Interoperability. Let’s just review a few key points that probably everybody listening knows but certainly bear repeating because they matter.
I don’t want to dig into the technical or regulatory details of interoperability. That is above my pay grade. But I want to talk about the really important stuff that maybe doesn’t get talked about a whole lot because you say the word interoperability and it’s like the magic word that transports the unwary into the land of shadow and smoke and mist. It’s like a self-published YA (young adult) novel half the time.
But let’s start here: First of all, consider that a lot of healthcare these days is conceived of as a scattering of micro-moments. It’s not even like we think of patients one at a time. We think about patients one ICD-10 code at a time. And we think about those ICD-10 codes in 20-minute increments whenever a patient happens to show up in clinic. The average Medicare patient these days sees five specialists and more than one PCP a lot of times. So, we’re not only breaking that patient down into codes per minute or something, but this is further broken down by clinician or practice.
Now consider that everybody knows—and when I say everybody knows, I mean it’s inarguable at this point—health happens at the whole-patient level, at the whole-person level, more accurately. It happens at the community level: 80% of patient outcomes are going to derive from what that patient does when they leave the office and whether they are able to and health literate enough to construct a reconciled treatment plan for themselves from the bits and pieces of information they’ve received scattered all over the place. You know in Star Trek when someone gets into the transporter to beam down to a planet and their whole body splinters into a gazillion little pieces? That’s how our healthcare industry treats patients. They are frozen in that moment and rarely, if ever, become whole on the other side.
So, when we talk about interoperability, what we’re really talking about is a means to an end. What we are discussing is creating the ability to treat the whole patient or—Heaven forbid!—consider the whole community because we have enough data that we can accurately and adequately see the whole picture. We are able to avoid prescribing a treatment that is dangerous to the patient, inefficient, duplicative, or low quality—which is what happens over and over again. It’s no amazing surprise that our healthcare industry wastes $1 in $4 we spend and doesn’t net outcomes that are great in almost any respect when compared to other countries.
Let me say this more bluntly, as if that wasn’t already pretty blunt: If I don’t know relevant and important details about my patient, then I cannot consistently deliver care that is high quality, safe, or cost conscious due to service duplication or uncoordinated care. I mean, how is anybody supposed to deliver evidence-based care when a lot of evidence may or may not be missing?
So basically, without interoperability piping in the right patient information, I cannot succeed in any risk-based arrangement, right? If care provided is consistently lower quality, uncoordinated, unsafe, or inefficient, how am I supposed to optimize my care delivery? Said another way, interoperability is essential for anybody who wants to succeed in a value-based arrangement. I need all the data on my patients, and I need it in a way that I can separate the signal from the noise. Of course, getting 40 pages of duplicative SOAP (subjective, objective, assessment, and plan) notes that are semi-accurate and that no one bothers to look at is just unhelpful.
Quick counterpoint: FFS (fee for service) loves siloed data. You know how much money everybody talks about could be saved if we eliminate duplicative services? Well, that’s how much some fee-for-service health system is gonna lose if you make it easy for clinicians to see that the patient already got that CAT scan.
So, in sum, interoperability is essential to high-quality, safe, and efficient care. A mark of a health system or provider practice who is really committed to patient outcomes is going to be their commitment to share data. The world has moved from a “Hey, you’re permitted to share data if you really want to” to a “You are obligated to share your data.” And right now, I am loosely quoting Micky Tripathi, PhD, MPP, who is the ONC’s (Office of the National Coordinator for Health Information Technology) national coordinator and also the guy in charge of TEFCA (Trusted Exchange Framework and Common Agreement) and implementing the provisions against information blocking that was in the Cures Act Final Rule last year.
In this healthcare podcast, I am speaking with the perfect person about interoperability, and that would be Lisa Bari, who is the CEO of Civitas Networks for Health, which is a national collaborative working to improve interoperability in this country to improve health. Since interoperability is a huge topic, what I wanted to understand from Lisa most particularly are: Who are the current roster of players in the interoperability space? Like, what is going on there? Lisa told me that there are four main groups of interoperability folks—EHR (electronic health record) systems; APIs (application programming interfaces); HIEs (health information exchanges), both profit and nonprofit; and then others like clearinghouses, etc—which we talk about in some detail in this episode.
We also discussed Larry Ellison’s bold proclamation that Cerner is going to build one national medical records database. It’s almost like Larry made it through the “welcome to the healthcare briefing” packet that his team gave him and immediately concluded that the interoperability problem is a technology problem, not a business case, fee-for-service, workflow, no universal ID, human, organizational, or government problem. Lisa adds some fidelity there.
Also, TEFCA … we talk about what it is and what it’s not. Short version: It’s a framework so that no one can say they won’t share data lest they get in trouble in some way. At the same time, it’s not gonna solve, as Lisa puts it, “the last mile of interoperability,” meaning it’s not going to put the right information in the right clinician’s hands at the right time. It just governs getting data from one organization to another organization but kinda has nothing to do with the clinical workflow, so to speak.
The Civitas Networks for Health annual conference, by the way, is coming up on August 21-24 if you are interested in going.
You can learn more at civitasforhealth.org.
Lisa Bari, MBA, MPH, is the inaugural CEO of Civitas Networks for Health, a national nonprofit member- and mission-driven organization that was previously known as the Network for Regional Health Improvement and the Strategic Health Information Exchange Collaborative. Civitas counts over 100 multi-stakeholder-governed regional health improvement collaboratives and health information exchanges as members and creates national opportunities for education and community building between its members, policy makers, and business partners. Their upcoming conference (August 21-24, 2022, in San Antonio or via livestream) focuses on the theme of data collaboratives and information exchanges creating the critical infrastructure for health equity. Previously, Lisa was the health IT and interoperability lead at the CMS Innovation Center, working on primary care innovation model policy, and additionally has a background in health IT marketing and strategy. She holds an MBA from Purdue University and a Master of Public Health in health policy from the Harvard TH Chan School of Public Health and serves on the boards of directors of HealthCare Access Maryland and the Zorya Foundation.
06:30 How does value-based care depend on interoperability?
07:38 Why is it really important to exchange information at the right time with the right purpose?
08:00 What is one of the easiest low-hanging fruit to achieve in value-based care?
09:42 What are the four kinds of companies getting into the interoperability space?
11:51 “As we know, there’s sort of technical interoperability … and then there’s semantic interoperability.”
12:59 Where are we right now with EHR basic interoperability?
15:33 Who should ACOs hire to get the right data at the right time?
17:00 Why is it important to delineate the different types of HIE?
22:09 What can ACOs assure with interoperability?
22:59 Is the demand among ACOs for interoperability there?
24:04 “If you’re in value-based care, you better care about what’s happening outside of the healthcare setting.”
24:36 EP108 with Chris Klomp.
26:25 “Every couple of years, someone talks about creating the ultimate database to rule them all. … It hasn’t happened yet, and I don’t think it’s going to happen.”
26:56 “The difficult thing about healthcare data … interoperability … is an organizational and a governance problem.”
28:49 “You’ve gotta start with the incentives … and then you do have to say … ‘We are not gonna hoard any more data.’”
29:10 What is TEFCA, and how does it fit into this interoperability conversation?
32:17 “I think partners are trying to solve for value and outcomes.”