Does interoperability have to be hard?

The ideal of interoperable electronic health records isn't hard to understand. Data that moves freely across a patient record from multiple points of care means that tests that might have been duplicated in the past get performed only once, it means that doctors get an accurate read on medical history, and patient data can be aggregated for research and analytics, leading to faster advances in diagnostics and treatments.

Congress and the the Office of the National Coordinator for Health Information Technology have put providers on a path to achieving interoperable health records. A bill report from the House Energy and Commerce Committee says that by 2018 "the administration must adopt interoperability standards that allow every health care provider to access and use longitudinal data on the patients they treat to make evidence-based decisions, coordinate care, and improve health outcomes as quickly as possible."

National Coordinator Karen DeSalvo said in February that “We have to ensure that HIT, an interoperable network of information and data flow, connects providers and patients across the continuum."

But things get messy, as they so often do, when reality doesn't match up to the policy road map. Currently the Department of Defense is in the midst of an $11 billion procurement for an electronic health records system that will be interoperable with the systems at the Department of Veterans Affairs and with the private sector. But leading military and VA health officials are the first to acknowledge that making interoperability work is a tough slog.

"Interoperability is a difficult issue," Dr. Terry Cullen, chief medical information officer and director of health informatics at the Veterans Health Administration, said at a July 9 health IT discussion on Capitol Hill. "We have done the best that we can with the resources that we have available to us, and you know what? It's not enough."

Together, the departments of Defense and VA are ahead of the health care industry on what Terry terms the "non-sexy, boring" issues of interoperability – data standards, terminology agreement, data hygiene, data ownership and provenance, and other elements of an interoperability framework. "We really are the cutting edge of the stick," she said.

Lt. Gen. Douglass Robb, a physician and director of the Defense Health Agency, noted that the speed of technological change contributes to moving the goalposts on what is meant by a patient record and what is meant by interoperability. "The problem is, every time we decide what [interoperability] looks like, it has the opportunity to do something else," Robb said. Creating an interoperable continuous record out of patient care might not be that hard, he said, but the game keeps changing. The health record is transforming into "a clinical support tool which is now being used by systems to also be a business support tool. The platform keeps growing new personalities," Robb said.

In her February speech, ONC's DeSalvo defined the problem as one of siloed data. "We need to set it free from its silos and follow the patient where it is needed in a safe, secure, private, and reliable way across accessible networks that are following the proper regulatory framework and in a business environment that allows for this to happen," she said.

The Department of Defense health systems serve a patient population of about 9.6 million, many of whom get at least some of their care through the VA or private providers. The outcome of DOD’s planned electronic health record procurement, and the mandate that it be interoperable with VA systems, is likely going to accelerate the pace of developing interoperability standards, leveraging some of the ground-level data work that Cullen described.

If the effort is successful, the promise for the future of health care for servicemembers, their families, veterans, and the general population is likely to be transformative, according to Dr. Karen Guice, the principal assistant secretary of Defense for health care. "The power of big data, based on comparable data being accrued across two very large federal departments and then being able to use that data to provide better health care for the future or to provide predictive analytics ... is huge from a business perspective," she said. "If you make that easy, the power of that to change policy, the power of it to improve people's lives is just enormous."