Six years ago, when “cloud” based computing appeared on the healthcare information technology horizon, I started dialing up some health IT experts to research the subject.
Because I didn't know, I asked them what they meant by “the cloud.”
I heard a universe of responses. For most, clouds were in the eyes of the beholder.
Fortunately, I ran into Peter Mell and Tim Grance, a couple of scientists with the National Institute of Standards and Technology, who had come up with a semiofficial definition (PDF).
It turns out, there were precious few, if any, true cloud implementations back then, when measured against their five-point description, but it didn't much matter.
Today, however, there's a similar need for a common definition of interoperability, and there's a lot more at stake, with Congress poised to big-foot into the operations of the federal health IT program, which has been run fairly successfully since 2004 by HHS without much congressional interference.
Fortunately, it looks as though we may have the basis of a definition of “open records,” aka interoperability, from two noted medical informaticians, Dean Sittig, professor of biomedical informatics at the University of Texas Health Science Center in Houston; and Adam Wright, a senior scientist in the general medicine division at Brigham and Women's Hospital, a senior medical informatician at Partners HealthCare, and an assistant professor of Medicine at Harvard Medical School, Boston.
Their work, “What makes an EHR 'open' or interoperable?” was published Monday in the Journal of the American Medical Informatics Association.
Here are Sittig's and Wrights' five basic tenets of an open record:
- An organization can securely extract patient records while maintaining granularity of structured data.
- An authorized user can transmit all or a portion of a patient record to another clinician who uses a different EHR or to a personal health record of the patient's choosing without losing the existing structured data.
- An organization in a distributed/decentralized health information exchange can accept programmatic requests for copies of a patient record from an external EHR and return records in a standard format.
- An organization can move all its patient records to a new EHR.
- An organization can embed encapsulated functionality within their EHR using an application programming interface (API). Goals: access specific data items, manipulate them, and then store a new value.
Last summer, discussions about the Defense Department's massive IT acquisition for the Military Health System were running high and the military's specification for an “open architecture” EHR were being discussed. That's when, Sittig said, HIStalk, a popular health IT blog, issued a challenge for someone to come up with a definition of an open record system. Sittig said he and Wright decided to take it on.
Interoperability, Sittig said, means different things to researchers like themselves than it does to patients or administrative workers in billing, but they're all potential users and beneficiaries of open records systems.
“You can put yourself in these different positions and see what it means to be open,” he said. “We realized no one was actually saying all these things, so we tried to say it.”
Wright said conversations about interoperability and open records tend to move in two directions. “One is a top-level sense that, 'Oh, we need interoperable EHRs'” without fully understanding what that means. The other is a discussion “so deep in the weeds” it's unintelligible to anyone without a tech background.
Congress is considering weighing in on the issue of interoperability and a related issue, so-called “data blocking,” the willful thwarting of interoperability for competitive advantage. Several members of Congress have reported hearing complaints from their constituents that there's a decided lack of interoperability out there in healthcare IT—despite the federal Treasury shelling out more than $30 billion on the electronic health-record incentive payment program.
At a hearing last fall, U.S. Rep. Phil Gingrey (R-Ga.), a physician, pointed to a RAND Corp. study alleging that EHRs from market-leader Epic Systems Corp., Verona, Wis., were “closed records,” and said Congress should take a closer look at the program, “given the possibility that fraud may be perpetrated on the American taxpayer” due to the reported lack of interoperability of some EHR systems.
During a hearing last week, witness Dr. Thomas Payne, medical director of IT services at University of Washington Medicine, told members of the Senate Health, Education, Labor and Pensions Committee that Congress should nudge federal program administrators to, among other things, beef up federal EHR certification requirements to ensure EHRs are tested and capable of “true interoperability.”
Earlier this week, though, Timothy Pletcher, the head of the Michigan Health Information Network Shared Services, testified before the same Senate committee that health information exchanges in the Wolverine State are moving 6 million messages a week, which is, of course, a lot of interoperability.
Pletcher pleaded with the senators to make some tweaks in the meaningful-use criteria of the federal program, most notably to prioritize interoperability use cases, but otherwise “stay the course.”
Payne, the American Medical Informatics Association's board chair-elect, said in an interview after the hearing he was pleased the senators at least asked him for a definition of interoperability.
In writing the definition, Wright said he and Sittig wanted to “focus the discussion on some real-world use cases” so that both groups could participate in the conversation.
Wright said he also thinks the common definition could influence the discussion between EHR vendors and their future customers. “It might help purchasers have a more focused and relevant conversation than they might have otherwise,” he said. “I hope so.”