Interoperability Matters: The ONC Interoperability Roadmap and Standards Advisory

February 11th, 2015 / By Amy Sheide

Healthcare reform has been a hot topic over the past few days and health information technology (HIT) is at the hub. Last week, the Office of the National Coordinator (ONC) released a Shared Nationwide Interoperability Roadmap¹, setting the goal to exchange and use “a common set of electronic clinical information at the nationwide level by the end of 2017.” Also, President Obama highlighted the Precision Medicine initiative² which included funding for ONC to support the development of interoperability standards, and CMS announced that Medicare payments are moving towards a model based on value and care coordination rather than volume and care duplication (and it is well known that lack of interoperability underlies the latter)³. This week at the ONC annual conference in Washington DC, each of these efforts is receiving a lot of attention and discussion. From all these initiatives, it seems one message is clear: Interoperability matters.

The ONC Interoperability Roadmap calls attention to three key components of improved health through an interoperable healthcare system: “1) Requiring standards; 2) Motivating the use of those standards through appropriate incentives; and 3) creating a trusted environment for the collecting, sharing and using of electronic health information.”¹ In support of the detailed Interoperability Roadmap (which is a 166-page read) the ONC also published a 16-page “2015 Interoperability Standards Advisory” designed to “coordinate the identification, assessment and determination of the best available interoperability standards and implementation specifications for industry.”4 Section I of this document lists the “Best Available Vocabulary/Code Set/Terminology Standards and Implementation Specifications,” summarized in Table 1 linked here.

ONC cautioned that the Standards Advisory is neither complete nor exhaustive and will be updated annually in December, incorporating advice from the HIT Standards Committee and public comments. This explains why three of the use cases (“Purpose” in Table 1 – see food allergies, functioning and disability, and industry and occupation) do not yet have a vocabulary standard specified, nor have implementation specifications been identified for any of them. Nevertheless, according to Table 1, an organization must be able to handle 20 different standard terminologies (excluding NPI which is not a terminology but a registry of unique identification numbers for covered health care providers). An organization must consider the following:

• Expertise is required to obtain and manage multiple terminologies, versions/evolution of content and variable file formats, keeping up with release schedules and the need for synchronization between multiple applications using these 20 terminologies.

• Multiple terminologies can be specified for one clinical data element (see encounter diagnosis, immunization, preferred language and medical procedure in Table 1). For example, codes from ICD-10-PCS, CPT, HCPCS and SNOMED CT are all acceptable for sending medical procedure information. Or, a different standard from that specified in Table 1 may have been used – for instance, many systems have coded radiology to LOINC instead of RadLex. Lastly, legacy systems may not store standard codes natively but instead use local, non-standardized code sets. Thus, organizations must determine how they are going to complete bi-directional translation among all these code systems for interoperability.

• How will systems represent clinical data elements that do not have a proposed standard? For example, care plans are considered a critical clinical data element in the ONC Interoperability Roadmap but no terminologies have been identified for the capture and exchange of the data in care plan fields, or for other nurse-documented data. Similarly, social determinant of health or behavioral health data seldom have existing standards. These data elements are important aspects of health and highly correlated with health outcomes that must be captured and shared.

• Lastly, to use interoperable data fully in care delivery, decision support and population based analytics, organizations must reach beyond code-to-code data interchange and have a knowledge base in place to integrate all the terminologies and leverage the relationships among concepts. For instance, between RxNorm, National Drug Codes (NDC) and SNOMED CT, there are thousands of codes pertaining to aspirin – as a substance or a product, with different strengths, formulation, manufacturer, packaging, etc. It is unrealistic to expect only a single code to be used for each data item. Instead, systems must interact with a terminology server that will allow them to recognize when all the codes have the same attribute of clinical significance – in this case, that all these codes have the same ingredient of aspirin.

Regarding the Interoperability Roadmap’s mention of “appropriate incentives,” ONC states that “value-based payment will foster standards based exchange to support care coordination and quality improvement,” supporting the CMS announcement of increasing emphasis on alternative healthcare payment models based on value and care coordination that may require a baseline level of health IT adoption or other provisions reinforcing interoperability. This suggests that in the future, use of the standards may be tied to reimbursement (see Figure 1).

HDD ONC Interop roadmap figure quality




Figure 1: CMS Timeline for Value Based Medicare Payments¹

Regardless of organizational objectives, federal programs or payment models, the emphasis on interoperability is going to be a key differentiator in the provision of more efficient health care, management of population health and personalized medicine. We at 3M applaud ONC’s leadership on this critical topic that will have a tremendous impact on healthcare. Over the last two decades, as we help our customers implement and manage standard vocabularies and meet their terminology and interoperability needs, we have encountered many use cases and in overcoming challenges, experienced sweet success in partnership with our customers within both public and private sectors. The release of the ONC Interoperability Roadmap and Standards Advisory provides an exciting opportunity to bring the strategies utilized within 3M to emerging areas of industry. Interoperability matters – to the healthcare consumer, the provider, the payer, the health system and to us.

Amy Sheide is a clinical analyst at 3M Health Information Systems (HIS), Inc. as a part of the Healthcare Data Dictionary (HDD) team.