EHR Interoperability Breakdown: Navigating the Future of Healthcare Data Exchange

Konstantin Kalinin

Head of Content

December 13, 2023

Oh, the interoperability in EHR systems – the Holy Grail of medicine… Imagine a world where every piece of a healthcare journey seamlessly interweaves with the technology that’s meant to support it. Sounds like a dream, right? But the reality is that we still live in a fragmented healthcare system where apps and EHRs don’t communicate as they should. It’s like juggling a series of disconnected puzzle pieces, ultimately leading to a disjointed and frustrating experience for patients and providers. Let’s change perspective, though. What if we told you there’s a solution to this disjointed puzzle?

Our belief at Topflight is simple yet powerful: to make digital healthcare a pleasant experience, the apps and EHR systems must flow together as one unit. That’s the magic of interoperability! We’re going to take a deep dive into how to make this dream of seamless healthcare data exchange a reality. So, buckle up and prepare yourself for a transformative journey into the future of healthcare data exchange.

Top Takeaways:

• EHR/EMR Interoperability is Essential for Seamless Healthcare: The ability to exchange data stored in EHRs with other systems and applications is crucial to creating a seamless, integrated healthcare experience. It not only simplifies interactions within the healthcare system but also empowers both patients and providers by making digital healthcare more user-friendly and efficient.
• The Power of EHR Integration Engines: Tools like Redox and Mirth can significantly streamline and simplify EHR integrations. They function as robust frameworks that can communicate with multiple EHRs, thereby eliminating the need for individual integrations with each system.
• Technologies Boosting EHR Interoperability: Several technologies and standards, such as HL7 Version 2, FHIR, CDA, SMART on FHIR, and CDS, are playing a significant role in enhancing EHR interoperability. These technologies enable various types of applications to seamlessly communicate with EHRs, facilitating the smooth and secure flow of data.

Table of Contents:

1. What EHR Interoperability Really Solves
2. How Interoperability Can Improve Patient Care and Empower Healthcare Providers
3. The Current State of EHR Interoperability
4. EHR Interoperability Tech Standards
5. Mirth, Redox, and Other Starter Kits to Boost Interoperability
6. Challenges in Achieving EHR Interoperability 
7. Topflight’s Stance on EHR Interoperability

What EHR Interoperability Really Solves

First, let’s talk about why electronic health record interoperability has been such a hot topic for over a decade now. Obama signed the HITECH Act, identifying interoperable EHRs as a critical national goal, into law in 2009. It’s almost 2024, and providers still get on their toes as soon as they hear this magic word.

Definition: EHR Interoperability is the ability to exchange data stored in electronic health records. Today, EHRs may need to connect to all kinds of external systems:

• other vendors’ EMRs
• applications for patients
• portals for providers
• insurance portals
• mobile apps
• wearables and smart sensors
• entire health systems

Only if PHI and other medical data can flow freely between EHRs and these external systems can we get close to true interoperability, simplifying interactions in the healthcare system. Based on our interactions with healthcare organizations, large and small, providers and patients want the same thing. They want to leverage the power of AI, the Internet of Medical Things, and other technologies by creating digital healthcare solutions that:

• securely integrate with EHRs
• sync medical data with EHRs
• automatically sign them in based on credentials stored in an EHR

“Think of EHRs as your passport or social security card – crucial documents, but not ones you interact with daily. Patients want a more fluid experience when interacting with their health providers; and providers, in turn, seek easier ways to engage and monitor patients.”

Joe Tuan, CEO of Topflight

EHR interoperability is crucial for enabling seamless user experiences for so many players, both on the consumer and enterprise levels. It connects disparate healthcare systems.

How Interoperability Can Improve Patient Care and Empower Healthcare Providers

As we’ve already established, the primary goal of EHR interoperability is to enable seamless, integrated experiences for both patients and providers. Here’s how that reflects on patient care and providers’ day-to-day operations:

• Create innovative, mold-breaking digital healthcare experiences

The interoperability of EHR systems helps replace outdated UIs from the 90s (so typical in major EHRs) with user-friendly front-end applications. When EHRs are truly interoperable, they can act as simple siloes of critical documentation, such as patient health data, physician orders, medical history, lab data, etc. Instead, providers and patients can easily navigate within custom-built, easy-to-use applications harnessing all this data. Interoperability, in its essence, is the panacea for the most pervasive issue in the healthcare industry: the fragmentation of healthcare experience. The complexity arises when applications don’t communicate with EHRs properly. Therefore, interoperability is about harmonizing the application-EHR interaction to create a unified, user-friendly platform so that patients don’t find digital healthcare daunting whenever an EHR comes into play. On the other hand, providers enjoy the advantage of having a dedicated front-end solution tailored to their needs. They can say goodbye to time-consuming authorization processes and the back-and-forth between an EHR and other applications. What’s more, they even have the flexibility to launch their custom apps effortlessly within the EHR if it aligns with their preferences and requirements.

• Improve health outcomes

In traditional settings, the lack of comprehensive and timely patient data often leads to misdiagnoses and incorrect treatment plans. However, accessibility to crucial healthcare information enhances the accuracy of clinical decision-making. In addition, sharing diagnostic results, treatment plans, and progress notes between specialists and primary care physicians can expedite patient management processes. This exchange of data across diverse platforms allows for a more coordinated and streamlined approach to care.

• Lower the cost of healthcare and make it more accessible

Interoperability plays a crucial role in making healthcare more affordable and accessible by:

• enabling access to previous results (say goodbye to redundant tests)
• allowing healthcare providers to remotely monitor patients, expanding access to care
• streamlining administrative tasks like intake, scheduling, insurance verification, and billing

By fostering efficient health information exchange, the interoperability of EMR systems has the potential to revolutionize the economics of healthcare, making managed care more accessible for everyone.

• Empower patients with information, encourage shared decision-making, and improve patient satisfaction

EHR interoperability directly supports the transition to a value-based care model by making critical patient health information readily available, thus equipping healthcare providers with the tools they need to deliver high-quality, personalized care. This approach not only fosters better health outcomes in hospital primary care but also enhances patient satisfaction, a key metric in the value-based care paradigm.

• Enhance the security of PHI

Due to the secure exchange of medical data, EHR interoperability and patient safety go side by side, enhancing the overall security of healthcare applications. It minimizes the risk of data breaches, as health information can be securely accessed and shared across platforms, eliminating the need for risky data transfers. As you can see, the benefits of EHR interoperability are plentiful: it fosters innovative digital healthcare experiences, improves health outcomes, lowers healthcare costs, empowers patients, and enhances PHI security, thereby revolutionizing both patient care and healthcare providers’ operations.

Also Read: A Guide to EHR/EMR Integration

The Current State of EHR Interoperability

Niko Skievaski, former CEO of Redox and a veteran of Epic during its formative years, provides a unique perspective on the EHR interoperability issue. According to Skievaski, the development of these IT systems in health care didn’t follow the typical path of a technology product, which usually evolves through phases of innovation and maturation. In stark contrast, EHR systems were thrust across the chasm from innovation to widespread adoption, driven by a regulatory framework imposed by the government. This accelerated adoption didn’t leave sufficient room for a thoughtful, organic approach to interoperability in public health. Once vendors or providers meet the meaningful use criteria, they begin to focus on other priorities: new, exciting features. The outcome is a repeated mantra that echoes through the halls of every prominent healthcare conference or special event: “Interoperability, interoperability, interoperability… could be better.” As soon as we solve it nationwide, everyone benefits.

Gentle Governmental Push

In the quest for greater EHR interoperability, regulatory bodies play a crucial role. A prime example is the Office of the National Coordinator for Health Information Technology (ONC), which has introduced the Trusted Exchange Framework and Common Agreement (TEFCA) to control EHR interoperability adoption. This initiative is not merely a gentle nudge towards interoperability – it’s a concrete plan with clear deadlines. By 2024, TEFCA aims to require support for HL7 FHIR-based clinical data transactions. This requirement isn’t arbitrary; it’s part of a strategic effort to establish a universal governance, policy, and technical foundation for nationwide interoperability. The organizations expected to adhere to this are the Qualified Health Information Networks (QHINs), key players in the healthcare data exchange landscape. The current frontrunners in the QHIN onboarding process include:

• CommonWell Health Alliance
• eHealth Exchange
• Epic Nexus
• Health Gorilla
• Kno2
• KONZA National Network
• MedAllies

These organizations are not just transforming their operations; they’re setting the pace for the entire industry. As they align with the TEFCA requirements, they are effectively paving the way for a new era of data exchange in the United States. But the TEFCA is just one piece of the regulations puzzle. There have been several major legislative initiatives that push forward EHR interoperability, such as:

• HHS Disincentives Rule: The Department of Health and Human Services (HHS) has proposed a rule that establishes disincentives for healthcare providers who have committed information blocking. This rule serves to ensure the free flow of health information and promote greater transparency.
• ONC’s Cures Act Final Rule: This data interoperability law was designed to provide patients and their healthcare providers with secure access to health information. It also seeks to foster innovation and competition by giving new market entrants and innovators the ability to access data in the healthcare system.
• Interoperability and Patient Access for Medicare Advantage: This initiative aims to empower patients by ensuring they have access to their own health information. It underscores the government’s commitment to fostering patient-centered healthcare through interoperability related to EHR platforms.
• Patient Protection and Affordable Care Act – Advancing Interoperability: This proposed rule would place new requirements on Medicare Advantage organizations and state Medicaid fee-for-service programs. It aims to advance interoperability, improving patient access to health information.
• HHS 21st Century Cures Act Implementation Rule: HHS has proposed a new rule to implement the 21st Century Cures Act further. The rule would help users determine whether predictive digital health information is fair, appropriate, valid, effective, and safe.
• CMS Changes to the Medicare Promoting Interoperability Program: Starting from CY 2024, the Centers for Medicare and Medicaid Services (CMS) has finalized changes to the Medicare Promoting Interoperability Program for eligible hospitals and critical access hospitals.
• HITECH Act: Introduced the Meaningful Use program.

These legislative initiatives in the US are setting the stage for a more interconnected future in healthcare. They’re pushing the healthcare industry towards a reality where seamless health data exchange is the norm, not the exception, and everyone gets to enjoy the EHR interoperability benefits. As we navigate the changing landscape of healthcare, it becomes increasingly clear that preparing your digital healthcare solutions for legislation from the onset or updating existing software to be fully interoperable is not only advantageous but essential for both regulatory compliance and optimal patient care outcomes.

Where do Major EHR Players Stand?

Legacy EHR systems, such as Epic, Cerner, and Athena, may be viewed as cumbersome or outdated, but they have impressive ratings. These EMR platforms are deeply integrated into large healthcare systems and serve thousands of patients. According to an electronic health record survey by Health Gorilla, the majority of the top 20 EHR vendors participate in one of the health exchange networks:

• 56% participate in the CommonWell Health Alliance
• 40% participate in CareQuality
• 32% participate in eHealth Exchange

So, it’s no surprise that any ambitious founder aiming to make a significant impact in this sector must consider integrating their products with these dominant players. Here’s what you need to know:

• Legacy Systems: Despite their complexities, legacy systems like Epic, Athena, and Cerner hold around 50% of the market share. Chances are, your clients are already utilizing one of these systems. To ensure your solution adds value and minimizes friction, seamless integration is key.
• Setting Expectations: Integrating with these national systems requires time due to review and approval processes, EHR analyst staffing, and application setup and testing. Flexibility is critical to meeting their workflows and data requirements.
• Preparation is Key: During prototype development, it’s recommended to start seeking permissions from the IT team, signing necessary agreements, and preparing for data access. This proactive approach ensures that once the prototype is shipped, integration can begin immediately, avoiding delays.
• Patient Interoperability: The technical challenge we aim to solve with EHR integration is patient interoperability – the seamless transfer of data from one system to another. Currently, many patients resort to faxing physical reports and emailing medical records due to the fragmented nature of the system.
• Technologies for Better UX: Technologies such as Patient Access API and SMART on FHIR are available but underutilized. Have you contemplated the implications of this underutilization? These technologies can significantly enhance user experience by enabling patients to download their records and offering single sign-on capabilities. Just imagine how much smoother and more convenient the patient journey would be if these technologies were fully integrated.

Also Read: Health App Deesign Guide

EHR Interoperability Tech Standards

In the context of the current global health scenario, as observed from various news updates, the importance of clear and concise guidance cannot be overstated, especially when it comes to sophisticated technologies such as those employed in the healthcare industry. The goal of EMR interoperability is to facilitate the smooth and secure flow of data between an EHR, or even multiple EHRs, and other applications. This means enabling various types of applications, whether in-house, white label, or based on open-source products, to seamlessly communicate with EHRs. Let’s review key technologies enabling successful EHR integrations. Choosing the right technology is critical to the success of your application, and it’s not as simple as ‘data is data.’

HL7 Version 2 Integrations

HL7 v2 is a push-based message system based on the HL7 data interface standard. It covers a wide range of data, making it an excellent choice for many application use cases. One of its unique features is the ability to provide real-time notifications of events within the EHR system, such as when a patient checks in for an appointment. However, it’s not without limitations. HL7 V2 is complex, and implementation can vary from two weeks to 3 months. One of the significant drawbacks is that this standard can be too variable: vendors can choose different variations for implementations, which eventually leads to more complex integrations.

FHIR (Fast Healthcare Interoperability Resources)

FHIR is the future of healthcare integration, with the potential for push notifications and support for various data types. Its adoption is growing, especially with CMS and ONC backing it. However, it’s important to note that FHIR won’t cover all your data requirements and has limited capabilities for pushing data back into the EHR.

#ProTip: A practical approach could be using FHIR for most of your data collection but leveraging HL7 V2 for data rights and event-based notifications. By understanding and effectively utilizing these technologies, you’ll be better equipped to navigate the challenges of integration in healthcare app development. Next, we’ll delve further into these integration issues and their solutions.

CDA Standard (Clinical Document Architecture)

By integrating with CDA, you can access data from every participating healthcare provider in the network (across the US or Europe). However, there’s a catch – parsing CDA documents can be pretty challenging, with estimates of up to 100 hours per provider organization for integration. But if you can overcome this hurdle, CDA documents can be a great source of data, especially for pushing information such as notes or lab results.

CDS Hooks (Clinical Decision Support Hooks)

Clinical Decision Support (CDS) Hooks are an emerging standard that allows users within the EHR to trigger events in your system and send messages back into the EHR. This is particularly useful for alerts and notifications. However, performance can be an issue, as these actions can take up to 10 seconds to return, potentially affecting user experience. Moreover, implementing CDS hooks into the EHR can be complex and time-consuming.

Proprietary EHR APIs

These are private APIs that some health records publish. They can be essential for your integration if the EHR supports a proprietary capability that isn’t supported by a public one. For instance, if you need to write an allergy back, set up an appointment, or post a payment that a patient made, these might be the tools you use. However, they come with limitations, including cost and non-standard data models.

SMART on FHIR: A Game Changer in EHR Integration

One of the most impactful advancements in EHR interoperability is SMART on FHIR (Substitutable Medical Applications, Reusable Technologies on Fast Healthcare Interoperability Resources). This technology standard is revolutionizing the way health apps integrate with EHR systems. What makes SMART on FHIR special? This “framework,” on top of the FHIR standard, provides a common API for exchanging health data while offering additional layers of security and authorization. As a result, developers can build health apps that can operate independently or within the EHR’s interface, securely syncing health data and using the same authorization scheme as the EHR (no pesky login dialogs).

• Single Sign-On (SSO): providers don’t need to sign in with other apps that sync health data with an EHR. SMART on FHIR ensures they get quick and secure access to all data they are entitled to according to their user role in the system. For those looking to choose a good SSO provider, learning about the most impactful ones in the current market becomes crucial. This ensures quick and secure access not only to EHR data but also elevates overall user experience in medical practice management, emblematic of the broader shift towards interconnected digital healthcare solutions.
• Ease of Integration: SMART on FHIR simplifies the integration process, making it easier for developers to build interoperable healthcare applications.
• Interchangeable Apps: Providers and patients can switch between an EHR and different health apps without worrying about compatibility issues. This flexibility fosters a more dynamic and patient-centric healthcare ecosystem.
• Security and User Experience: SMART on FHIR not only ensures secure data exchange but also enhances the user experience by seamlessly integrating with the EHR’s interface. This technology works equally well for seamlessly launching third-party standalone applications and for apps that launch right within an EHR (both for providers and patients).

Building a SMART on FHIR application involves several steps, from choosing the type of app and implementing EHR interoperability security measures to testing the app using SMART sandboxes and deploying it. But, as with all technology, there are challenges. Not all EHR vendors support SMART on FHIR, defending their status quo, and implementation discrepancies can arise. In essence, SMART on FHIR is a powerful tool that enhances interoperability and EHR usability by enabling the seamless exchange of health data among various applications. Such technologies help improve communication between separate healthcare solutions.

There’s Always More

There are also other standards shaping the landscape of EHR interoperability worth mentioning:

1. DICOM (Digital Imaging and Communications in Medicine): This is a standard for transmitting, storing, retrieving, printing, and sharing medical imaging. While it might not be directly related to EHRs, it plays a crucial role in integrating imaging data into EHR and interoperability.
2. CCDA (Consolidated Clinical Document Architecture): A more refined version of the CDA, the CCDA allows for the standardized exchange of patient summaries, referrals, discharge instructions, and other documents between EHR systems.
3. Blue Button 2.0: An API from the Centers for Medicare & Medicaid Services (CMS) that allows Medicare beneficiaries to connect their health data to applications, services, and research programs they trust.
4. OpenEHR: An open-source standard for electronic health record data. It uses a two-level modeling approach, allowing for flexible and vendor-neutral data storage. Compared to FHIR, openEHR goes a step further—it not only defines ‘what’ data to share and ‘how,’ but also ‘why.’ It provides a framework for modeling clinical content (like discharge summaries or lab results), making it more about data management and less about data exchange. Therefore, these technologies can complement each other. FHIR can be used for data exchange, while openEHR can handle data modeling and storage

Remember, the key to successful EHR integration isn’t just knowing about these standards – it’s about understanding which one fits your needs best. Each standard has its strengths and weaknesses, and the choice often depends on the specific use case, the existing infrastructure, and the future goals of the healthcare system. That’s the beauty of technology – there’s always more than one way to reach your destination. And with the proper knowledge and tools, you can choose the path that leads you to success.

Mirth, Redox, and Other Starter Kits to Boost Interoperability

When it comes to developing a healthcare application, starting from scratch isn’t the best approach. Instead, consider using existing tools and platforms that can help speed up your processes. Leveraging integration engines can significantly ease EHR interoperability. These tools offer a robust framework that can communicate with multiple EHRs, thereby eliminating the need for individual integrations for each system (complete interoperability of EHR standards is a myth). Although slight modifications may still be needed on a per-EHR basis, the overall efficiency and speed of your processes are greatly enhanced, thereby optimizing your healthcare application’s performance. Here are some resources we can recommend to simplify EHR integrations and ensure interoperability:

• Network Platforms: These are usually paid services like Redox, which we’ve had great success with. One organization was able to get live on an SIU HL7 feed with Redox in just two weeks. While there’s a cost involved, it can be more cost-effective when you factor in the time saved and reduction in project management overhead.
• Integration Engines: Tools like Mirth Connect, a free integration engine, are invaluable. They allow for FHIR API calls and HL7 feeds to push data. There are also paid alternatives (e.g., Iguana or Rhapsody) that provide even more value, although an open-source Mirth implementation handled by an expert healthcare app development company works wonders. Our data integration experts love this tool for its swift and efficient EHR integration capabilities.
• FHIR Servers: These are similar to integration engines but are more focused on the FHIR data model. They offer tooling for managing large amounts of FHIR data, allowing for SQL operations, searches, and queries. They can also automatically trigger downstream processes when you receive a FHIR resource.
• Open-Source Code: There’s a wealth of open-source libraries available in every coding language. These tools can significantly simplify your work and speed up the development process. As reiterated in numerous blogs, it is advisable not to reinvent the wheel when developing a healthcare app. Instead, capitalize on existing tools and platforms while also carefully considering the advantages that EHR interoperability standards and tools bring in terms of data accessibility and workflow improvement.

We’ve still got a long way to go before the interoperability of EHR systems becomes a reality.

Related: Medical App Development Cost

Challenges in Achieving EHR Interoperability

It can be highly challenging to achieve full EHR interoperability – it’s often a complex process with multiple obstacles that healthcare organizations must navigate strategically. Let’s explore some of the common issues that can arise and how we can overcome them.

Dealing with Administrative Hurdles in EHR Interoperability

Understanding interoperability on paper is only the beginning – the real challenge lies in execution, especially with major EHRs. Despite these systems claiming to adopt the same standards, obtaining permissions from the healthcare system to interact with the EHR data (especially when we’re pushing data in) can be a tall order. For instance, our experience with Epic, the system we interact with quite often, may involve months of waiting for non-technical matters to be resolved. Surprisingly, these administrative hurdles can take longer to overcome than the technical aspects of integration. Thus, setting realistic expectations upfront is a crucial component of successful interoperability.

Verify workflow when integrating with an EHR

The success of healthcare mobile app development and web healthcare applications hinges significantly on the quality of their integration. Even the most well-designed app with top-notch functionality can fail if it doesn’t integrate seamlessly into the existing workflow. So, it’s crucial to consider workflow while planning your app’s integration. Factors to take into account:

• Ensuring user satisfaction and minimizing workflow disruptions
• Balancing data integration with data review within the EHR system
• Reducing unnecessary clicks and pop-ups

Drawing on the insights from various studies, it’s evident that an electronic health record questionnaire can be a valuable tool for understanding user experiences and identifying potential improvements for interoperable EHR platforms.

Optimize for Long API Calls

Long API wait times are another challenge. If you’re integrating with an FHIR application, be prepared for API calls that might take anywhere from 15 seconds to 3 minutes to return data. This is where integration tools like FHIR servers and integration engines can be invaluable, acting as middleware that takes care of the integration process while your application functions separately.

HIPAA Complications Aren’t That Complex

HIPAA compliance is another vital aspect to consider. The balance between business use cases and security/compliance can be tricky, but fear should not dictate your decisions. Understanding how to securely store data is essential, but don’t shy away from keeping PHI (Protected Health Information). Data security is vital during HIPAA-compliant app development, but it should not hinder your business operations or application functionality. Factors to take into account:

• Identifying sensitive information
• Understanding customer SRAQ processes
• Assessing threat actors and vectors
• Evaluating risks
• Developing plans for corrective actions

Consider EHR Integration from the Outset

Lastly, when designing your application, consider EHR integration from the outset. Data and workflow constraints can be costly, and retrofitting your application later can lead to complications. Incorporate data integration concepts into your development and design process right from the start to ensure your application functions seamlessly within the existing infrastructure. Factors to take into account:

• Data retrieval methods: push vs pull
• Deciding between scheduled and event-based workflows
• Accessing historical and narrative data
• Mapping and aggregating data
• Integration tools and strategies

If your vision doesn’t factor in how you’ll receive data and how it will flow back to the EHR on an event-based basis, you may find your application struggling to function due to limitations in available integrations. And let’s not forget: data and workflow constraints can be costly. So, as you develop and design your application, consider these data integration concepts.

Topflight’s Stance on EHR Interoperability

One of the biggest challenges in healthcare product management today is understanding and adapting to the macroeconomic forces at play. The reality is that providers won’t change their EHRs overnight. You might think, “Why don’t we just create a lightweight EHR to make things faster?” Good thought, but it’s been tried before and resulted in more EHRs, increasing the administrative burden. So, what’s the practical solution? We propose a modular approach where third-party (custom-built) apps work seamlessly with EHRs using interoperability standards. Can you imagine the time saved by automating intake or using clinical decision support tools? Or the benefits of remote patient monitoring, where data collection and virtual healthcare communication lead to better patient outcomes without requiring office visits? In all these cases, interoperability remains the critical challenge. For instance, we had an advisor who spent six months exploring an intake software, only to abandon it due to lack of integration with their legacy EHR. We firmly believe that those innovators who can balance the use of third-party apps while respecting the choice of EHRs will be the game-changers. They will help clinics not just survive but thrive in this evolving environment.

Reach out today to explore the myriad aspects of an EHR system interoperability and ensure your healthcare product’s scalability. Once addressed effectively, these aspects can propel your healthcare organization toward a brighter future. We’re right here to help you get there. We have vast experience in assisting large hospitals, medium-sized clinics, and healthcare startups to integrate EHRs with:

• AI engines
• wearables and smart medical sensors
• standalone web portals and apps that launch right within an EHR
• mobile apps