Promises of Interoperability


John D’Amore
President and Chief Strategy Officer

“An ounce of performance is worth pounds of promises” – Mae West

Nearly 10 years ago, I wrote about the potential of using data from Electronic Health Records (EHRs) for quality measurement and population health here. Back then, a series of impediments to interoperability were identified. Some of the them came from EHR limitations. Some stemmed from the intricacy of any standard that organizes complex medical data. Despite those concerns, I and many others in the field remained optimistic of the potential of clinical data standards.

As we enter 2019, I’ve taken a moment to reflect on how far we’ve come. We’ve been through three stages of Meaningful Use, the federal program for EHR adoption, each of which has used progressively better standards to summarize and communicate clinical data. First there was HITSP C-32, then there was C-CDA 1.1 and today there is C-CDA 2.1 for clinical documents.

These standards have integrated years of experience and hard-work from the community, but like all standards, they have flaws and inadequacies.  To examine the most recent version, the C-CDA 2.1, I had the chance to lead a large research team, including the Veterans Administration, Office of the National Coordinator for Health IT and Intersystems. We tested over 50 certified technologies to see how they did at achieving interoperability.

The results show promise. We saw progress on many issues we identified in previous research, like this 2014 study. But we still found some issues that could be improved through better implementation of the standard and tools that check compliance and integrity. In particular, we found that schematron validation, which checks XML released as part of the C-CDA standard, was inadequate to identify some critical issues affecting clinical data interoperability.

We presented these results at the American Medical Informatics Association (AMIA) 2018 Symposium. To our delight (and a bit of astonishment), we were awarded a “Most Distinguished Paper” for AMIA 2018. The full study is available here for download.

One of the most intriguing things revealed in the research is the massive variation among different EHRs displaying the same medical data. The C-CDA standard focuses primarily on machine readable content, leaving the rendering of human-readable tables and lists up to individual EHR developers. A supergraphic produced as part of the AMIA research shows the astonishing heterogeneity of how 38 technologies display the same three medications:

Click to enlarge

Variation in how standards are implemented is a key reason why Diameter Health exists. That includes virtually all standards, such as HL7 2.x messaging, C-CDA, QRDA and FHIR. We’ve demonstrated remarkable performance using standards to normalize, transform, enrich and deduplicate medical data. This has delivered returns to our clients, and most importantly, the patients they serve. While the road to interoperability is long and winding, we are proud to help translate potential into results. Thank you to all who have helped us in this journey and we look forward to the exciting times ahead.

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