HIT Interoperability Still Maddeningly Elusive

On the issue of interoperability, there is considerable evidence that technology vendors, federal regulators, and healthcare providers are persistently speaking past each other, resulting in the same kind of gridlock we see elsewhere in politics.

Apple last week introduced a glorified fitness trainer for your wrist that fell far short of being a medical device, and with good reason. Washington, of course, is known not as a hotbed of innovation, but as a hotbed of regulation. Medical devices, being but one part of healthcare under regulation's watchful eye, are no exception.

Nothing epitomizes the last few decades of regulatory culture like the usual process for public input into a new regulation, whether from the Food and Drug Administration or the Office of the National Coordinator for Health Information Technology.

Acts of Congress or presidential directives lead to the establishment of task forces, which themselves spawn subcommittees, which report out or back to larger committees, which in turn take public comment before deliberating and then deciding to move forward, or to wait for more information, or to do nothing at all due to factional fighting or lack of leadership.

This is American democracy in action, and you can see a version of it at any local school board or city council meeting.

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But the governance process has its idiosyncrasies. Public comment typically is limited to three minutes or less. Even testimony of invited speakers on a typical ONC panel is limited to five minutes. Try to summarize any of the many issues facing healthcare in five minutes. They are too complex. It cannot be done, even with time for Q&A afterward.

The prospect of such a governing process being brought to bear against healthcare IT's biggest challenge —interoperability—is daunting indeed.

Month after month, members of ONC's health IT policy committee, its health IT standards committee, and various designated subcommittees advise ONC and the Centers for Medicare & Medicaid Services how to craft regulations and guidelines to achieve the triple aim through health IT.

But committee members bring their own experiences and biases, as do invited speakers and members of the public. And on the issue of interoperability, there is considerable evidence that participants are speaking past each other in the same kind of gridlock we see elsewhere in politics.

To sum up the conundrum facing those who would mandate health IT interoperability, I would submit that getting participants to truly interoperate requires a spirit of cooperation all too often missing between opposing factions, whether they are providers, payers, or vendors.

In short, no one wants to see the outcome of these interoperability efforts, including ONC's proposed ten-year roadmap, convey a competitive advantage to a rival. And since there are a variety of "siloed" interoperability efforts already underway ranging from Epic's CareEverywhere to the Commonwell Alliance to Healtheway, SureScripts, and DirectTrust—each of these efforts has more or less signaled why it is the demonstrably superior way to tackle interoperability.

Technology is always the joker in the deck. Here is a way to think about this. When the U.S. was a young country and the railroads were just starting, different railroad builders were using different gauges (widths between rails) preventing trains from moving from one company's tracks to another's.

At a certain point, the government mandated a standard width of railroad gauge, and that was that. Trains evolved, but with almost no exception, railway innovation did not require changing the gauge.

Even in the information age, certain standards, such as the method of clearing checks between rival banks, fell into a kind of permanence that allowed innovation without requiring the underlying plumbing to be ripped out. Indeed, the TCP/IP protocol underlying the entire Internet is a shining example of this.

But healthcare technology faces a continuous threat that some new way of doing things—some tech innovation—will appear and sweep aside the "railroad gauge" of a few years ago. This can threaten incumbents and innovators alike.

This is now on the brink of happening on a grand scale, through the emergence of HL7's FHIR standards, by which software programs are connected over the Internet using the most popular modern method of doing so, known as REST. You may not know REST, but you know many Web sites that rely upon it, from Facebook to Google to Twitter and lots more.

The ONC's policy and standards committee is now trying to find a way to implement interoperability in meaningful use Stage 3 with an option to allow FHIR.

It's a stretch for two reasons: FHIR isn't fully defined yet, and the Stage 3 Notice of Proposed Rulemaking is already being written by CMS and will be out for public comment this fall. There seems no way the final Stage 3 rules can be written after FHIR is fully baked and out of the standards oven.

Fortunately, you have a unique opportunity as of this writing to weigh in on this issue and lots more, without being limited to three minutes, and without waiting for CMS to issue its proposed rule.

That is because this week, National Health IT Week, ONC has left open the ability for anyone to leave their thoughts on how best to achieve interoperability at a Wiki which ONC established for public comment on Connecting Health and Care for the Nation, ONC's "concept paper" for its 10-year interoperability roadmap, itself due out in draft form in January 2015.

Although ONC asked for all comments by last Friday, as of Monday evening the Wiki was still allowing comments on variety of aspects of health IT interoperability. Some prominent stakeholders such as the AMA and HL7 have already weighed in.

But this is a golden opportunity for providers, who often have the very tough task of implementing and attesting to meaningful use requirements, to participate in a way that will ripple not only through the ten-year plan but also through the rules being written for Stage 3 of meaningful use.

Throughout this process, again and again you will hear a common refrain: True interoperability will also require an accelerated effort to align incentives away from fee-for-service and toward value-based purchasing or accountable care. I have no doubt that the EHR vendors can be brought into alignment with standards that can work today (Direct, CCDA) or the fast-emerging FHIR standards.

But only when it is in each provider's best interest to share patient data with all other providers, including the hated rival across the street or across town, will true interoperability occur. Until then, stakeholders will continue not to truly listen to each other, or to patients, but will continue talking past each other.