Why is Healthcare Interoperability Necessary?
Before we dive deeper into FHIR, let’s explore the landscape in which it exists.
The dream of freeing health data from its silos has been discussed for over 3 decades, with numerous standards and initiatives advancing this goal worldwide. The potential benefits would be huge, but so are the challenges that exist.
But what is healthcare interoperability? As defined by HIMSS,
Interoperability is the ability of different information systems, devices and applications to access, exchange, integrate and cooperatively use data in a coordinated manner.
This exchange would extend across organizational and national boundaries, allowing for improvements in the health for individuals and populations.
Some more benefits of healthcare interoperability include,
- Improved quality of care for patients
- Reduced physician burden in decision making and coordination with payers
- Enhancing care coordination across stakeholders and departments
- Empower patients with more information about their health, available to them easily
- Support public health initiatives with greater insights on population health
- Enable greater research and development in healthcare procedures and products
- Meet regulatory requirements implemented by more and more governments worldwide
Barriers to healthcare interoperability
Here are some of the challenges faced in having interoperable health data today.
- Lack of standardization: Health data is complex and is managed by many stakeholders, including vendors, providers and government organizations. Medical terminology used is not standard, and even when standards exist, adoption and normalization of data to those standards has an impact.
- Fragmented systems and data silos: Right now, a lot of health data exists in silos, even within a hospital or organization. E.g. departments in a hospital may use different and incompatible EHR vendors. Standard compliance by vendors is one aspect of this, another is the retrieval of data that is currently in legacy systems.
- Data security and privacy: Sharing health data must always go hand-in-glove with ensuring patient privacy and data security, and can act as a blocker for adopting interoperability standards. In this case, interconnected healthcare systems would reduce the risk of errors and security gaps due to manual intervention.
- Professional burden: Healthcare professionals need to learn to use a new tool that is introduced which is often a decision they are not consulted for. They often are sceptical of the utility of new EHR systems as they often support administrative and billing workflows better than clinical requirements.
Levels of interoperability in healthcare
There are 4 levels of interoperability in healthcare as defined by HIMSS and informatics experts. Some of these levels are easier to achieve with existing healthcare IT technology while others require further innovation and development.
-
Level 1 - Foundational interoperability: This is also known as simple transport and is the most basic level of interoperability. Here, data is transferred securely from one device to another, without any transformation or interpretation of data. E.g. APIs to a system.
-
Level 2 - Structural interoperability: In this level, also called structured transport, all data is standardized into a particular format - where the syntax, format and organization are pre-defined - which is understood by multiple systems or devices. E.g. If two systems use FHIR for information exchange, they are performing structured transport.
-
Level 3 - Semantic interoperability: Semantic interoperability or semantic transport involves exchanging data between systems, such that the receiving system can understand and use the data sent. This would require the systems to use a common vocabulary to represent standardized data. E.g. the HTI-1 rule mandates crucial data elements in patient care be shared using common vocabulary standards.
-
Level 4 - Organizational interoperability: This level brings together governance, policies, and trust frameworks to enable secure and timely communication and use of data. Initiatives like the Trusted Exchange Framework and Common Agreement (TEFCA) support this, and emphasize the importance of trust, privacy and data governance
| Level | Name | Definition |
|---|---|---|
| 1 | Foundational Interoperability | Basic data transmission |
| 2 | Structural Interoperability | Standard formats for data exchange |
| 3 | Semantic Interoperability | Sharing data with common standard terminologies |
| 4 | Organizational Interoperability | Governance and policy frameworks for organizations |
Healthcare data interoperability governance in the United States
21st Century Cures Act and Information Blocking
The 21st Century Cures Act, also known as the Cures Act, made it the norm to share electronic health information in the US. In this context, there are exceptions made for Information Blocking, or for practices that interfere with the free access of electronic health information. These exceptions are either for non-fulfulfilment, procedures for fulfilment, or practices related to actor participation. For example, Information Blocking exceptions exist for privacy, security, preventing harm, infeasibility and health IT performance. Procedures for fulfilling requests include licensing, feels and content. Additionally, there are exceptions related to actor participation in the Trusted Exchange Framework and Common Agreement or TEFCA.
TEFCA
The Trusted Exchange Framework and Common Agreement or TEFCA operates nationwide in the United States as a framework for health information sharing.
The TEFCA framework connects health information networks (HINs) across the country. These networks support health information sharing for specific states, regions and localities, or among customers using the same EHR vendor. They operate via Qualified Health Information Networks or QHINs, where each represents a network of health systems, HINs, public and federal care providers, payers and health IT vendors. Contributing to QHINs is voluntary.
Another aspect is The Seqoia Project, a TEFCA Recognized Coordinating Entity (RCE). The RCE signs a Common Agreement with each QHIN, defining the baseline legal and technological requirements for national information sharing.
The United States Core Data for Interoperability or USCDI
The USCDI is a standardized set of health data classes for nationwide information exchange. They also include constituent data elements that are defined for access, exchange or use of electronic health information. Data classes usually represent a common theme or use case such as, allergies and intolerances, plan of treatment, clinical notes, etc.
