitals are deploying electronic health records and exchanging a limited set of data points and documents. Especially for smaller hospitals, “just exchange” represents a herculean effort in terms of acquisition, deployment, training and implementation.

But adoption of EHRs, meaningful use of the technology, and peer-to-peer exchange of data were never defined as the endpoints of this revolution. They are the foundation on which the next chapter – interoperability — will grow.

I asked a former colleague of mine, Joyce Sensmeier, HIMSS Vice President, Informatics, how she distinguished exchange from interoperability.

“I think of exchange as getting data from one place to another, as sharing data. Ask a question, get an answer,” she said. “Interoperability implies a many-to-many relationship. It also includes the semantics – what do the data mean? It provides the perspective of context, and to me, it’s going towards integration.”

There are other definitions as well. One CIO I correspond with told me he relies on the IEEE definition, which is interesting because ONC uses it too: “the ability of two or more systems or components to exchange information and to use the information that has been exchanged.” And as I was writing this blog, John Halamka beat me to the punch on his blog with a post titled So what is interoperability anyway?

His answer: it’s got to be more than “the kind of summaries we’re exchanging today which are often lengthy, missing clinical narrative and hard to incorporate/reconcile with existing records.”

Sensmeier notes that interoperability, like exchange, is an evolutionary step on the path to a learning health system. I like that metaphor. As with biological evolution, healthcare IT adaptation is shaped by an ever-changing environment. We shouldn’t expect that every step creates a straight line of progress — some solutions will be better than others. The system as a whole learns, adopts the better practices, and moves forward.

(This, incidentally, is why Meaningful Use has proven unpopular among some providers. Although it  emerged from excellent thinking in both the public and private sector, its implementation has taken the command-and-control approach that rewarded — or punished —providers for following processes rather than creating positive change.)

Moving from exchange to interoperability, DeSalvo said at HIMSS15, will require “standardized standards,” greater clarity on data security and privacy, and incentives for “interoperability and the appropriate use of health information.”

I’ve seen two recent reports that suggest the effort will be worthwhile, even if the payoff is not immediate. A study from Niam Yaraghi of the Brookings Institute found that after more than a decade of work,  “we are on the verge of realizing returns on investments on health IT.” And analysts with Accenture report that healthcare systems saved $6 billion in avoided expense in 2014 thanks to the “increasing ubiquity of health it.” Accenture expects that number to increase to $10 billion this year and $18 billion in 2016.

Sensmeier says she expects that reaching “true operability” will occur faster than “just exchange” did.

“It won’t happen overnight,” she warns, “but it won’t take as long, either.” With evolving agreement on standards, the infrastructure of HIEs and new payment models, the path to interoperability should be smoother than the one that got us to where we are today.

What questions do you have?