Section 1.3 Assess
Interoperability for EHR and HIE
Understand interoperability and healthcare industry standards in relation to electronic health records
(EHRs) and other e-health topics.
Time needed: 2 – 3 hours
Suggested other tools: NA
How to Use
1. Review the definitions and significance of interoperability for local public health (LPH)
departments that provide home health services and social services agencies.
2. Use this knowledge as you clarify your e-health needs.
Interoperability Defined
HIMSS (Health Information and Management Systems Society) defines interoperability as, “ the
extent to which systems and devices can exchange data, and interpret that shared data. For two
systems to be interoperable, they must be able to exchange data and subsequently present that data
such that it can be understood by a user” (HIMSS.org, 2014)1.
Levels of Interoperability
Interoperability can be classified into 3 levels: foundational, structural, and semantic. The levels
build on one another, and can be depicted as a pyramid:
1. Foundational interoperability
Foundational interoperability is the most basic form of health information exchange. This
type of exchange:

allows data exchange from one system to be received by another

does not require the ability for the receiving system to interpret the data
1
HIMSS.org(2014). What is interoperability? Accessed January 14, 2014 from: http://www.himss.org/library/interoperabilitystandards/what-is?navItemNumber=17333
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Example: A patient is discharged from an inpatient behavioral health unit with a referral to a
home care agency. The inpatient facility would like to send a referral summary document to
the home health agency. The inpatient facility has an EHR that can create a referral summary
in a PDF format, which staff at the home health agency can read. The inpatient facility could
then send this PDF to the home health agency electronically, using secure email or via a
secure messaging service called Direct. In this case, the home health agency’s electronic
record system does not automatically add the referral summary to this patient’s record.
Instead, a worker at the home health agency will need to read the PDF, and enter the data into
the agency’s EHR. Note that we say could. This is because the home health agency must
have the ability to receive the secure email or be enrolled with a Direct service provider. So,
in this example of basic, functional interoperability, data could be exchanged, but it is not a
seamless electronic exchange (the two EHR’s aren’t “talking” to each other).
2. Structural interoperability

defines the structure or format of data exchange (i.e., the message format standards
like HL72)

clinical or operational purpose and meaning of the data is preserved and unaltered

ensures that data exchanges between systems can be interpreted at the data field level
Example: A patient who has been receiving care at a behavioral health clinic has been
referred to a home health agency for ongoing care. The agency would like to know about the
patient’s social and family history. The behavioral health clinic uses an EHR that creates
exchange documents using the HL7 messaging standard. Therefore, the behavioral health
clinic can transmit a field of information that is labeled “social history” to the home health
agency. The EHR at the home health agency can “see” (based on the incoming message) that
the incoming information contains social history information, and therefore, deposits that
information into the corresponding field within the social service agency EHR. The sending
and receiving systems both have “pipes” in place to connect to one another AND they are
using the same message formats to transmit the information.
3. Semantic interoperability

uses both structured and coded data to ensure the receiving system can interpret the
data
Example: A behavioral health (BH) clinic treats a client who suffers from diabetes and HIV,
in addition to their behavioral health issues. The client sees a primary care provider, an
endocrinologist for diabetes and an infectious disease specialist for their HIV. The BH
providers must understand the medications and various diagnoses from all these providers in
order to provide appropriate care.
With true semantic interoperability, the BH clinic’s EHR could automatically reach out to the
other clinics, pull the various diagnoses and medications and format this information so that
it would appear in the proper fields in the BH EHR. That way the BH provider could quickly
view the pertinent information in a format they understand. Further the BH EHR could use
this data to implement clinical decision support rules (where the computer suggests actions or
flags dangers).
2
Health Level Seven, is a non-profit organization involved in the development of international healthcare informatics interoperability
standards. "HL7" also refers to some of the specific standards created by the organization. .
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Identified Benefits of Interoperability:
Experience in health care indicates that interoperability can bring important benefits, including 3.

Better care coordination

Improved patient engagement

Better medication management to promote adherence and decrease abuse

Streamlined, harmonized reporting
Challenges and Forward Progress to Interoperability in Privacy and Security:
Across the spectrum of those covered by the MN Mandate for Interoperable Electronic Health
Records, there is concern about privacy and security, especially when the information about a patient
or client is moving from one agency, hospital, clinic, or practice to another. The good news is that
properly implemented technology can help overcome these issues. See below for some challenges
and progress:
Challenge: Concerns about the appropriate storage and maintenance of behavioral health and
substance abuse data.
Forward progress: The Substance Abuse and Mental Health Services Administration
(SAMHSA) has been leading efforts to develop standards and recommendations about what
data to include in an electronic summary document (referred to as a “CCD”) disclosed by a
behavioral health provider through the international standards development organization
called Health Level 7 (HL7) 4.
Challenge: Concerns about how to comply with federal health information privacy laws, how
to determine the chain of responsibility for following up with patients (i.e., when a patient
does not make it to a referral appointment), sharing sensitive information through
dashboards, storage and access to psychotherapy notes, referral management, liability issues,
etc.
Forward Progress:
3

EHR vendors have created technology that ensures that 42 CFR Part 2 requirements
are met in a way that allows for rapid approval of information sharing (or restriction
of sharing) based on client preferences. See a video demo here:
http://www.satva.org/

The federal government, through its BEACON Grants gathered providers together to
demonstrate how data in an electronic record can be segmented, so that a client can
grant permission to share some data and not other. See a YouTube video here:
https://www.youtube.com/watch?v=4lMG96nmWS0
http://www.healthit.gov/providers-professionals/faqs/what-are-benefits-health-information-exchange
4
HealthIT.gov(2014). Behavioral health roundtable: Summary report of findings. Accessed January 14, 2014 from:
http://www.healthit.gov/sites/default/files/bh-roundtable-findings-report_0.pdf.
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Tips and More Resources:
Be sure that any EHR considered for use conforms to the applicable technical and semantic
standards. Adherence to these interoperability standards supports data exchange. Talk to vendors and
their customers to make sure the advertised benefits are backed up with real functionality that
actually works for people in your profession.
For additional information on Minnesota’s state mandate for interoperable EHRs and state regulation
and advice on health information exchange see:

2015 Interoperable Mandate Policy Guidance see: http://www.health.state.mn.us/ehealth/hitimp/2015mandateguidance.pdf

MN e-Health Initiative’s Standards Guide see: http://www.health.state.mn.us/ehealth/standards/g2standards2011.pdf

A list of MN State Certified HIE vendors is available here:
http://www.health.state.mn.us/divs/hpsc/ohit/hieguidance/hieservicestable.pdf

A printer-friendly version of A Practical Guide to Understanding HIE, is available here:
http://www.health.state.mn.us/divs/hpsc/ohit/hieguidance/hieguide.pdf
Copyright © 2014 Stratis Health.
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Updated 03-10-14