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Interop Findings: Standards Summary

Standards

Health IT Standards present an evolving landscape. Aspects of healthcare data exchange are working today, but clincians and patients face serious challenges on the ground. There are multiple perspectives about the best path forward.

Under the Meaningful Use Stage 2 incentive program, 2014-certified EHRs enable exchange of clinical data via the Consolidated CDA document format. Two key patterns are: exchange among clinicians ("Transitions of Care") and exhcnage at a patient's request ("View, Download, Transmit").

But while exchange occurs today, challenges include:

  • An immature ecocystem. C-CDA data can be hard to interpret, with the same fields used in inconsistent ways, though implementations are improving with real-world testing.

  • Awkward workflows. It can be hard to know which providers are able to receive data, and hard to produce a message that includes relevant context (rather than just an automatically-generated data dump). Most workflows today require a human in the loop to compose a message or click through a portal. But in practice, just describing structured data is not enough; we need automatable Application Programming Interfaces that allow data to move seamlessly.

  • Care coordination. Particular challenges for coordinating are across clinical settings include the need for shared longitudinal care plans, the ability to create persistent connections among systems (rather than providing a one-time data dump), expose consistent patient identifiers, and shared strategic commitment to this work.

  • Limited data standards. Standards necessarily focus on a limited, high-value "common data set". But real-world healthcare data are broad and deep, and the need for interoperability extends to sharing data that have not been standardized (and can't readily be).

Recommendations and future directions

  • There is tension between the desire to solve problems with new standards and technology vs. making iterative improvements to the technology on the ground today. At least some continued investment in existing document formats is worthwhile.

  • Emerging standards like FHIR look like a promising way to deliver more consistent structured data. ONC and CMS should work to motivate industry-wide adoption of common APIs.

  • Standards should be developed and extended to address high-value data with greater precision, including patient encounter notifications, lab and prescription notifications, behavioral health data, and social determinants of health.

  • Some vendors have introduced open API programs that provide documentation and an online sandbox where developers can build and test applications outside of a live production environment. It is still unclear whether it makes sense to regulate a single API that all systems must implement, vs. promoting a proliferation of vendor-specific APIs.

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