Interoperability, the 21st Century’s Golden Fleece

Jason, mythic hero prior to the Greek Dark Ages, was tasked to find the Golden Fleece before he could claim his throne. For this quest, Jason recruited other Greek heroes, Hercules, Orpheus, Castor and Pollux, to name a few of the Argonauts.

Today, a new Jason summons new heroes to join in the quest for the new Golden Fleece. This modern-day JASON is actually a group of distinguished, credentialed scientists who provide advice to the U.S. government, principally the Department of Defense (DoD), on science and technology issues.

Taking a cue from the DoD, the Agency for Healthcare Research And Quality (AHRQ) sponsored JASON’s consideration of access to and integration of health data. The resulting white paper, “A Robust Health Data Infrastructure,” was published on April 9 and was deservedly, widely referenced.

In this intense 69-page paper, interoperability, specifically the lack thereof, is the problem, and a defined IT architecture is essential to the solution. To which Carla Smith of HIMSS posted and asked, “Can architecture be defined in 12 months?” I think a case can be made for the parallel question, “Can interoperability be defined in 12 months?”

Many would define interoperability as the capability of sharing information and services. “Share,” the operative word, is nebulous, textured and mischievous. Suppose I desire the information of enterprise A and the information of enterprise B to be interoperable. If I can view enterprise A’s information and enterprise B’s information, and that’s all that I can do, is the information interoperable?

Suppose an end user, a physician, wants to see his patient’s hemoglobin A1c levels over the past six months. But suppose the patient has hemoglobin A1c levels drawn by three different enterprises – the emergency department, walk-in clinic and preferred lab service vendor. Being able to view all three enterprise results has value, but is not interoperability. The capability of integrating the data and sorting by date and time brings a higher level of interoperability than just sharing a view. Interoperability, like safety, is not a binary state, but a continuous distribution spectrum.

The JASON publication is four months old, in IT time almost a different era. But the recent draft of a bill by the Senate appropriation committee, as reported by Clinical Innovation & Technology (CI&T), invites a refocus on the JASON work.

The draft bill would require the Office of the National Coordinator for Health IT’s (ONC) Health IT Policy Committee to issue a report on the operational, technical and financial challenges of EHR interoperability, as well as the role of EHR certification in advancing or hindering interoperability.

Why are lawmakers jumping in on this topic? “It appears that the Senate believes that the lack of interoperability is preventing a return on investment from the HITECH Act, and that moving more quickly towards immediate interoperability will make our healthcare system better, safer and maybe even more affordable,” opined Dr. Peter Basch, MD, medical director of ambulatory EHR and health IT policy at MedStar Health.

But Basch is wary of moving too fast or too broadly. He told CI&T, “I like a more reasoned course, what I would term ‘just enough interoperability.’ Frustrations aside, many clinicians are as concerned about too much information as too little, particularly when that information comes without filters or context.”

Similarly, in making its architecture recommendations, the JASON report is tempered: “The architecture should identify the small set of necessary interfaces between functions, recognizing that the purpose of the software architecture is to provide structure, while avoiding having ‘everything talk to everything.’ ”

More specifically, I believe the JASON report is advocating IT architecture as the basis for effective, “just right” interoperability. Not too much, not too little, but just right.

That architecture should be understood as the components that make up the overall information system, hardware, software, licensing personnel, governance and strategy and how they are structured to support the business enterprise.

Understanding all of this allows one to prioritize the enterprise’s databases. And guess what? Everything does not need to integrate with everything else. Some silos are actually okay at times and are frequently indicative of smart IT architecture.

We read in the ONC’s “A 10 Year Vision To Achieve An Interoperable Health IT Infrastructure” that “an interoperable health IT ecosystem makes the right data available to the right people at the right time across product and organizations in a way that can be relied upon and meaningfully used by recipients.” IT architecture defines who the right people are, what information they need and in what time frame they need it, to make meaningful decisions to achieve better quality at lower costs, the Golden Fleece of the 21st century.

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