What Is Interoperability?

Interoperability is focused on ensuring organizations would securely and reliably be able to exchange information at a national level, or interoperate with one another. As standards and specifications are adopted, the scope of interoperability expands to being both a national and global agenda, ensuring all organizations, countries, and communities can securely and reliably exchange health information. Interoperability seeks to address two primary challenges:

  1. Securely establishing a communications channel to transfer information or messages at the transport layer
  2. The message payload and subsequent standards used to structure a message sent and received over the NwHIN Exchange

Payload interoperability focuses on the ability of the organization on the receiving end of a message transfer to consume and display the exchanged information within their systems. This has been dubbed semantic interoperability. The DIL seeks to provide a platform to test both transport layer and semantic interoperability of the payload.

System to System Testing

During the early stages of development, testing, and implementation of healthcare system gateways, both the Interoperability Testing Lab and the Developers Integration Lab were not available to the onboarding candidate for compliance testing. Seeking to ensure quality was built into their solutions, developers resorted to techniques allowing a gateway to test itself. However, at times this testing technique failed to expose critical defects until integration testing or peer-to-peer testing was achieved.

Recognizing the DIL is focused on supporting the developers, a mechanism was needed to allow a gateway to serve in either the role of an initiator or responder. The DIL was designed and built by developers, for developers, using the experience obtained and interacting with multiple teams while onboarding a candidate. We recognized there were instances when developers working on gateway-to-gateway technology would need immediate visibility into what another gateway saw and responded to as both an initiator and responder. This need is evident when developers work late into the night and need to continuously test their gateway to ensure interoperability without having to facilitate meetings and coordination with another development team. This self-service capability allows development hours to be better spent on debugging issues and implementing high quality gateways rather than time spent in meetings, coordination, and reading test message logs.

Internal Organization Exchange Is Controlled

Health information exchange introduces a wider world of organization to organization relationships. Furthering the idea of collaboration, the secure exchange of health information requires a community adoption based on adherence to standards and specifications. Through the efforts highlighted in the Coordination of Care effort, or the exchange of a patient's medical information from one healthcare organization or care provider to another, organizations must learn how their infrastructure will communicate with another, or interoperate with various organizations.

Interoperability Challenges

Interoperability challenges are not localized to the application code layer. One organization may develop a gateway technology and implement it in strict adherence to the standards while another organization may invest in a product offering by an IHE compliant vendor. While both gateways may successfully comply with the specifications outlined within the NwHIN and IHE specifications, these gateways cannot be assumed to interoperate.

Gateway technologies, whether Java based or .NET run on underlying technologies such as frameworks, web service stacks, Java.net application servers, and operation systems with security controls such as the Federal Information Processing Standard (FIPS) or NON-FIPS. These underlying technologies must be tested to ensure interoperability. An instance of an interoperability challenge occurred recently when the Message Transmission Optimization Mechanism (MTOM) within the underlying technology stack prevented two organizations from exchanging multi-part documents.

Interoperability can break any time as organizations perform routine upgrades and apply software patches to their system gateways. Only through comprehensive testing practices can interoperability challenges be recognized early; preventing major issues moving into production systems and disrupting potentially life threatening coordination of care.

Technology Plays the Key Role

The exchange of information between organizations is not new. Early challenges included Electronic Data Interchange (EDI) and the X12 initiatives within banking organizations and the stock market. As a consequence of the innovations in the banking system and interoperability among banks, an American consumer can utilize an ATM or another banking branch to withdraw funds at any time with relative ease and comfort knowing their information is secure.

Interoperability also plays a key role with the FBI and new procedures for submitting fingerprints electronically. This initiative allows service centers throughout the country to be able to capture fingerprint identity electronically and submit the captured image to the FBI Automated Firearms Identification System (AFIDS). Each finger, palm print, and thumb print is digitized and transferred from the service center which collects the finger print information to the FBI which acts as the repository for this information.

In comparison, the exchange of health information requires technical challenges which must be overcome. Within these health information exchanges, a request for information on a patient may go to an unknown number of organizations wishing to collaborate providing the top level care through information exchange.

The Standards and Specifications

At the core of interoperability are the SDOs and the various standards created to ensure the secure and accurate exchange of health information. Numerous organizations participate to provide expertise and knowledge around specific segments of the health exchange domain at large; each organization provides expertise into a specific domain and ways to define and categorize health data. These organizations include, but are not limited to:

Each organization contains its own governance, board level and processes controlling development versioning changes, refinements, and publishing of harmonized standards for use by the industry. Many of these SDOs are supported by the very industry which utilizes their products including, as an example, HL7. Other organizations were created seeking to harmonize these SDOs into a usable business model called profiles, one such organization is IHE which currently publishes a number of these harmonized standards and specifications describing how to securely exchange health information.

National Vs. Global

The need to exchange information at a national level revolutionized the idea to create organizations, such as the Nationwide Health Information Network (NwHIN) Exchange, to facilitate and implement a method to securely share medical information among multiple entities. According to the vision portrayed by these organizations, a patient's record and medical information could travel with the patient anywhere within the United States. If the patient was in need of medical care, clinicians and health care providers within the NwHIN network could easily access a patient's medical information.

As additional organizations became involved in the exchange of health care information, the scope expanded from simply exchanging information nationally, to exchanging information across multiple countries. Addressing the unique needs of multiple other healthcare organizations and entities such as the CDC and Department of State, exchanging information at a global level became a priority. These needs include providing Americans outside of the United States with similar access, support, and coordination of care. Both The Healthcare Information Management and Systems Society (HIMSS) and Integrating the Healthcare Enterprise (IHE) are currently seeking to ensure these standards to securely exchange patient information are adopted worldwide.

Secure Health IT Exchange

The Health Insurance Portability and Accountability Act (HIPAA) defines the policy relating to protections of Americans with respect to their health information. One of the primary directives by the HHS as federal agencies pertains to exchanging health information with the highest security to ensure no personal information is exposed. Unlike a credit card which can be cancelled and re-issued, a person's identity and health information can never be recovered if exposed. The NwHIN Exchange seeks to ensure its exchange of information follows the highest degree of security while providing accuracy and timeliness of delivery.

Industry definition

The industry is currently comprised of federal, state, and local agencies who have immediate need of collecting, storing, and selectively retrieving related medical information on file or available for the approved use. The Center for Medicare and Medicaid services (CMS) along with the Social Security Administration (SSA) are both required to validate eligibility and coverage of American citizens prior to a claims payment. Should the claim be evaluated as being invalid or false, the payment will not be sent to the filer. Providing this ability for the SSA and CMS to quickly determine claims eligibility and subsequent payments to a filer provides a way to prevent fraud, waste, and abuse and allows filers who need the payment to receive their payment in a timely fashion.