With the New Year on its way, ONC has issued its latest missive on how to move the healthcare industry towards interoperability. Its Interoperability Standards Advisory for 2017, an update from last year’s version, offers a collection of standards and implementation specs the agency has identified as important to health data sharing.
I want to say at the outset that this seems a bit, well, strange to me. It really does seem like a waste of time to create a book of curated standards when the industry’s interoperability take changes every five minutes. In fact, it seems like an exercise in futility.
But I digress. Let’s talk about this.
About the ISA
The Advisory includes four technical sections, covering a) vocabulary/code sets/terminology, b) content/structure standards and implementation specs, c) standards and implementation specs for services and d) models and profiles, plus a fifth section listing ONC’s questions and requesting feedback. This year’s version takes the detailed feedback the ONC got on last year’s version into account.
According to ONC leader Vindell Washington, releasing the ISA is an important step toward achieving the goals the agency has set out in the Shared Nationwide Interoperability Roadmap, as well as the Interoperability Pledge announced earlier this year. There’s little doubt, at minimum, that it represents the consensus thinking of some very smart and thoughtful people.
In theory ONC would appear to be steaming ahead toward meeting its interoperability goals. And one can hardly disagree that it’s overarching goal set forth in the Roadmap, of creating a “learning health system” by 2024 sounds attractive and perhaps doable.
Not only that, at first glance it might seem that providers are getting on board. As ONC notes, companies which provide 90% of EHRs used by hospitals nationwide, as well as the top five healthcare systems in the country, have agreed to the Pledge. Its three core requirements are that participants make it easy for consumers to access their health information, refrain from interfering with health data sharing, and implement federally recognized national interoperability standards.
Misplaced confidence
But if you look at the situation more closely, ONC’s confidence seems a bit misplaced. While there’s much more to its efforts, let’s consider the Pledge as an example of how slippery the road ahead is.
So let’s look at element one, consumer access to data. While agreeing to give patients access is a nice sentiment, to me it seems inevitable that there will be as many forms of data access as there are providers. Sure, ONC or other agencies could attempt to regulate this, but it’s like trying to nail down jello given the circumstances. And what’s more, as soon as we define what adequate consumer access is, some new technology, care model or consumer desire will change everything overnight.
What about information blocking? Will those who took the Pledge be able to avoid interfering with data flows? I’d guess that if nothing else, they won’t be able to support the kind of transparency and sharing ONC would like to see. And then when you throw in those who just don’t think full interoperability is in their interests – but want to seem as though they play well with others – you’ve pretty much got a handful o’ nothing.
And consider the third point of the Pledge, which asks providers to implement “federally recognized” standards. OK, maybe the ISA’s curated specs meet this standard, but as the Advisory is considered “non-binding” perhaps they don’t. OK, so what if there were a set of agreed-upon federal standards? Would the feds be able to keep up with changes in the marketplace (and technology) that would quickly make their chosen models obsolete? I doubt it. So we have another swing and a miss.
Given how easy the Pledge is to challenge, how much weight can we assign to efforts like the ISA or even ONC’s long-term interoperability roadmap? I’d argue that the answer is “not much.” The truth is that at least in its current form, there’s little chance the ONC can do much to foster a long-term, structural change in how health organizations share data. It’d be nice to think that, but thinking doesn’t make it so.
You are quite correct in all of that. I laughed (sadly) with the mention of jello. I have 5 sets of records for one hospital procedure and they were produced intentionally to add and remove data as simple as “inpatient record”, “ambulatory record”, and “bedded outpatient”. They couldn’t remove the imbedded default classification which was wrong. How bad is it that a hospital was performing operations and yet did not know – the EMR defaulted to Inpatient for lack of admission orders! Would anyone ever go there again when something so basic had not been determined? I had not thought of it as jello but my term is “amoeba”. Definitely gelatin like in nature – a shape shifter. All patients should have the information. It is not unlike our rights to see our credit reports. The system must be totally transparent for us to challenge the content and the addition of affective bias put in health records – similar to the game of gossip when we were kids. Patients need empowerment. My days of blind trust are over – it is now trust but verify. Patients deserve better and best.
Why, oh why, does ONC not first address the problem before trying over and over again to evolve a “solution”?
The issue of “interoperability” has been addressed across many sectors of the economy and basically, it goes like this.
http://wp.me/pzzpB-tB
A generic data exchanger accommodates automated data sharing on a need-to-know basis, across any number of data publishers and subscribers, each reading and writing data using their own native data element naming conventions.
Given buildup of a respectable set of data transport formats, organizations do not need to write parsers and formatters to post/retrieve data from data exchange engines.
Just as internet download sites can be mirrored to increase capacity, the same approach applies to data sharing via data exchangers.
Civerex offered a couple of years ago to donate its Data Exchanger to ONC for use across the healthcare industry. We never heard back.
Of course, for interoperability to work, software vendors have to first make it possible for their systems to export data and to import data.
Data blocking for ‘customer retention’ just keeps the healthcare industry a couple of decades behind.
ONC is rudderless and lost at sea. They work in buzzwords and not in the real world.
Their EHR policies have set back usability, interop, safety, security, and burden at least 10 years. We need new blood.