Category: Open & Interoperable
January 30 2017
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Hans Buitendijk is a Senior Strategist at Cerner.  For over 30 years, he's been solving the challenges of interoperability and integrating health information systems into the daily workflow of clinicians. His main focus is bridging the discussions between our application capabilities with the need to access and exchange data across systems.

Interoperability is one of the main areas of focus in the health care industry today. Many definitions of interoperability exist, but for health care IT, the current definition is the ability to exchange data between two or more systems, enabling users on either system to view, access and take advantage of data originally generated in another system.

In the early days of health care interoperability, the main focus was on connecting multiple systems within a provider organization with one another. Provider incentives were clear: interoperable systems would improve the efficiency, effectiveness and quality of information management across their HIT infrastructure within their organization. Health care providers had the opportunity to define their vocabulary and translate the information through chart abstraction or other means into claims transactions for external reporting.

The industry quickly learned that what worked with one provider did not always work out-of-the-box across providers, even when using the same vendor, because of localized configurations and customizations. The standards that worked well to enable providers to connect their internal systems fell short of immediately connecting systems across providers and organizations.

Today, the focus has shifted from intra-provider, cross-vendor interoperability to cross-provider and cross-vendor interoperability, enabling clinical data to follow the patient. How did this happen, and what does it mean for future trends in interoperability?

The evolution of interoperability standards 

For any system to communicate with another system, protocols, terminology and policies must be agreed upon to manage the exchange of data. In other words, whether data is pushed through messages, pulled through services or summarized through documents, standards must be in place in order for systems to understand the shared data. 

When the focus was on intra-provider, cross-vendor interoperability, availability of general standards, such as HL7 V2, was sufficient to enable providers to meet their needs with support from their vendors. Everybody could come to agreements within their own organizations without worrying about anybody else. Over the last 30 years, providers have implemented localized standards to solve their specific interoperability use cases. This has created thousands of isolated islands, each with their own unique methods for defining and managing data.

Standards were frequently too flexible to result in consistent, unambiguous interoperability across provider organizations. Additionally, common vocabularies, protocols and syntax had not yet been agreed to across providers, even when providers used the same vendor. A new layer of implementation guides had to be developed and agreed upon. 

It was time to harmonize, synchronize and enable systems to communicate beyond the walls of the organization where they were originally developed. Health information exchanges (HIEs) showed promise at a local, regional level to help bridge variances, but that still would not solve the national challenges at a time when HIEs struggled to survive. Even within HIEs, documents and messages generally were still not consistently populated.  

All stakeholders – providers, vendors, registries, agencies and payers – started to work together to create new guidance on how to interpret each standard for a particular use case to ensure the same basic interoperability was deployed across all providers without significant differences.

What’s next for interoperability? 

Health care has come a long way toward enabling cross-provider interoperability, but there is still a lot of room for improvement. Yes, we now have a consolidated-clinical document architecture (C-CDA) implementation guide, but we still do not populate the C-CDA consistently across providers. Some of the questions surrounding this standards gap include:

  • How much information should it include? “Everything,” or what is deemed necessary by the sender? 
  • How much data should be structured versus free text, enabling downstream users to easily incorporate data to support clinical decision support, for example? 
  • How do we capture data so it is structured to support downstream reuse, but not encumber the provider who creates that document? 

The search for answers to these questions is underway. One emerging solution that’s already starting to help: application program interfaces (APIs). With the advent of APIs using the FHIR® standard, we introduced a new class of interoperability capabilities. These APIs enable reusable access to well-defined data elements where the same API can support many different use cases that we may not have thought about yet (as long as it involves the same data elements). This is a new class of interoperability that can be adopted across providers or with any other stakeholders, particularly patients. Now, we’re seeing a new level of flexibility while simultaneously maintaining critical consistency across providers and vendors as everybody begins to support a core set of common APIs. 

With this new flexibility, we need to learn how to find the right balance between sending messages containing raw data versus formatted documents, and interacting at a data element level across systems. In order to determine the right level of granularity to structure data -- whether that data is part of an order, data request or discharge summary -- requires collaboration across all stakeholders. The conversation about establishing the right guidance and standards is what will help solve these issues and deploy the next generation of interoperability. 

Cerner’s interoperability standards and goals 

As a leader in health care interoperability, Cerner is committed to ensuring the right data is available to the right person at the right time to enable the right decisions to be made for the right patient. We are also committed to helping establish the practical standards and guidance to make this happen across systems necessary to provide a common -- and at times virtual or actual -- integrated health record for a person. 

At Cerner, associates are in the trenches helping to develop standards and serving in leadership roles that set direction and move the industry forward. Here are a few of the ways we’re working toward this goal:

  • Leadership (ONC’s HIT Standards Committee)
  • Standards (HL7, NCPDP and X12)
  • Guidance (IHE, CAQH-CORE)
  • Vocabulary (Regenstrief [LOINC], IHTSDO [SNOMED])
  • Quality measures (NQF)
  • Data networks (CommonWell and various state-based and private HIEs)
  • Trust frameworks (DIRECT Trust)
  • Interoperability frameworks (Carequality)
  • Advocacy organizations (HIMSS, EHRA, CHIME, AONE, WEDI and many others)

With each of these initiatives, we’re aiming to get to a common set of standards and guidance that enables consistent communication not only within and across providers and with other stakeholders. For interoperability to be complete and successful, we must get to a state where we can plug in a new system and have basic, essential data access and exchange happening from the moment the system is live. 

FHIR® is the registered trademark of HL7 and is used with the permission of HL7.

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