Facilitating the Secure Exchange of Health Information
By: Michael Brown, AEGIS.net, Inc.
As consumers, the ability to transfer funds between an online merchant and a bank account is a task we perform on a daily basis. To transfer funds from one institution to another, the systems on both the “sending” and “receiving” end must be able to read and interpret the messages sent between the two. Purchasing a good from an online merchant electronically indicates these systems can communicate with one another successfully, or “interoperate” as the funds are transferred from the consumer’s personal account to the merchant’s account. Many of the interactions and complexities to securely complete the transaction are seamlessly performed in the background; the consumer needs only to click “Pay”. However, interoperating, or interoperability among various health care organization systems is still in its infancy. Many organizations and systems continue to experience roadblocks in sending and receiving medical information. The limited amount of time allotted for testing interoperability implementations leads to additional complexities and has underlined the need for an automated test suite to quickly and accurately test interoperability. Improving and testing interoperability among multiple health care organizations will improve quality of care received by patients, decrease fraud waste and abuse, and decrease health care costs for providers and patients within the United States. AEGIS.net, Inc.
2275 Research Blvd. | Suite 500 | Rockville, MD | 20850
www.aegis.net | Phone: 703.893.6020
The Importance of Interoperability
Interoperability standards provide a common language and set of expectations that enable interoperability between systems and/or devices. Ideally, data exchange and standards should permit data to be shared among clinician, lab, hospital, pharmacy, and patient regardless of application or application vendor. Facilitating interoperability among multiple systems means the development of gateways and adapters. Gateways provide a “bridge” from one health care system to another, enabling the secure transfer of medical information and allowing gateway-­‐to-­‐gateway communication. Every system must have a gateway to exchange information with another system. Adapters attach to the gateways and health care system, acting as a translator for both the gateway and health care system for the message that is sent and received during a transaction. These gateways include the necessary interoperability standards to enable a secure and accurate transaction from one health care system to another. Standards-­‐based, interoperable health IT solutions are necessary for effective and secure health information data exchange. A significant percent – some estimates are as high as 85% – of the information needed to care for a patient at some point needs to cross enterprise boundaries; interoperability is mandatory to ensure that 1
information flows readily and securely. Additionally, interoperability provides an effective tool in combating health-­‐related fraud, waste, and abuse (FW&A) – an area that inflicts staggering costs on an already burdened system. Medicare and Medicaid FW&A costs taxpayers billions of dollars each year; beyond representing an economic concern, fraud risk 2
affects all aspects of compliance, including patient safety. FW&A can be greatly reduced when medical claims data can be linked to an Electronic Health Record (EHR) and exchanged between the payer and provider. Utilizing advanced analytics, a provider can detect certain types of fraud, waste, and abuse before administering a procedure. The payer can evaluate the attached medical claim and either validate and pay 3
the claim or invalidate the claim. Ensuring interoperability between the payer and provider significantly prevents fraudulent claims within the health care system, lowering health care costs to providers. Ensuring interoperability impacts the patient’s wallet and health as well. A major component of interoperability centers around the accuracy of information and content sent between two or more health care systems. Providing immediate patient information and medical data to health care providers mitigates the risk of performing unnecessary medical procedures during a patient encounter. Doctors that are given access to abundant and accurate patient data that is securely exchanged among health care systems are better able to identify and perform necessary procedures. Interoperability allows the patient’s total health information to be used as a whole to support better health care decisions and ensure more coordinated care. Health care IT will continue to transform the way health care is administered and provided to patients and interoperability is becoming an increasingly critical yet difficult aspect of achieving mission and meaningful 4
use success. 1
“Breaking Barriers to Interoperable Health Care.” Government Health IT Conference and Exhibition. HIMSS. 2012. http://www.govhealthitconference.com/interoperability.aspx 2
Testimony of Daniel R. Levinson, Inspector General, U.S. Department of Health & Human Services. March 2011. http://www.finance.senate.gov/imo/media/doc/030211DL1.pdf 3
Hanson, Susan P. “Fraud Control: New Tools, New Potential.” Journal of AHIMA 77, no.3 (March 2006): 24-­‐30. http://library.ahima.org/xpedio/groups/public/documents/ahima/bok1_030850.hcsp?dDocName=bok1_030850 4
“Meaningful use” refers to specific objectives that define the use of electronic health records (EHR) and related technology within a healthcare organization, as established by the U.S. Department of Health & Human Services (HHS). The Health Information Technology for Economic and Clinical Health (HITECH) Act provided HHS with the authority to establish programs to improve health care quality, safety, and efficiency through the promotion of health information technology (HIT), including EHRs and private and secure electronic health information exchange. Under HITECH, eligible health care professionals and hospitals can qualify for Medicare and Medicaid incentive payments when they adopt certified EHR technology and use it to achieve specified objectives. To date, meaningful use objectives have been released for stage 1 and stage 2 that indicate the necessary HER standards for providers to qualify for the bonus payments. Draft recommendations for meaningful use stage 3 may be released as early as August 2012. Page | 2
AEGIS.net, Inc.
2275 Research Blvd. | Suite 500 | Rockville, MD | 20850
www.aegis.net | Phone: 703.893.6020
Incentive to Achieve Interoperability
Under the 2009 federal economic stimulus package, health care providers who can demonstrate meaningful use of certified EHRs qualify for Medicaid and Medicare incentive payments. Proposed rules have been published that outlining the requirements for health care providers attesting to stage 2 of the meaningful use program. 5
Interoperability is a major theme highlighted within meaningful use stage 2. Health care organizations seeking to qualify at the stage 2 level must implement the capability to send and receive health care information to and from different health care organizations. However, not all health care systems are the same, and ensuring health care interoperability becomes a difficult task. Stakeholders at all levels are realizing that interoperability is not only the key enabler, but also a key obstacle to achieving both the criteria for meaningful use and collecting the associated incentives. According to a survey conducted by the Optum Institute, 75 percent of hospital CIO 6
respondents expected to meet meaningful use stage 2 requirements by February 2012. The survey also demonstrated that despite the sizeable investments made by health care organizations to adopt system-­‐
wide EHRs, hospital CIOs are still concerned with the growing costs and burdens related to the lack of interoperability among systems. The lack of interoperability also hinders the health care reform goals of bundling payments and improving population health. Within the requirements for stage 2, The Office of the National Coordinator for Health IT (ONC) emphasized the importance of interoperability – demonstrating the capability to connect and accurately 7
exchange electronic medical information with external systems in a secure environment. Subsequently, verifying health care systems can exchange medical information with external entities has become a national priority to achieving quality of care for patients. Testing interoperability must be attainable quickly and reliably. Currently, Interoperability Testing is a slow process, requiring many parties to initiate and respond to various test scenarios. The additional time and resources spent on testing may delay development and deployment efforts for health care organization gateways and interoperable EHRs. Deploying a system into a production environment without properly applying interoperability testing techniques and tools increases the risk of being unable to interoperate. This translates into poor quality of care received by patients, as health care providers are unable to exchange electronic medical information in a timely fashion. Delays in processing Medicare, Medicaid, and insurance claims as a result of implementing an un-­‐interoperable system can also negatively impact a patient’s claims payment or an insurance provider’s bottom line. Tight schedules and rapid turnaround are common themes in health care interoperability; consider the challenge given by leaders of the ONC while visiting the HIMSS 2012 Interoperability Showcase in Las Vegas, NV. Participants were gathered together and issued a challenge: establish, within an hour’s time interoperable health information exchange with another showcase participant with whom you have not previously exchanged information. Participants made multiple configuration and development changes to their gateway systems to communicate with other gateways found within the showcase.8 5
Manos, Diana. “Interoperability Still a Barrier to Meaningful Use, Experts Find.” Healthcare IT News. 16 February 2012. http://www.healthcareitnews.com/news/interoperability-­‐still-­‐barrier-­‐meaningful-­‐use-­‐experts-­‐find 6
“A CIO Survey of HIT Adoption Trends.” Optum Institute. 2012. http://institute.optum.com/research/featured-­‐publications/cio-­‐survey-­‐of-­‐hit-­‐
adoption-­‐trends/~/media/OptumInstitute/Page_Elements/Articles/OPTUM_CIO_HIT_Survey_Feb2012.pdf 7 “Stage 2 Rules Offer Flexibility, Push Interoperability.” iHealth Beat. 23 February 2012. http://www.ihealthbeat.org/articles/2012/2/23/mostashari-­‐stage-­‐2-­‐rules-­‐offer-­‐flexibility-­‐push-­‐interoperability.aspx 8 Fridsma, Dr. Doug. “HIMSS 2012 Interoperability Showcase Participants Get a Surprise Challenge.” Health IT Buzz. U.S. Department of Health and Human Services. 29 February 2012. http://www.healthit.gov/buzz-­‐blog/health-­‐innovation/himss-­‐2012-­‐interoperability-­‐showcase/ Page | 3
AEGIS.net, Inc.
2275 Research Blvd. | Suite 500 | Rockville, MD | 20850
www.aegis.net | Phone: 703.893.6020
While several systems were able to rapidly establish interoperability, the gateways tested during this exercise will evolve over time, incorporating additional features, functionality, and specifications for health interoperability. The interoperability showcase provided a common area for developers to interact, meet, and test their gateway interoperability. However, interoperability testing generally consumes a considerable amount of time, as gateway developers are spread throughout the globe and have multiple development priorities. The need for an automated testing lab to ensure an organization’s gateway interoperates with both a new version of another gateway in production and previous versions (backwards compatibility) as well, at any time, has arisen. Creating a Testing Solution
In response to the growing need for interoperability, AEGIS has designed and developed a test platform, the Developers Integration Lab (DIL). Our company has a background in health information exchange protocols and understands the business needs of the Health IT Community. This relevant experience and expertise gave us insight into the need for a truly interoperable and appropriate testbed platform. We understand the difficulties experienced among Federal Partners and Health care organizations to ensure interoperability. The DIL allows for automated, Internet-­‐based interoperability testing against Nationwide Health Information Network-­‐compliant and other gateway implementations. Through the DIL, organizations can test interoperability with other gateway implementations at any time as the need arises. We created the DIL with an eye toward automation and easy-­‐to-­‐use tools to provide users with an accessible, flexible platform to test gateway-­‐to-­‐gateway communication. The DIL provides a simple user interface for candidates to navigate; within minutes, a candidate can register on the DIL, install certificates, and begin interoperability testing. It is meant to facilitate and successfully execute the testing process among various organizations’ gateways. Ending the Isolation of “Stand-alone” Information
Interoperable networks of health information exchanges are a critical element for health care improvement. Interoperability promises to support quality improvement and system efficiency. Utilizing an automated testing platform to ensure interoperability among health care organizations will provide improved research to support evidence-­‐based medicine, increase decision support, reduce medical errors, and decrease costs. Interoperable health information exchange networks will lead to significant improvements in patient care as demonstrated by a significant body of research. Certainly, there is no “one-­‐size-­‐fits-­‐all” solution to a seamless exchange of health information across a variety of systems and platforms. It will take a variety of approaches and a great deal of cooperation to achieve interoperability goals at a national level, ensuring quality of care, decreasing FW&A, and decreasing health care costs. The Developers Integration Lab was built with these national goals in mind; preventing the deployment of un-­‐interoperable systems into production by providing a central testing platform to ensure interoperability among many external entities at any time. Page | 4
AEGIS.net, Inc.
2275 Research Blvd. | Suite 500 | Rockville, MD | 20850
www.aegis.net | Phone: 703.893.6020
About AEGIS
AEGIS.net, Inc. (AEGIS) is a CMMI-­‐Maturity Level 3 rated, ISO 9001:2008 certified small business and premier provider of Information Technology consulting services to Federal Civilian, Defense and Commercial sector clients. Our objective is to help our clients achieve their goals by transforming business needs into technical results. Contact
For more information please contact AEGIS.net, Inc.: Mario Hyland Ellen Wyly Barry Dickman Senior Vice President Business Development Manager Senior Consultant Email: [email protected] Email: [email protected] Email: [email protected] Page | 5
AEGIS.net, Inc.
2275 Research Blvd. | Suite 500 | Rockville, MD | 20850
www.aegis.net | Phone: 703.893.6020