Data “integration” has been a buzzword for years, but only now are healthcare organizations realizing what it truly means to integrate — both within and outside their own four walls. To achieve collaboration across the entire continuum of care, a significant shift in data standardization and integration must occur. Joint efforts between the Department of Veterans Affairs (VA) and the Department of Defense (DoD) are a start, and promise to spur momentum toward communication with private health systems as well. The ultimate goal is nothing less than the creation of a longitudinal patient record that helps lower costs, enhance care and improve day-to-day efficiencies.
The eHealth Exchange is one example of a national collaboration aimed at expanding the interoperable exchange of information. Formerly known as the Nationwide Health Information Network Exchange (or NwHIN), eHealth Exchange illustrates the fact that adoption of data and terminology standards is the linchpin for health information sharing.
Toward this end, several initiatives have started to establish various sets of standards to make more interoperability efforts like eHealth Exchange a reality. The VA and DoD are working cooperatively to deploy technology systems and terminology standards that will better support care collaboration between the federal agencies. Already, the VA has adopted the Continuity of Care Document (CCD/C32), which is certified for the exchange of clinical information on eHealth Exchange. Eventually, standards will also be used to foster collaboration between federal agencies and private healthcare organizations.
HIE hinges on terminology standards
The healthcare industry recognizes the need for standardized terminologies that can act as “universal adapters” to facilitate the flow of data and achieve interoperability among multiple organizations using disparate systems. Arriving at a consensus about exactly what they should be, however, is the difficult part. While multiple terminology standards (for example, SNOMED CT, CPT, and LOINC) already exist, not all of them have been widely adopted and implemented.
To counter this problem, the VA is seeking to introduce standard terminology that can be adopted by other government agencies — as well as the public sector — through strategic partnerships with private health IT companies. For the past several years, for example, the VA has worked to standardize terminology translations for the eHealth Exchange through the Standards and Terminology Services (STS) Support Services and the Virtual Lifetime Electronic Record (VLER) programs which aim to leverage standardized terminologies such as ICD-9 and ICD-10, SNOMED CT, CPT, and LOINC to support the interoperability of data. There are also a variety of programs focused on standardizing data across the VA and the DoD.
The VA and DoD are not the only government agencies using technology to enhance care collaboration in the healthcare setting, of course. The Centers for Medicare and Medicaid Services (CMS) is partnering with a team comprised of commercial health IT companies on an initiative called “Electronic Submission of Medical Documentation” (esMD), which is designed to give providers a more efficient way of delivering medical records needed to process claims.
esMD builds on eHealth Exchange technology to ensure documentation remains secure as it is transmitted. Electronic document transmission helps to improve efficiency by eliminating the need to scan and fax physical paper to CMS. Furthermore, CMS believes the adoption of esMD can help improve efficiency of information exchange and reduce improper payments it makes to providers, estimated in the billions of dollars annually.
The use of standards in the exchange of medical orders and documents will enable information to be processed more quickly and accurately. With the widespread adoption of esMD, providers could fulfill medical documentation requirements efficiently, and with minimum disruption to workflow processes.
Stakeholder engagement converges with IT
The technology requirements for enhancing interoperability and collaboration are the same for both the government and private healthcare sectors. The key to adoption will be the willingness of both sectors to work together, using available technology and standard terminologies.
In the past, government agencies such as CMS often worked independently, developing forms and procedures that private health organizations accepted with limited participation in the development process. Today, government agencies are working in conjunction with outside organizations to develop collaborative pathways. One of the challenges, however, is convincing private IT companies of the value of engaging in collaboration.
Although the industry acknowledges the benefits of standardization, it comes at a cost. Vendors comprehend the real-world difficulties that arise from implementing standard terminologies, clinical decision support and other care collaboration measures. For instance, the “Meaningful Use” criteria established for electronic health records (EHRs) will require vendors to update their applications to be compliant with new and evolving standards. As a result, the Office of the National Coordinator (ONC) is soliciting their feedback with respect to standardization and interoperability requirements.
Ideally, all stakeholders should be actively contributing to the discussion — including providers, patients and patient advocacy groups. IT subject matter experts who are also clinicians, for example, can better anticipate the potential impact of standard terminology adoption on clinical workflows and patient care. As patient engagement becomes a more significant driver in the future of healthcare, individuals will not only be more necessary to the discussion but more likely to prefer an active role in decisions that impact their care.
An example of one cross-collaboration project involving the federal government, the private sector, and the public is the “Blue Button” initiative, which provides patients with the capability to download their personal health information from a personal Web portal. The VA developed the Blue Button in collaboration with CMS, the DoD, and a consumer engagement workgroup. Subsequent mobile applications for Blue Button have been developed by private sector health IT companies.
As a result of the initial success of Blue Button, the Office of the National Coordinator for Health Information Technology (ONC) has taken up the role of standard-bearer by encouraging public sector companies to develop their own versions of the Blue Button for pharmacies, insurance companies and other health organizations. The ONC promotes these collaborations using the Standards and Interoperability Framework, which is a Wikispace environment where participants can share work and exchange ideas.
[See also: HIE and the patient privacy conundrum]
The ONC is a primary driver of these collaborative efforts in that it provides the people and processes necessary for developing methodologies for public engagement. By providing these valuable resources, ONC removes some of the obstacles to participation and makes it easier for the business community to get involved. The deliverables under ONC’s projects are completed fairly quickly, which helps reduce the cycle time for gathering and analyzing information. The short cycle times increase the likelihood that companies will be willing to commit to these projects.
Standards and interoperability support a collaborative care environment
Healthcare will continue to develop strategies for creating a collaborative environment that enhances patient care, increases efficiencies and lowers overall healthcare costs. The adoption of universal terminology standards to enable interoperability will play a central role.
All healthcare organizations — public and private alike — must work together closely to bring about the standardization of terminologies. In partnerships with the private sector, the VA, DoD, CMS and other federal agencies are becoming proactive, pooling their resources to learn, share, innovate and deploy technology solutions. It is this kind of collaboration that will sustain true integration, enabling interoperability across the continuum of care.
Viet Nguyen, MD, is Chief Medical Information Officer for Systems Made Simple (SMS). He works as a terminologist with the Veterans Administration in supporting its terminology and interoperability efforts. He trained at the University of Utah as a medical informatics fellow and remains a practicing internist and pediatrician.