Health Information Technology Interoperability

1. Health Information Technology Interoperability

2. Learning Objectives After reading this chapter the reader should be able to: • Identify the need for and benefits of interoperability • Describe the concept of Health Information Organizations and how they fit into the Nationwide Health Information Network • State the most important data standards and their role in interoperability • Describe the importance of data security and privacy as part of HIPAA

3. Health information technology (HIT) interoperability means that electronic applications, devices or systems are able to exchange health-related information. Interoperability is a critical element in the future success of health information exchange (HIE) at the local, regional and national level. As an example, patient data within an electronic health record is interoperable if it can be shared with another computer or information network.

4. In 2008 the National Alliance for Health Information Technology released a new set of definitions that would help clarify the ambiguity of several HIT terms:

5. Health Information Exchange (HIE) is the “electronic movement of health-related information among organizations according to nationally recognized standards”. Health Information Organization (HIO) is “an organization that oversees and governs the exchange of health-related information among organizations according to nationally recognized standards”. Regional Health Information Organization (RHIO) is “a health information organization that brings together health care stakeholders within a defined geographic area and governs health information exchange among them for the purpose of improving health and care in that community”

6. Health Information Interoperability Issues Adoption. • The government should develop incentives for physicians and insurers that include grants and pay for performance initiatives. • They should also work to revise or eliminate legal barriers such as the Stark and Anti-Kickback laws. • Gaps in health IT adoption should be identified and remedial policies should be developed. • The shortage in health IT manpower needs to be addressed and corrected. • Lastly, the public needs to know that interoperability will ultimately improve the quality of medical care and patient safety

7. Clarity • There is a need to certify health IT products in terms of functionality, security and interoperability. • Data standards must be developed with the help of the National Health Information Community (NHIC) • The NHIC should require HIT developers to cover privacy specific problems and standards for labels and packaging.

8. Connectivity National standards for patient authentication and identity need to be developed. The Department of Health and Human Services should work with other agencies to fund a national health information network. There should be criminal punishment for privacy violations. Patients should not be discriminated against based on health data

9. National Health Information Technology In order for Electronic Health Information to be interoperable we need to focus on the following points: • "Be a decentralized architecture built using the Internet linked by uniform communicationsand a software framework of open standards and policies • Reflect the interests of all stakeholders and be a joint public/private effort • Be patient centric with sufficient safeguards to protect the privacy of personal health information • Have incentives to accelerate deployment and adoption of a NHIN • Enable existing technologies, federal leadership, prototypes and certification of EHRs • Address better refined standards, privacy concerns, financing and discordant laws regarding health information exchange"

10. • Leverage the Internet as an infrastructure; think web-based • Build upon existing successes; take advantage of any existing infrastructure • Have a realistic implementation plan; build incrementally or by phases or modules • Develop strong physician involvement; involve medical schools and medical societies • Obtain hospital leadership commitment; much of the information to be shared comes from hospital IT systems • Obtain support from the business community; vendors who have networking experience will be valuable partners • Establish a neutral managing partner; a commission or network authority

11. As a result for the previous recommendations the following architecture was established:

12. This architecture consist of: • NHIN Gateway implements the core services such as locating patients at other health organizations within the NHIN and requesting and receiving documents associated with the patient. It also includes authenticating network participants, formulating and evaluating authorizations for the release of medical information and honoring consumer preferences for sharing their information • Enterprise Service Component (ESC) provides enterprise components including a Master Patient Index (MPI), Document Registry and Repository, Authorization Policy Engine, Consumer Preferences Manager, HIPAA-compliant Audit Log and others. This element also includes a software development kit (SDK) for developing adapters to plug in existing systems such as electronic health records to support exchange of health information across the NHIN. • The Universal Client Framework enables agencies to develop end user applications using the enterprise service components in the ESC

13. Web Services and Service Oriented Architecture Before the internet data resided on a local PC or server. Web services are platform independent applications that communicate with other web based applications/services over a network (Internet). Because HIOs are based on Internet-based web services, we are adding a short primer on the subject for better understanding.

14. Web services require threebasic platform elements: • SOAP (Simple Object Access Protocol): a communication protocol between applications. It is a vendor independent format (XML based) for sending messages over the Internet. It reuses the HTTP for transporting data as messages • WSDL (Web Services Description Language): a XML document used to describe and locate web services • UDDI (Universal Description, Discovery and Integration): a directory for storing information about web services, described by WSDL. UDDI communicates via the SOAP protocol

15. Several models of health information exchange data storage have appeared: • Federated—means that data will be stored locally on a server at each entity such as hospital, pharmacy or lab. Data therefore has to be shared among the users of the HIO • Centralized—means that the HIO operates a central data repository that all entities must access • Hybrid—a combination of some aspects of federated and centralized model

16. Pros and Cons of HIO models

17. In order for a HIO to succeed, multiple participants will need to be involved in the planning phase. Examples would be:

18. • Insurers (payers) • Physicians • Hospitals • Medical societies • Medical schools • Medical Informatics programs • State and local government • Employers • Consumers • Pharmacies and pharmacy networks • Business leaders and selected vendors • Public Health departments

19. Multiple functions need to be addressed by a HIO such as: • Financing: it will be necessary to obtain short term start up money and more importantly a long term business plan to maintain the program • Regulations: what data, privacy and security standards are going to be used? • Information technology: who will create and maintain the actual network? Who will do the training? Will the HIO use a centralized or de-centralized data repository? • Clinical process improvements: what processes will be selected to improve? Claims submission? Who will monitor and report the progress? • Incentives: other than marketing what incentives exist to have the disparate forces join? • Public relations (PR): you need a PR division to get the word out regarding the potentialbenefits of creating a HIO • Consumer participation: in addition to the obvious stakeholders you need input from consumers/patients26

20. Health Information Organization concerns • Everyone has a different business model. Is this a public utility with no public funding? • Who will fund HIOs long term? Insurers? Employers? Consumers? Neither private nor government organizations take full responsibility. What happens when the grant money expires? • Will we have universal standards or different standards for different HIOs? • There could be dependence on vendors. BCBS of Tennessee partnered with Cerner who has an EHR product and will receive a per member per month subscription fee

21. • What should be done with geographical gaps in HIOs and what regions should they cover? Should they be based on geography, insurance coverage or prior history? • Are poorer cities, states and regions at a disadvantage? • How can you create a NHIN if multiple HIOs fail and the adoption rate of EHRs is low? • The federal government is funding NHIN trials with grant money. Will they fund all HIOs to connect to the NHIN? • What are the incentives for competing hospitals and their CIOs/CEOs in the average city or region to collaborate? • Who will accredit HIOs, CCHIT or the Electronic Healthcare Network Accreditation Commission (EHNAC)?

22. Data Standards According to the Institute of Medicine’s 2003 report Patient Safety: Achieving a New Standard for Care “One of the key components of a national health information infrastructure will be data standards to make that information understandable to all users”

23. Major data standards and how they facilitate the transmission of data. Extensible Markup Language (XML): • Although XML is not really a data standard it has become a programming markup language standard for health information exchange. In order for disparate health entities to share messages and retrieve results, a common programming language is necessary • XML is a set of predefined rules to structure data so it can be universally interpreted and understood • XML consists of elements and attributes • Elements are tags that can contain data and can be organized into a hierarchy • Attributes help describe the element

24. XML Example <automobile> <car id= “Ford” model=”2008”> <phone id =”1”> All phone information <number>9216604</number > </phone> </car> <car id=”Chevy” model=”2008> <phone id = “2”> All phone information <number>9335676</number> </phone> </car>

25. Health Level Seven (HL7) • A not-for-profit standards development organization (SDO) with chapters in 30 countries • Health Level Seven’s domain is clinical and administrative data transmission and perhaps is the most important standard of all • "Level Seven" refers to the highest level of the International Organization for Standardization (ISO) • HL7 is a data standard for communication/messages between: o Patient administrative systems (PAS) o Electronic practice management o Lab information systems (interfaces) o Dietary o Pharmacy (clinical decision support) o Billing o Electronic health records • HL7 uses XML markup language • The most current version of the HL7 standard is 3.0 but version 2.0 still widely in use • The Clinical Document Architecture (CDA) is part of the HL7 standard and makes documents human readable and machine processable by using XML.

26. The CCD will have 17 data content/component modules as part of the C32 standards as noted in the table below. Each module will have additional data elements:

28. Digital Imaging and Communications in Medicine (DICOM) • DICOM was formed by the National Electrical Manufacturers Association (NEMA) and the American College of Radiology. They first met in 1983 which suggests that early on they recognized the potential of digital x-rays • As more radiological tests became available digitally, by different vendors, there was a need for a common data standard • DICOM supports a networked environment using TCP/IP protocol (basic Internet protocol) • DICOM is also applicable to an offline environment

29. Institute of Electrical and Electronics Engineers (IEEE). IEEE is the organization responsible for writing standards for medical devices. This includes infusion pumps, heart monitors and similar devices.

30. Logical Observations: Identifiers, names and codes (LOINC) • This is a standard for the electronic exchange of lab results back to hospitals, clinics and payers. HL7 is the messaging standard, whereas LOINC is the interpretation standard • The LOINC database has more than 30,000 codes used for lab results. This is necessary as multiple labs have multiple unique codes that would otherwise not be interoperable • The lab results portion of LOINC includes chemistry, hematology, serology, microbiology and toxicology

31. • The clinical portion of LOINC includes vital signs, EKGs, echocardiograms, gastrointestinal endoscopy, hemodynamic data and others • A LOINC code example is 2951-2 for serum sodium; there would be another code for urine sodium. The formal LOINC name for this test is: SODIUM:SCNC:PT:SER/PLAS:QN (component:property:timing:specimen:scale) • LOINC is accepted widely in the US, to include federal agencies. Large commercial labs such as Quest and LabCorp have already mapped their internal codes to LOINC • RELMA is a mapping assistant to assist mapping of local test codes to LOINC codes • LOINC is maintained by the Regenstrief Institute at the Indiana School of Medicine. LOINC and RELMA are available free of charge to download from www.regenstrief.org/loinc • For more detail on LOINC we refer you to an article by McDonald

32. EHR-Lab Interoperability and Connectivity Standards (ELINCS) • ELINCS was created in 2005 as a lab interface for ambulatory EHRs and a further “constraint” or refinement of HL7 • Traditionally, lab results are mailed or faxed to a clinician’s office and manually inputted into an EHR. ELINCS would permit standardized messaging between a laboratory and a clinician’s ambulatory EHR • Standard includes: o Standardized format and content for messages o Standardized model for exchanging messages o Standardized coding (LOINC) • The Certification Commission for Healthcare Information Technology (CCHIT) has proposed that ELINCS be part of EHR certification • HL7 plans to adopt and maintain the ELINCS standard • California Healthcare Foundation sponsored this data standard

33. National Council for Prescription Drug Programs (NCPDP) • A standard for exchange of prescription related information • The standard facilitates pharmacy related processes • It is the standard for billing retail drug sales

34. Systematized Nomenclature of Medicine: Clinical Terminology (SNOMED-CT) • SNOMED is the clinical terminology commonly used in software applications including EHRs • SNOMED is also known as the International Health Terminology • This standard was developed by the American College of Pathologists. In 2007 ownership was transferred to the International Health Terminology Standards Development Organization www.ihtsdo.org • SNOMED will be used by the FDA and the Department of Health and Human Services • This standard currently includes about 1,000,000 clinical descriptions • Terms are divided into 11 axes or categories • The standard provides more detail by being able to state condition A is due to condition B • SNOMED links to LOINC and ICD-9 • SNOMED is currently used in over 40 countries • EHR vendors like Cerner and Epic are incorporating this standard into their products • There is some confusion concerning the standards SNOMED and ICD-9; the latter used primarily for billing and the former for communication of clinical conditions

35. Example A study at the Mayo Clinic showed that SNOMED-CT was able to accurately describe 92% of the most common patient problems 73 SNOMED-CT Example: Tuberculosis D E – 1 4 8 0 0 . . . . . . . . . . . Tuberculosis . . Bacterial infections . E = Infectious or parasitic diseases D = disease or diagnosis

36. International Classification of Diseases 9th revision (ICD-9) • ICD-9 is published by the World Health Organization to allow mortality and morbidity data from different countries to be compared • Although it is the standard used in billing for the past 30 years, it is not ideal for distinct clinical diseases • ICD-10 will provide a more detailed description with 7 rather than 5 digit codes. ICD-10 would result in about 200,000 codes instead of the 24,000 codes currently used.