Health Data Without Borders
An Introduction to Healthcare Interoperabilty
OKKK so today we’re going to look into healthcare interoperability. I’m just going to give a quick definition and background, and then provide a lot of resources about specific parts of the ecosystem: the public and non-profit standards-setters, the standards themselves, private companies operating in the space and little about what they do, and then some general resources at the end.
The aim here, as usual, is to provide a broad overview without getting super detailed, and to link liberally to more detailed sources.
What is Interoperability?
Healthcare organization collect a lot of data: clinical data about patients, prescription data about their medicines, claims data for billing and a lot more. That data is useful to providers, patients, pharmacies and payers.
Healthcare interoperability is how that data gets shared between organizations and individuals.
Public & Non-profit Standards Organizations
I’m risking some confusion by lumping organizations that set policy standards (ei. what information is mandated or suggested to be included in interoperable systems) from technical standards (ie mandating the format and structure of the information being shared). I hope by making that distinction here and in the text below it will be clear which is which.
ONC - The Office of the National Coordinator for Health Information Technology
ONC is the office within the Department of Health and Human Services (HHS) that supports the adoption of information technology across the healthcare ecosystem, and to promote exchange of health data.
It was created in 2004 and mandated through legislation in the HITECH Act of 2009.
It promotes the use of interoperable standards but does not itself maintain them. It is responsible for the USCDI (the US Core Data for Interoperability), TEFCA (Trusted Exchange Framework and Common Agreement) and other US policy standards (as opposed to technical standards). That means it sets up the requirements of the types of data the technical standards must handle.
There’s more on USCDI below.
HL7 - Health Level Seven
HL7 is an international, non-profit standards developing organization whose mission is “To provide standards that empower global health data interoperability.”
HL7 developed many of the standards we’ll discuss below, especially FHIR and CDA.
CMS - Center for Medicare and Medicaid Services
This is the agency that runs Medicare and Medicaid, and therefore sets a lot of precedents for the health care industry.
Interoperability-wise, they have a few APIs, especially the Blue Button APIs for claims data that is a model for other payers’ FHIR-based claims data sharing
HIEs - Health Information Exchanges
Networks that allow the sharing of patient health care data between providers and health care systems. These can be administered by governments or private companies.
IHE - Integrating the Healthcare Enterprise
IHE is an initiative by healthcare professionals and industry to improve the way computer systems in healthcare share information. IHE promotes the coordinated use of established standards such as DICOM and HL7 to address specific clinical needs in support of optimal patient care. Systems developed in accordance with IHE communicate with one another better, are easier to implement, and enable care providers to use information more effectively.
Standards
FHIR - Fast Healthcare Interoperability Resources
A set of standards developed by HL7 that standardizes how health information is organized and transmitted into an interoperable format. This is the easiest to parse, and most '‘interoperable” of the standards that exist, but there is considerable variation in how it is implemented, so it still has its challenges.
On FHIR, other standards and APIs, Health API Guy is a great resource. I won’t try to match him here, but I will link liberally to his content.
And here are some links from Health API Guy:
General
Documentation - Very detailed documentation on FHIR. Take it with a grain of salt, though, as features and capabilities described in the spec aren’t always available with the EHR vendor you may aim to work with.
Community- A great Zulip (pseudo-Slack that’s free) to ask questions and interact with the community.
FHIR Blogs- Lot of perspectives about FHIR to be had here.
CDA - Clinical Document Architecture
CDA is an HL7 standard that is older than FHIR and harder to parse. Generally it has some XML-encoded metadata (eg. provider name, document type, document ID, etc. ) and then a body that is often just a .doc or pdf file.
CDA files are still very common even though there are some clear advantages to FHIR.
SMART
Including this as an example of an implementation of FHIR. SMART is a nonprofit standards group run out of Boston Children’s Hospital that has a few projects in the interoperability space, including a FHIR-based app-launcher. The docs and standards are worth a perusal.
USCDI - US Core Data for Interoperability
USCDI is the core set of data that ONC requires as part of their interoperability standard. It can be applied to FHIR data objects, as shown in this FHIR USCDI implementation guide. It includes several broad categories that should be included in an exchange of health information
Allergies & Intolerances
Immunizations
Assessment and Plan of Treatment
Care Team Members
Clinical Notes
Goals
Health Concerns
Problems
Patient Demographics/Information
Medications
Laboratory
Procedures
Provenance
Smoking Status
Unique Device Identifiers for Implantable Devices
Vital Signs
Blue Button
FHIR-based API for pulling claims and beneficiary data for Medicare beneficiaries.
It set a precedent for other FHIR-based sharing of claims data, the type of which is used by 1upHealth and Flexpa for common use cases
CCD - Continuity of Care Document or CCRs Continuity of Care Record
CCDs/CCRs are based on the CDA architecture. It should contain a subset of the total information known about a patient, but it’s the subset that is needed to continue care of the patient. It’s usually meant to be exchanged when a patient is changing care settings.
DICOM - Digital Image and Communications in Medicine
DICOM is a standard for digital imaging originally published by the American College of Radiology - National Electrical Manufacturers Association Standard for Digital Imfaging and Communications in Medicine. Now it’s administered by the DICOM Standards Committee. DICOM specifies a data interchange protocol, digital image format, and file structure for biomedical images.
TEFCA - Trusted Exchange Framework and Common Agreement
This one is pretty new! TEFCA outlines a common set of principles, terms and conditions with the aim of developing a common agreement for exchanging health data by Health Information Networks (HINS).
It will establish Qualified Health Information Networks (QHINs) that meet the requirements and Participant Health Information Networks (HINs).
TEFCA should be less immediately relevant to any health care company that does not aspire to being an HIN.f
Interoperability Companies
Networks
CommonWell
A nonprofit network of health data exchanges representing 27k+ provider sites, 171M+ individuals and 2.6B+ health records. They use IHE standards as well as FHIR-based standards. It integrates with many EHRs and API on-ramp providers.
Carequality
A nonprofit network that supports 300M documents exchanged each month, Carequality is an interoperability framework connecting health information networks throughout the country. It integrates with many EHRs and API on-ramp providers.
SureScripts
A private health data network that integrates with EHRs, Pharmacy Benefits Managers, pharmacies, and clinicians.
Managed service offerings
These companies will help you integrate with sources of clinical data:
HIE on-ramps
These companies provide APIs to help you connect to Health Information Networks more easily and with more scale:
Tools to help you build interoperable features more quickly
Resources:
I linked to a bunch of relevant resources above, but the key overall sites are:
ONC: https://www.healthit.gov/
HL7: https://www.hl7.org/
SMART: https://docs.smarthealthit.org/
Blue Button/CMS: https://bluebutton.cms.gov/
If you need to work with these standards a lot, I recommend reading the Health API guy:
