Further interoperability work is necessary to fuel telehealth, care at home, and social determinants of health initiatives, says HIMSS leader Hal Wolf.
Last March, the U.S. Department of Health & Human Services released two final rulings designed to enhance healthcare interoperability. While it was a much anticipated milestone moment, it only marks the beginning of a long road ahead, says Hal Wolf, president and CEO of the Healthcare Information and Management Systems Society (HIMSS).
HealthLeaders recently spoke with the healthcare and informatics expert. In Part 1 of this story, Wolf explains the gaps that the pandemic revealed and the role healthcare IT and HIMSS will play in bridging the divide. In Part 2, he explores how interoperability and a national patient identifier are key elements in paving the way forward, and he peers into the future, offering his predictions about how healthcare will change in the next three years. Following are excerpts from the interview, edited for space and clarity.
HealthLeaders: What barriers do we still have to overcome from a technical standpoint to get us to the next phase of healthcare transformation?
Hal Wolf: We know that we have to go to a standard language for interoperability to occur. We've got to do so quickly and immediately, but the bottom line is no matter how much I can exchange data in a common language, if I don't have a national patient identifier to ensure that the patient I'm getting information on is [the right] person, I'm wasting cycles. I'm wasting time. I'm endangering their outcome. It's fair, I think, to say we'll never achieve true interoperability until we have a single patient identifier.
HIPAA is designed to secure information, but in our archaic system right now, every time you go into a doctor, a new clinic, or a hospital, you take that exact same personal information, and replicate it in a whole bunch of different places. You have to refresh that information going into a brand-new facility versus having one record that follows you around and having one database. Your vulnerability of bad information, hacking, or something of that nature goes up every single time. Having significant information in a multitude of locations, frankly, is less secure.
I'm going to feel more secure when we have a singular data environment that's extremely well managed and secure with a national identifier behind it, and the means behind that—with blockchain or whatever security apparatus we need—for the aggregation and the collection of my data from multiple places.
Hal Wolf, president and CEO of HIMSS (Photo courtesy of HIMSS)
HL: What is the status of legislation related to creating a national patient identifier?
Wolf: It has passed the House the last two years. The holdup right now is in the Senate, which has been distracted by the election as well as the pandemic. But behind the doors there are discussions to ensure that the patient identifier is brought forward. We're beginning to hear that there's a real opening for it and the recognition that we're not going to be able to keep people safe unless we can get to their records swiftly and completely. We're expecting the Senate to move forward with it.
HL: The final interoperability rules came out last March. What's next in that arena?
Wolf: The next big push is something HIMSS got involved in, which is the Global Consortium for eHealth Interoperability. There are a number of existing standards out there—such as HL7, IHE, and Continua—that all do different things. Until last year, there seemed to be a concept by many different people that each one of the standards was competing with each other when, in fact, they do different things. Interestingly enough, several of those organizations came to HIMSS and asked us to create one consortium so we can exchange best practices on a global basis. This exchange is now taking place. The Office of the National Coordinator for Health Information (ONC) is a member and a number of different countries have lined up.
HL: Can you tell us more about this?
Wolf: The Global Digital Health Partnership (GDHP) is involved, and the World Health Organization (WHO) is looking at it. Everyone recognizes that if we don't do this on a global basis, here's what happens: The United States creates a data infrastructure and environment. Then we want to put that information through the United Nations, WHO, or other Centers for Disease Control and Prevention (CDC) counterparts around the globe. They have a database that has a different piece of information. How are we going to exchange information? How are we going to do the research? How do we respond just in time to global crises and the exchange of information? This isn't going to be the last time that [something like COVID-19] happens; we need to be able to share information.
The next point [involves portability of patient records.] People are not stagnant; they move around. The idea of borders doesn't work for pandemics or viruses. People shouldn't have to be the carrier pigeon of their own information.
We want to make sure that [developers] understand how to use standards on a consistent basis and give examples of how to use the standards. If someone is looking for a solution, they don't have to reinvent the wheel. The real trick here is to give people examples and make it uniform around the globe.
We also added a fourth dimension to interoperability this past year, which isn't just technical; it also focuses on the definition of outcomes. Interoperability isn't just a technical exchange; it also can be an idea exchange and a betterment exchange.
HL: Take us three years into the future. Paint a picture of how you think healthcare will be different based on what's already in motion today.
Wolf: Given a three-year time frame:
- Telehealth and digital health encounters will probably equate to somewhere around 20% of the total encounters that exist. That doesn't mean a one-for-one swap out of face-to-face encounters. We opened up a new channel of distribution and access to healthcare through the use of digital health. This is a lesson learned that I've seen in every program that's gone to scale. They may have 50% of their encounters now in a digital format, but the number of physical encounters remains the same.
We have a lot of pent-up demand in this country and around the globe. We don't reach out to doctors to get quick answers to simple questions. We have a tendency to use "Dr. Google," which isn't necessarily the best source unless you know what you're looking for. We don't think about the fact that you can send an email to your own doctor and get a reply in the next 12 to 24 hours. So digital health is going to increase.
- Secondly, especially in the U.S., we'll be putting a plan together and building out that national patient identifier. We'll be figuring out how it's going to be stored, where the information will be, what are the roles and responsibilities. That's not a light switch. You just don't declare it one day and the next thing you know, it's going to magically appear. We need to do it thoughtfully. We need to do it securely. We need to do it judiciously. And we will.
- The third piece where we're going to see quite a significant increase is care at home. Whether it's monitoring, sensoring, or whatever the case may be, we're going to see a lot more devices tracking people in their home environment and at the individual level. Thanks to interoperability, that's going to come into play. That will help us in our clinical decisions.
- The fourth thing, which I think will be very prominent over the next three years, is the development and the use of social determinants in how we think about population and individual health. Especially in the United States, we've been catching up on the idea of social determinants, and we just are now getting them into play. COVID-19 put a spotlight on many of the gaps that we have and how social determinants are playing a role in that. Digital health is one of the great equalizers.
I think we'll see strong development on those four things over the three years. That excites me. It won't be 100% done in three years, but we're looking at important change management.
HL: One of the fears about telehealth is that it would create a new market, versus replacing face-to-face encounters. Your prediction confirms that. At a time when the physician workforce is declining, that's not good news. Would you like to comment about that?
Wolf: You're absolutely right. There are two gaps. A significant portion of the primary care workforce is approaching retirement in the next 10 to 15 years. We won't have the primary care doctors that we need to be able to do encounters every single time someone wants to go in for a checkup. Secondly, we have a 13 million clinician gap that's expected by 2030. According to WHO figures, it's about 7.5 million now. So what do you do with these shortcomings? This is where clinical decision support, home monitoring, and telehealth [including communication modalities such as] email come in. [These tools] can take what would normally be a 20-minute slot and make it five minutes on each side with a quick exchange.
If [telehealth] is opening up another channel, we have to take a strong look at scope of practice. We need to make sure that doctors are taking care of doctor issues. Clinicians, [such as] nurse practitioners, are filling in the gap where they can. We have to be smart in our use of clinical decision support and the controlled use of artificial intelligence and machine learning, which have the proper basis behind it for knowledge management.
“We know that we have to go to a standard language for interoperability to occur.”
HIMSS President and CEO Hal Wolf
Mandy Roth is the innovations editor at HealthLeaders.
A standard language for interoperability is essential for healthcare to move forward.
Resistance to a national patient identifier is softening, but legislation is currently stuck in the Senate. Support is moving in favor of this measure, and HIMSS expects action following the election.
The Global Consortium for eHealth Interoperability is bringing together stakeholders from around the world to address interoperability issues in unison.