elenabs/istock via getty images
Top challenges to widespread health data interoperability
While progress has been made, achieving nationwide health data interoperability will require streamlining HIE participation and data standards adoption.
Despite ongoing policy efforts aimed at promoting health data interoperability, data sharing remains a challenge across the care continuum.
Defined as the ability for different systems to access, exchange, integrate and cooperatively use data in a coordinated manner, health data interoperability is key for achieving optimal health outcomes.
Not only is seamless data exchange critical for patient-centered care, but it is also necessary to inform population health initiatives, improve public health and alleviate information sharing burdens on clinicians. However, several key barriers stand in the way to a fully interoperable healthcare continuum.
Inconsistent EHR adoption
Certified EHR adoption is a critical first step toward interoperability, as it enables electronic health information exchange (HIE) that meets the technological capability, functionality and security requirements adopted by HHS.
Since the HITECH Act of 2009 incentivized the use of certified EHRs, implementation has grown exponentially. However, HITECH incentives did not apply to all healthcare organizations. As a result, interoperability gaps persist across certain parts of the care continuum.
For instance, according to American Hospital Association (AHA) survey data from 2019 and 2021, 86% of non-federal, general acute care hospitals had adopted a certified EHR, compared to 67% of psychiatric hospitals. Furthermore, ONC analysis of Substance Abuse and Mental Health Services Administration survey data shows that psychiatric hospitals lag even further behind in the implementation of interoperability and patient engagement capabilities.
Certified EHR adoption also lags across specialty hospitals, rural healthcare settings and long-term and post-acute care settings, complicating interoperability.
According to a 2023 report from the Office of the Assistant Secretary for Planning and Evaluation, about 80% of nursing homes and home health providers are adopting EHRs with features similar to those of certified EHR systems. However, the report indicated that the EHRs lack alignment with data standards and use cases for HIE interoperability.
Varied standards adoption
While EHRs are the first step logical step to enhancing electronic health data exchange, EHR adoption is not enough to ensure seamless data sharing. A 2022 study found that even across healthcare organizations that use the same EHR vendor, interoperability is not guaranteed.
Researchers assessed interoperability across 68 oncology sites using one of five EHR vendor products. The study assessed interoperability based on 12 key oncological data elements with well-established data standards. However, they found that many oncology tests remain uncoded in EHRs due to the way data is collected.
For instance, clinicians often manually transcribe estrogen receptor and progesterone receptor status from pathology reports without applying standardized coding.
A data brief from the Assistant Secretary for Technology Policy (ASTP) based on 2023 national survey data also found varied adoption of the United States Core Data for Interoperability (USCDI) data standard across HIEs.
USCDI is a standardized set of data elements for national HIE. ASTP updates the standard annually to stay up to date on policy, technology and clinical changes across the industry.
About four in 10 HIEs routinely sent data (or made data available) that adhere to USCDI v1 or v2, and 33% routinely received data from their participants that adhere to USCDI v1 or v2. However, about 30% of HIEs reported not knowing if the information they received or sent (or made available) adhered to USCDI's semantic standards requirements, suggesting a lack of awareness and use of the standard.
Fragmented HIE participation
HIE participation is growing, with 88 percent of hospitals participating in electronic health data exchange as of 2021, according to a 2023 ASTP data brief based on AHA Annual Survey results.
However, ASTP analysis found that about four in 10 hospitals participate in multiple HIE networks, indicating possible challenges to data sharing across networks and reinforcing the need for joining numerous networks.
GAO analysis of 2021 AHA survey data found that small hospitals were less likely to participate in HIE via EHR vendor networks, national HIE networks and regional HIEs compared to medium/large hospitals. Additionally, the report found that the percentage of rural hospitals that reported they “often” used fax or mail to share patient health data was higher than the percentage reported by non-rural hospitals.
Federal efforts such as the Trusted Exchange Framework and Common Agreement (TEFCA) aim to reduce the number of networks and HIE methods that hospitals need to use for their interoperability needs.
TEFCA’s “network of networks” approach is designed to provide a single on-ramp to nationwide HIE, which could ease the burden of participating in multiple networks and make interoperability more feasible for lesser-resourced organizations.
However, a 2023 GAO report based on interviews with ONC, CMS and state agency officials revealed that while TEFCA could address HIE barriers, participation is voluntary and does not address challenges to electronic data exchange among small and rural providers, such as health IT staffing shortages and gaps in broadband access.
Persistent information blocking
The 21st Century Cures Act of 2016 prohibited information blocking, which is defined as any practice likely to interfere with accessing, exchanging or using electronic health information (EHI). The law also mandated that certified EHRs support standardized API access for single patient and population services using the HL7 FHIR standard.
Most certified developers have published their APIs and related documentation on the publicly accessible Certified Health IT Product List, according to a Health IT Buzz blog post.
Despite this progress, ASTP has received daily information blocking complaints since the information blocking regulation went into effect in 2021. Notably, almost 90% of information blocking complaints received by ASTP have been against healthcare providers.
ASTP listening sessions have revealed various concerns about potential information blocking. For example, healthcare providers might be imposing preconditions on the access, exchange and use of EHI that the HIPAA Privacy Rule or jurisdictional laws do not mandate.
Other concerns include perceived data access barriers, such as gatekeeping, delays and challenges in establishing API connections.
Enforcement of the information blocking rule is underway, with an HHS and CMS final rule that subjects providers to "appropriate disincentives" should the Office of Inspector General (OIG) find them guilty of information blocking.
The future of interoperability
While progress has been made in advancing healthcare interoperability, significant challenges remain. Addressing gaps in EHR adoption, streamlining HIE participation, overcoming financial barriers and enforcing information blocking regulations and will require sustained collaboration among policymakers, healthcare organizations and health IT vendors.
Federal initiatives like TEFCA represent a step toward nationwide interoperability, but ensuring widespread adoption -- especially among under-resourced providers -- will be necessary for success. Additionally, stronger incentives for interoperability and investments in health IT infrastructure will be critical to closing interoperability gaps across the care continuum.
Hannah Nelson has been covering news related to health information technology and health data interoperability since 2020.
