Chapter 13 Week 7
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AB102615_Ch13.pptxHealth IT and EHRs: Principles and Practice, Sixth Edition
Chapter 13: Interoperability and Health Information Exchange
© 2017 American Health Information Management Association
© 2017 American Health Information Management Association
Interoperability
…is the ability of two or more systems or components to exchange information and use the information that has been exchanged
Continuum of interoperability assures not only an exchange of data, but that data can be understood and used:
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Technical Interoperability
For many years, interoperability was achieved through use of standard messaging protocols to write software (called an interface) that serves as an intermediary between two systems
However, this allowed for situational and optional data fields, reducing the extent to which they were truly “standard” across all systems
Example of a line of interface code:
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Standard Protocols for Technical Interoperability
Standards development organizations (SDOs) create protocols for writing interfaces
Because there are so many systems to interface and some have very different properties and/or must interface with organizations other than providers (such as a provider must send a claim to a health plan, a physician must send a prescription to a pharmacy), interface engines have been developed to manage the many different interfaces existing in any one organization.
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Standards Development Organizations
ANSI – umbrella organization accredits standards development organizations (SDOs)
SDOs
HL7: Predominant SDO for health data exchange
DICOM: SDO for clinical image exchange
NCPDP: SDO for exchange of prescription & pharmacy data
ASC X12: SDO for exchange of healthcare financial data
ASTM International: SDO for management of health data
IEEE develops standards for wireless transmission of data
Related organizations
CAQH CORE: Authoring entity for operating rules associated with X12 standards
IHE: Develops integration profiles to improve HL7 & DICOM data exchange
S&I Framework: Contributes to use of existing standards
NIST: SDO for federal information processing standards
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Health Level Seven (HL7)
Two versions:
V2.x supports traditional client/server platforms for point-to-point exchange
V3 uses an XML schema for use in a WSA; not backward compatible with V2.x, but transitional strategies are being developed
HL7 transitional strategies:
Reference Information Model (RIM)
Clinical Document Architecture (CDA)
Fast Healthcare Interoperability Resources (FHIR)
Blue Button
Decision Support Services (DSS)
Virtual Medical Record (vMR)
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Transmission of CDA via HL7 V2.x or V3
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Semantic Interoperability
Conveying meaning in a manner that ensures the receiver of data interprets the data in the same manner as the sender intended
Semantic interoperability requires:
Specification of the vocabulary used to denote data in a message (see chapter 10)
Understanding of relationships among data, requiring information and data modeling
Use of standard identifiers
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Information Modeling
Describes how types of data may be used together to provide value (such as DIKW continuum)
Information modeling tools
Entity relationship diagrams
Unified Modeling Language
Agile modeling
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Data Normalization
Ability to reconcile data elements so there is no redundancy in a data repository
Semantic normalization is translation among different terminology standards (aka data mapping)
Mapping diagnoses coded in ICD-10-CM to SNOMED CT and lab test results from LOINC to SNOMED CT normalizes the coded data so they can be used together, such as to alert that a patient may have a hospital acquired infection
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Identifiers
Employer Identification Number (EIN), issued by the IRS, is used by CMS as the identifier for employers when referenced by health plans and providers in exchange of insurance and sponsor information
National Provider Identifier (NPI) adopted in 2004 by CMS establishes common identification of physicians, hospitals, and other providers
Health Plan Identifier is in the process of being adopted by CMS that would create a standard way to identify health plans in claims and other financial transactions
Unique healthcare identifier for individuals has been on hold due to privacy concerns by Congress since first introduced in HIPAA
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Process Interoperability
Process interoperability is the human factors of usability and workflow, standardized through business or operating rules
Sufficient attention is not being paid to process interoperability
HL7 observes that process interoperability optimizes the communication of information and does so in a time-, event-, or sequence-oriented manner to coordinate the processes of the care team. The following factors would optimally achieve integration of computer systems into actual work settings:
Explicit user role specification
Useful, friendly, and efficient human-machine interface
Data presentation/flow supports work setting
Engineered work design
Proven effectiveness in actual use
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Interoperability Standards Advisory
In 2015, ONC initiated a process to identify, assess, and determine the best available interoperability standards and implementation specifications for healthcare in an annual Interoperability Standards Advisory, which addresses:
Vocabulary, code sets, or terminology (such as semantics)
Content or structure (such as syntax)
Services (such as infrastructure components deployed and used to fulfill specific interoperability needs)
Excluded are low-level transport standards common to all computers and networks; also excluded are standards that address administrative simplification in healthcare
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Importance of Interoperability
Interoperability is important to improve the quality, cost, and experience of healthcare in the US. Specific issues surround:
Medication reconciliation
Unnecessary diagnostic tests
Transportability and ubiquity of health information
Interoperability is needed to improve the quality and cost of care:
U.S. spends $6,714 per capita on health care, in comparison to Switzerland (next highest) at $4,311; yet:
40 out of 193 countries have lower infant mortality rates than the US
U.S. life expectancy is ranked 35th among developed nations
There are dramatic variations among regions and racial or ethnic groups in the rates of death from preventable causes
Some improvements in total cholesterol, cigarette smoking, and aerobic activity have been offset by high levels of obesity, hypertension, diabetes, and number of individuals reporting fair or poor health
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Challenges to Interoperability and HIE
US healthcare has a cottage industry mentality,
Where providers value discretionary and independent decision making
Hold the view that health information is the property exclusively of the provider
Information systems have largely focused on individual functions and operations of departments, creating proprietary silos
Information system vendors have imposed high costs on switchover (such as using proprietary constructs) to gain competitive advantage
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Status of HIE Organizations (HIO)
An HIO is an organization that oversees and governs the exchange of health-related information among organizations according to nationally recognized standards
HIOs are in various stages of development:
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Basic HIO Services
Sustainable HIOs are providing:
Connectivity to EHRs (across the continuum of care and with health plans)
Alerts to providers (such as primary care provider alerted that patient is in ED or was admitted)
Consultations (supports exchange of data as well as selection of providers in a narrow network of those with favorable quality and cost)
Results delivery
Health summaries for continuity of care (between providers and with patients)
Clinical documentation
E-prescribing
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Advanced HIO Services
Deidentification and data aggregation
Data warehousing and analytics
Billing and clearinghouse services
Transcription
Coding or revenue cycle management
EHR hosting
Public health surveillance
Many others
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HIE Architecture
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HIE Technical Services
Registry and Directory services
Person identification (PID) in the form of identity matching
Record locator service (RLS)
Identity management (IdM) = security services
Consent management
Opt-in: Data may not be exchanged by default unless the individual consents
Opt-out: Data may be exchanged by default unless restricted by the individual
Data exchange
Directory
PID
RLS
IdM
Security
Consent
Mgt
Data
Data
Copyright © Margret\A Consulting, LLC.
Reprinted with permission
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HIO Agreements
HIE data sharing agreement
HIO participation agreement
HITECH clarifies that HIOs are business associates
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(AHIMA) Data Governance Policies for HIE
Data conversion planning policy
Enterprise data integrity maintenance policy
Policy on an integrated medical record
Core patient identifiers and naming convention policy
Medical record corrections policy
Duplicate record validity determination policy
Record search policy
Data conversion testing policy
Electronic record linking policy
Maintenance of user and provider master records policy
Patient involvement in medical record accuracy policy
Legal medical record and eDiscovery policy
Data ownership agreements and DURSA
HIE opt in/opt out policy
Red flag alert
Data governance terms and definitions
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Data Governance in HIE
The five rights for HIE might include: right user (person, entity, system, or patient/consumer), right location, right record, right authority, and right consent
Such rights constitute health data stewardship:
Stewardship, in general, is personal responsibility for taking care of something one does not own.
Data stewardship has become an important function in corporate America—where management of the corporation’s data assets is critical for competitive advantage.
Health data stewardship encompasses “the responsibilities and accountabilities associated with managing, collecting, viewing, storing, sharing, disclosing, or otherwise making use of personal health information” (American Medical Informatics Association 2007).
Health data stewardship extends beyond HIPAA’s protected health information to personal health information, which includes health information that may be held by individuals themselves or in commercial PHR systems not subject to HIPAA
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NCVHS Health Data Stewardship
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eHealth Exchange
A national health information infrastructure was first described in 2001, when such a framework was called the nationwide health information network. Today, the framework for such a network is called eHealth Exchange and is managed by a federal contractor
eHealth Exchange is NOT a physical network that runs on HHS servers, nor a large network that stores patient records.
Federal funding is supplemental to advance nationwide interoperability through standards harmonization, compliance certification, and privacy and security solutions.
eHealth Exchange participants pay an annual service fee based on their revenue for maintenance of trust framework, specifications, service registry, (digital) certificate management, etc.
A community of users supports governance activities
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eHealth Exchange
© 2017 American Health Information Management Association
Forms of Exchange in eHealth Exchange
Directed Exchange is a push technology that uses a secure form of e-mail managed by a health information service provider (HISP) to enable sending and receiving of secure information. The Direct Project provides best practices for HISPs
Query-based Exchange is a pull technology that enables providers to search and discover accessible clinical sources on a patient. The first open-source software to conduct such exchange was CONNECT; today other companies have developed their own interfaces
Consumer-Mediated Exchange provides patients access to their health information. It is not a formal process overseen by the federal government, but promoted through MU, vendor use of Blue Button technology, and other efforts
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Certifications & Accreditations for HIE
EHNAC
With DirectTrust offers ONC-endorsed accreditation to HISPs
DirectTrust
Supports secure Directed Exchange
NATE
Develops Trust Bundles that are common policies and procedures for different types of exchanges
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