On 29 September, Congress’ Government Accountability Office (GAO) released a report highlighting the status of efforts by non-federal entities to achieve interoperability of health information, including electronic health records (EHRs).
EHRs are designed to contain a patient’s medical history, diagnoses, medications, treatment plans, immunization dates, allergies, radiology images, and laboratory and test results in a digital format that can be shared by providers across more than one health care organization, allowing for better informed medical treatment. All clinicians involved in a patient’s care ” from the doctor, to specialists, testing laboratories, medical imaging facilities, pharmacies, emergency clinics, etc. ” would have access to the same basic information about the patient’s health. With EHRs, critical health information on medical conditions, allergies and immunities, and prescriptions would be available to medical first responders in an emergency or to physicians treating patients away from home or who have been dislocated by natural or other disasters.
The envisioned national health IT system would go beyond health provider access to standard clinical data to enable opportunities for clinical research and analytical tools that can provide a broader view of patient care. Medical researchers would be able to validate treatment options for various illnesses, as well as spot emerging health risks and identify promising new treatments, therapies and cures.
The two biggest obstacles to realizing the advantages of EHRs have been ensuring appropriate levels of patient privacy and the challenges related to ensuring the interoperability of the health records and the systems used to read and store them. IEEE Standard Computer Dictionary provides a widely referenced definition of interoperability as “the ability of two or more systems or components to exchange information and to use the information that has been exchanged.”
The federal government made interoperability of electronic health records a national priority in 2000, and later mandated interoperability of federal health records by 2014. A strategic partnership between the Veterans Administration and the Department of Defense is driving substantial progress toward interoperability of military electronic health records, and the Department of Health and Human Services has promulgated various federal rules and regulations, and is currently soliciting comments on proposed interoperability standards through the office of the National Coordinator for Health IT. However, interoperability challenges encountered in the non-government sector, coupled with a growing interest in global interoperability, suggest that there are still substantial barriers to realizing a truly interoperable national health information system.
It was this area of non-federal initiatives to achieve or facilitate electronic health record interoperability that the GAO examined. For purposes of its study, GAO adapted IEEE’s definition as “EHR interoperability is the ability of systems to exchange electronic health information with other systems and process the information without special effort by the user, such as a health care provider.” GAO then looked at 18 specific non-federal interoperability initiatives. What they found is that the majority of providers were still in the process of developing, or encouraging others to adopt, their products or services. The non-federal efforts varied in a number of ways, including the types of electronic systems being used, the actual or planned cost of products and services, geographic service areas, patient uses and organizational structures. For example, some initiatives planned to make products and services available at no cost, while others were using fee-based structures that varied according to the type of user (e.g. a solo practitioner versus a hospital) or the amount of data exchanged. Patient access and control over health information also varied widely by initiative.
The stakeholders’ interviewed by GAO described five key challenges to achieving EHR interoperability, which are consistent with challenges described in past GAO work. Specifically, the challenges they described are:
- Insufficiencies in health data standards
- Variation in state privacy rules
- Accurately matching patients’ health records
- Costs associated with interoperability
- The need for governance and trust among entities, such as agreements to facilitate the sharing of information among all participants in an initiative.
How each stakeholder is responding to each challenge varies, with each entity taking different approaches.
With respect to standards, the GAO found that:
“While standards for electronically exchanging information among EHR systems exist, stakeholders and initiative representatives said that these standards are not sufficient for achieving EHR interoperability. This challenge stems from the fact that some standards are not specific enough and, as a result, the systems that implement these standards may not be interoperable. According to some stakeholders, some standards allow EHR systems to use different formats and terminology when exchanging data. However, this resulting variability prevents the receiving system from processing the information and properly integrating it into the patient record; in other words, the systems are not interoperable. Information that is electronically exchanged from one provider to another must adhere to the same standards, and these standards must be implemented uniformly, in order for the information to be interpreted and used in EHRs, thereby enabling interoperability.”
When asked how the goal of interoperability could best be moved forward, the stakeholders emphasized the need for health providers to take a stronger role, suggesting that the medical community has not fully embraced the potential of EHRs as a valuable tool for improving clinical care.
For more information, see the GAO study (GAO-15-817) at: https://www.gao.gov/assets/680/672585.pdf