Combined with the widespread adoption of the Fast Health Interoperability Resource (FHIR) standard, the 21st Century Cures Act and Trusted Exchange Framework and Common Agreement (TEFCA) will soon drive interoperability of health information from the enterprise to the patient. These two regulations, and the FHIR standard, will effectively serve as the “pipes” to connect the points where healthcare information is acquired and where it is eventually accessed and used.
FHIR defines a basic structure for what goes into the pipes but still enables the sending and receiving of nearly any information encountered in a medical setting: codes from various terminologies and code sets, free-text narratives, images, operative notes, discharge reports, patient summaries and problem lists, lab results, orders, and other items. It is an intentional catch-all to include a wide variety of content. This begs the question, what happens with this information when it comes out of the other end of the pipe?
This is commonly referred to as the pending “data tsunami,” which is a bit of a misnomer since only some of it will be actual data. On the receiving end, the primary challenge will be what to do with the data––how to filter it, organize it, and put it to work at the point of care.
This where the interoperability “rubber” meets the road.
Let’s break down interoperability. “Inter” is defined as “between,” and “operable” is defined as “functional, practicable, or usable.” So, 21st Century Cures, TEFCA, and FHIR take care of how to move information between systems. The remaining (and daunting) challenge is the ability to do something with it all when the faucet is opened.
The industry press was full of pieces discussing the issues that the Offices of Inspector General for the Departments of Defense and Veterans Affairs have had exchanging information between their systems, and clinicians’ ability able to find what they need when they need it. Users reported issues that could negatively impact patient care. Considering that these issues were between systems based on the same core product, imagine the additional complexity of sharing information between disparate platforms.
In a completely open environment with disparate systems not using the same core product, the challenges to “operability” on the receiving end will only increase. Users will need powerful tools to filter incoming information and organize it so that clinicians can make use of what they need without wasting time sorting through everything else. Population analytics can help to evaluate trends in a group of patients, but how is it useful at the point of care for an individual patient?
In any transmission system where just about anything goes into the pipes, a filtering system is needed on the receiving end. Ignoring the challenges of free-text narratives for a moment, consider clinical data coded in the various terminologies and code sets commonly in use. The combined number of possible codes in ICD10-CM, SNOMED, LOINC, RxNorm, CPT, HCPCS, DSM5, UNII, CVX, and CTCAE total more than 200,000––any of which may be relevant for a specific patient. A key requirement in the coming world of 21st Century Cures, TEFCA, and interoperability will be the ability for a clinician to see a diagnostically filtered view of that incoming information for a specific patient and for any specific patient problem or condition.
The ideal solution is to enable a clinical user to select any item on a patient’s problem list and instantly see all relevant information for that problem––including the symptoms, history, physical exam findings, lab orders and results, procedures, therapies, comorbidities, and potential complications and sequelae.
The FHIR standard, 21st Century Cures, and TEFCA are shaping the future of interoperability. Meanwhile, these and other influences are converging and will necessitate new ways of thinking about electronic health records. The baseline truth is that clinical systems, rather than simply supporting the coding of billable transactions, must work in concert to provide tools for the management of a patient’s health––preferably at the point of need––and involve all resources in the community who participate in the care of a patient.
David Lareau is the CEO of Medicomp.
For more on interoperability, check out the AHIMA advocacy page.