- A learning health system is not possible without conformance to five EHR interoperability use cases by healthcare providers and health IT developers, claims the authors of an article published in the Journal of the American Medical Informatics Association (JAMIA). And important to the challenge of advancing EHR interoperability is the understanding of open in the context of health IT.
"Many commentators assume that an open EHR shares some of the qualities of 'open-source' software, which usually implies that the application’s source code is available, often free of charge, for review, use, and even modification," write Dean F. Sittig of the University of Texas Health School of Biomedical Informatics and Adam Writer of Brigham & Women's Hospital. "While we support the open-source concept, it has no bearing on whether an EHR satisfies the definition we propose below."
The authors go on to downplay the importance of "underlying data structures or the language used to access data are critical to the openness of an EHR" in light of the health IT infrastructure ultimately necessary for supporting health data exchange.
"The heaviest part of the burden lies in agreeing on a data model for sharing information and translating the stored data to that model. The internal representation of the data, in either the sending or receiving EHR, is largely immaterial," they argue.
The EXTREME —Extract, Transmit, Exchange, Move, and Embed — use cases laid out by Sittig & Wright address the health data exchange needs of five groups of stakeholders:
Each use case represents functionality important to 1) clinicians, so they can provide safe and effective health care to their patients regardless of where previous care was delivered; 2) researchers, so they can advance our understanding of disease and health care processes through use of advanced data mining techniques and experimentation with new application features and functions; 3) administrators, so they can better track health care costs and quality while reducing their reliance on a single-source EHR developer; 4) software developers, so they can develop innovative solutions to address limitations of current EHR user interfaces and new applications to improve the practice of medicine; and 5) patients, so they can access their personal health information no matter where or from whom they receive their health care.
The JAMIA article includes the requirements for each of the five use cases for EHR interoperability. What it also includes is an admission that barriers to EHR interoperability are not entirely technical.
"In addition to having all EHRs meet these technical requirements, we must also begin addressing the myriad socio-legal barriers to widespread health information exchange that is required to transform the modern EHR-enabled health care delivery system," write Sittig & Wright.
In an interview with HealthITInteroperability.com last month, Sittig explained that existing regulation — that is, the Health Insurance Portability and Accountability Act (HIPAA) — shares much of the blame for limiting health data exchange and that Congressional interested in EHR interoperability is failing admit how the federal government helped create the current predicament.
"Right now, we have a lot of rules and regulations in our society that are prohibiting this," he states. "The federal government complains about interoperability, but they're the ones that have made the single most important rule that's stopping interoperability, and that's the fact that we don't have a unique patient identifier for all patients in the United States."
As Sittig also noted, health IT developers are more than capable of making their technology interoperable so long as the practice is not disadvantageous to them:
Vendors could easily build stuff that was interoperable, and whenever they decided that they wanted to, they have, and so there's a lot healthcare organizations that don't really want to share any data because the people they're sharing data with are their competitors, and sharing data would mean they would lose either revenue or patients or something like that.
Congress is currently asking questions about its role in advancing EHR interoperability and exchange health data in hearings before the Senate Committee on Health, Education, Labor & Pensions, but its witnesses are mostly answering questions about technology and not policy.