EHR Interoperability – Are We There Yet? A Look at Progress and Barriers

In a world where nearly 90% of office-based physicians in the United States use Electronic Health Records (EHR), the importance of EHR interoperability has never been more critical. This statistic underscores a significant shift in managing and sharing healthcare information. EHR interoperability, at its core, is about the seamless exchange and utilization of patient data across different healthcare platforms.

They do more than just improve patient care — they reduce medical errors and improve the entire healthcare process, making everything more efficient.

What’s great about these solutions is how they let healthcare providers easily share and access patient info. This helps in making better decisions and providing care that’s more in sync with each patient’s needs.

To fully understand EHR interoperability solutions, we need to recognize their role in shaping a healthcare system that is interconnected, efficient, and centered around patient needs. 

Key Takeaways

• Widespread EHR Use but Limited Interoperability: Although nearly 90% of office-based physicians in the U.S. use EHRs, there is still a lack of seamless data exchange and usage across different existing systems.
• The Growing Market and Regulatory Push: The healthcare interoperability market is expected to reach approximately $8 billion by 2024. The Centers for Medicare & Medicaid Services (CMS) have introduced the Interoperability and Patient Access rule to promote efficient data sharing, emphasizing standards like FHIR (Fast Healthcare Interoperability Resources).
• Interoperability Improves Healthcare: It reduces medical errors, ensures efficient healthcare delivery, and enables better-informed decisions and coordinated care. 
• Types of Interoperability: EHR interoperability involves four levels – foundational, structural, semantic, and organizational. 
• Adoption Rates and Remaining Barriers: While there is a steady increase in the adoption of interoperability standards, challenges remain, such as the lack of a nationwide patient data exchange, issues with standardization, costs, competitive interests, and concerns around privacy and security.

Types of Interoperability

Interoperability in healthcare is broadly categorized into four levels: foundational, structural, semantic, and organizational. Each of these levels represents a different stage of capability in data usage that contributes to the overall effectiveness of healthcare delivery.

• Foundational Interoperability: This is the basic level where EHR systems or applications can securely communicate data to and receive actionable data from each other. At this stage, the systems do not interpret or process the data; they simply send and receive it. An example of this is sharing a PDF document containing patient information between systems. The receiving system can store the PDF, but cannot further process the data within it without manual effort.
• Structural Interoperability: This level builds on foundational interoperability by defining the format, syntax, and organization of data sharing. It includes the data field level for interpretation and relies on message format standards to maintain the meaning of the data during the exchange. A common example of structural interoperability is ePrescribing, where the health IT system and the pharmacy’s system use the same data standards for prescription elements.

• Semantic Interoperability: At this stage, various EHR systems can exchange data and interpret it accurately with a common format and meaning. This involves the use of clinical terminologies like SNOMED CT, ICD, and LOINC to ensure that the data is transferred accurately, meaningfully, and clinically relevant. Semantic interoperability allows for effective data sharing, reducing duplicative testing and enabling better care coordination.
• Organizational Interoperability: This level includes governance, policy, social, legal, and organizational considerations that facilitate secure communication and use of data within and between organizations. This level is crucial for ensuring the trust factor in data exchange, which is particularly important in the context of laws like the 21st Century Cures Act.

For healthcare organizations, it is essential to understand these levels of interoperability as they navigate the complexities of health data exchange and strive to improve patient care outcomes.

Current State Of Interoperability

The current state of interoperability in healthcare is a dynamic and evolving area, significantly influenced by developments in technology and regulatory frameworks. Let’s delve into three key aspects: interoperability standards, their impact on medical data sharing, and the adoption rates of these new standards.

Interoperability Standards: HL7, CDA, FHIR, and more

The worldwide market for healthcare interoperability is experiencing robust growth, with forecasts indicating it could reach a value of around $8 billion by the year 2024. This surge is largely attributed to the rapid increase in clinical data. However, the industry faces significant headwinds, particularly the problem of data inaccuracy. This problem is exacerbated by disparate electronic health record (EHR) systems common across various U.S. healthcare systems.

To tackle this problem, the Centers for Medicare & Medicaid Services (CMS) have introduced the Interoperability and Patient Access rule. This initiative aims to enhance the efficiency of data sharing. It heavily emphasizes the adoption of FHIR (Fast Healthcare Interoperability Resources), developed by Health Level Seven International (HL7), a set of standards specifically designed to facilitate more effective and streamlined healthcare data interchange.

FHIR vs. Previous Standards

However, the journey towards efficient healthcare data exchange began long before FHIR and included the adoption of various technologies like Cloud Fax. Initially, healthcare organizations relied heavily on traditional fax machines to exchange data. Cloud Fax technology emerged as a digital evolution of traditional faxing, offering a more secure and efficient method for transmitting healthcare information. This transition from physical fax machines to Cloud Fax services marked a significant step in the digitalization of healthcare communication, bridging the gap between older, paper-based processes and modern digital solutions.

As the healthcare industry transitioned from traditional faxing to Cloud Fax technology, marking a significant advancement in digital communication, it also witnessed parallel evolutions in data structuring and exchange protocols. From the early protocols like HL7 Version 2, HL7 Version 3, and IHE, introduced in the 1980s and 1990s, to the more structured Clinical Document Architecture (CDA) and Direct, each step represented an evolution in how healthcare data was structured and exchanged. 

HL7 Version 2 offered a simple, widely adopted messaging format, while HL7 Version 3 introduced a more complex and structured approach to healthcare messaging. CDA, in particular, provided a standard for the structure and exchange of clinical documents, enhancing consistency and clarity in healthcare communication. Direct, for instance, focuses on secure messaging for health information exchange, while IHE integrates multiple standards to improve system interoperability. 

FHIR, developed by Health Level Seven International (HL7), emerged as a response to the need for a more flexible, web-based standard. When compared to its predecessors, FHIR stands out for its use of modern web technologies, ease of implementation, and interoperability. Unlike HL7 Version 2 or 3, which had complex interfacing requirements, FHIR uses a RESTful API approach, making it more accessible to developers and more adaptable to various healthcare environments. The standard is designed for simplicity and speed, with a focus on easy data exchange and interpretation. 

By understanding these different standards, stakeholders can better navigate the complex landscape of healthcare data exchange. Here is a comparison table outlining the key aspects of various healthcare data standards:

Based on the comparison table, it is evident that FHIR (Fast Healthcare Interoperability Resources) represents the most advanced solution among the various healthcare data standards discussed. The adoption of FHIR is rapidly increasing worldwide. As of 2019, the adoption rate of FHIR-enabled API technology was quite significant, with 84% of hospitals and 61% of clinicians having adopted this technology. This can be seen in the number of healthcare providers, software developers, and regulatory bodies endorsing and implementing FHIR-based solutions. 

And it’s not just them, the big names in the EHR world, such as Andor Health, CVS Health, and Optum, are on board too. They’re weaving these new standards into their products, which is helping the whole healthcare industry get on the same page. This is a big deal because when everyone’s using the same approach, everything improves – patient care gets better, costs start dropping, and the whole process of delivering healthcare becomes a lot smoother and more efficient.

The Effect On Clinical Data Exchange

The evolution of interoperability standards in healthcare, as outlined in a study by the National Center for Biotechnology Information (NCBI), has fundamentally revolutionized the exchange and use of clinical data. These advancements have had a profound impact on the healthcare industry, transforming the way patient information is shared across various platforms.

Enhanced Coordination of Care

One of the most significant impacts of these standards is the improved coordination of care. With the ability to securely and swiftly move patient health information across different healthcare systems, clinicians now have immediate access to a comprehensive view of a patient’s medical records, lab test results, and other critical information. This accessibility enables healthcare organizations to make more informed decisions, ensuring that each patient receives care that is tailored to their specific needs and medical history.

Improved Patient Outcomes

The interoperability of clinical data has directly contributed to enhanced patient outcomes. Doctors and medical professionals can now quickly identify health issues, understand the patient record in greater depth, and devise treatment plans that are precisely suited to each individual. This immediate and holistic view of patient data reduces the likelihood of data errors and improves the overall effectiveness of treatment plans.

Integration with Digital Health Applications

The impact of these standards extends beyond traditional healthcare settings. They have paved the way for the integration of patient data with various health applications and services. This integration has opened up new avenues in healthcare practice, such as remote patient monitoring and personalized health applications. These digital health tools offer ongoing healthcare support, making healthcare more accessible, especially for patients who might not have regular access to traditional care settings.

Facilitation of Remote Healthcare

With the rise of telemedicine and remote healthcare services, interoperability standards have become even more crucial. They ensure that patient data can be reliably and securely accessed from remote locations, allowing healthcare providers to offer continuous care regardless of physical barriers. This aspect of healthcare is particularly beneficial for patients in rural or underserved areas, where access to healthcare facilities may be limited.

Promotion of Personalized Medicine

Finally, these standards are instrumental in the advancement of personalized medicine. By enabling the easy exchange and analysis of vast amounts of patient data, healthcare providers can develop more personalized treatment plans, based on the unique genetic, environmental, and lifestyle factors of each patient. This approach to medicine not only improves the effectiveness of treatments but also paves the way for future innovations in healthcare.

In summary, the impact of standards on clinical data exchange is profound. They have transformed healthcare delivery, improving patient outcomes, enhancing the coordination of care, enabling integration with digital health tools, facilitating remote healthcare, and promoting personalized medicine. 

Remaining Barriers

The journey towards achieving full interoperability in healthcare is marked by several significant barriers, despite considerable progress in certain areas. 

Lack Of True Nationwide Patient Data Exchange

While significant strides have been made in interoperability within certain healthcare networks, the broader landscape remains fragmented. For instance, a patient who receives care from a hospital in New York might find their health records are not readily accessible by a clinic in California. 

This is partly because, as of 2021, only about 74% of hospitals had adopted bulk data export technology, which is fundamental for interoperability. Yet, a mere 12% of these hospitals had used this technology for switching EHR systems. This indicates a significant gap in establishing a national patient health data-sharing network that can seamlessly connect different systems across the country.

Issues Around Standardization

The effort to standardize health data sharing across various platforms is ongoing but faces several challenges. For example, while FHIR has been a breakthrough in standardization, its implementation varies across different health systems, leading to inconsistencies in how data is interpreted and used. This inconsistency is often worsened by EHR vendors who may prioritize their proprietary formats over universal standards. As a result, healthcare organizations may struggle to integrate information from different sources effectively, complicating patient care and data management.

Costs And Competitive Interests

In the complex landscape of healthcare IT, costs and competitive interests form a crucial backdrop to the ongoing conversation around interoperability. These factors shape the strategies and decisions of both vendors, often leading to a delicate balancing act between collaboration and competition.

• Substantial Integration Costs and Risks: The integration of new interoperability frameworks involves significant costs for both vendors and providers. For instance, a study by the Healthcare Information and Management Systems Society (HIMSS) found that initial costs for an EHR implementation can range from $15,000 to $70,000 per provider. Moreover, the transition period often leads to lower productivity rates. A study by the Journal of the American Medical Informatics Association highlighted that during EHR implementation, hospitals typically experience a temporary drop in efficiency, often taking months to return to pre-implementation productivity levels.

• Competitive Advantage Concerns: Healthcare IT vendors are often reluctant to enable easy transfer of patient data to other systems. It arises from the desire to promote one’s own products and retain customers. For example, a leading EHR vendor may resist adopting universally compatible data standards, fearing that it could make it easier for healthcare providers to migrate to competing solutions, thereby weakening their market position. This creates barriers to promoting interoperability, as it can undermine the unique selling propositions of their platforms.

• Revenue and Lock-in Effects: Vendors typically aim to secure long-term contracts with healthcare providers, often creating dependencies on their specific systems and discouraging open data sharing. This approach can make it difficult for healthcare organizations to switch to or integrate different IT solutions, effectively locking them into using a single vendor’s system. The fear of losing this client ‘lock-in’ can be a significant barrier to vendors embracing open interoperability standards, as it could potentially reduce their control over the healthcare providers’ IT infrastructure.

• Intellectual Property Worries: The development of proprietary data schemas and exchange protocols involves significant investment by vendors. Open sharing of this proprietary technology and data could potentially dilute their intellectual property advantages. For many vendors, interoperability is seen as a double-edged sword: while it can enhance the utility of their systems, it also requires them to relinquish some level of control. Competitive differentiation can be a tough pill to swallow for businesses built on proprietary technologies. 

Privacy And Security Concerns

Enhanced data sharing increases the risk of privacy breaches and cybersecurity threats. For instance, as interoperability expands, the management of patient consent and the secure handling of sensitive health information becomes more complex. Additionally, with fewer than half of US hospitals fully engaged in all four domains of interoperability in 2018, the concerns around information privacy and patient safety become even more apparent. 

Many hospitals cite technical and governance challenges to data sharing, particularly when different electronic health records vendors are involved. These concerns highlight the need for robust security measures and clear governance frameworks to ensure that patient health data is protected even as it becomes more widely accessible.

In conclusion, while there has been clear progress in certain areas of healthcare interoperability, these barriers illustrate the multifaceted challenges that must be overcome to achieve a truly interoperable healthcare system. Reaching this goal involves technological advancements as well as a collective effort from all participants in the healthcare ecosystem.

EHR Interoperability Solutions: Bottomline

In today’s healthcare environment, electronic health record interoperability is key to increasing provider efficiency and improving patient outcomes through seamless data exchange. Central to this are patient records in EHR and EMR systems, which improve care delivery and also help with predictive analytics. The current state of EHR interoperability in the US demonstrates significant progress along with ongoing challenges.

On the one hand, the widespread adoption of EHRs and the development of standards such as FHIR clearly demonstrate a movement toward better interoperability. However, the industry has not yet achieved the goal of a seamless nationwide exchange of EHR data. Several significant barriers, including standardization challenges, high costs, competitive interests, and security concerns, continue to obstruct this goal. These obstacles highlight the complexity of fully integrating diverse EHR software from various healthcare providers.

Overcoming these barriers requires collaborative efforts, technological advances, and a continued focus on standardization and patient-centered solutions. While the industry has made progress, addressing these complex challenges is essential to fully realizing the benefits of a unified healthcare system. Ultimately, the potential for interoperability in healthcare will reach new heights and evolve over time.