After years of being in competition with one another, EHR giants Epic and Cerner are working together and participating in an initiative coordinated by the Department of Health and Human Services Office of the National Coordinator for Health IT to create interoperability.
More specifically, the two EHR vendors are working together with third-party mobile health applications so that patients can access their health information -- in this case, medication information -- through these mobile applications. What this means is that should a patient download and use one of these third-party mobile applications, those applications would be able to access the patient's information whether located in Cerner's EHR or Epic's or Allscript's and so on.
Tricia Lee Wilkins, pharmacy advisor and health IT specialist at the Office of the National Coordinator for Health IT (ONC), explained that in 2016 a number of health IT organizations signed interoperability budgets with ONC, committing to work together and have best practices that will increase sharing of information.
The third-party mobile applications include Medisafe, a medication management mobile application based in Boston; RxREVU, a prescription intelligence platform based in Denver; and CareEvolution, which provides secure interoperability, analytics and population health technologies and is based in Ann Arbor, Mich.
"Why [this initiative is] a big deal is that we're not just talking about pulling a medication list from within one provider or clinic using one single system," Wilkins said. "We're demonstrating interoperability in that we're able to pull this medication list from different EMR systems and then of course hand that over to a patient through a mobile application through the use of APIs."
What this means for interoperability in healthcare
This initiative is working to put interoperability in the hands -- literally -- of the patient, Wilkins said.
Wilkins added that this effort is an industry and vendor-led effort that ONC simply coordinated and helped facilitate.
"We were happy to help coordinate and help as far as just giving some structure to it and just a kind of neutral environment for different organizations and companies to come together and talk about how to get it done," she said.
This is an important first step, Avinash Shanbhag, deputy director for the Office of Standards and Technology at ONC, said.
The EHR vendors demonstrated the ability to share information with the third-party mobile applications by creating a sandbox environment.
Shanbhag said this "is a necessary stepping stone for these [mobile] applications to then be readily able to connect to the system and provide their settings. You can imagine now that Medisafe, RxREVU, and CareEvolution apps are tested and validated in the sandbox environment. When provider organizations implement [Allscripts, Epic and Cerner] solutions, they will automatically be able to be leveraged by these three apps."
The role of standards
The EHR vendors who are participating in the initiative and the third-party mobile apps were able to connect and share information via the Fast Healthcare Interoperability Resources (FHIR) standard.
"[The] FHIR standard seems to be a natural stepping stone for an industry to use because it has all the features of security and access that are really ubiquitous in the mobile apps but, at the same time, provides the ability to the vendors to build out their healthcare-specific information [from the] … electronic health record," Avinash said.
Tricia Lee Wilkinspharmacy advisor and health IT specialist at ONC
John Gresham, vice president of DeviceWorks and interoperability at Cerner, said in an email that, "APIs based on open standards such as FHIR provide for the best near-term potential for Cerner to support our clients around Meaningful Use, and allow developers to quickly build and scale apps for use by patients and clients."
However, FHIR is not the only option when it comes to interoperability standards and solutions.
Wilkins explained that ONC has the Interoperability Standards Advisory (ISA).
"Think of it like an almanac, if you would, of kind of the best known standards for specific use cases … we're pointing folks to our ISA … where you can find out what the maturity level is for certain standards to meet those needs," Wilkins said.
Omri Shor, founder and CEO of Medisafe, thinks that while standards like FHIR are important, that is only the base layer for interoperability. It's one thing to create a standard like FHIR, he said, but approving a solution like Medisafe and working to pull the information into the application, is a whole other level
Shor explained there are a lot of questions that need to be answered before a mobile application begins pulling information out of various EHRs. For example: "What should be the exact regulations? How do we know that the solution is keeping the patient's privacy? How do we know that it's secured enough and no one will steal the information? ... Which apps do we allow to access the patient's data?" Shor asked.
Interoperability not yet happening in the real world
In mid-December 2016, the vendors -- the EHR vendors and third-party mobile application vendors -- demonstrated how this data sharing is possible at the Connected Health Conference in Maryland.
"In real time, we were able to view a hypothetical patient requesting information … [that] Epic and Cerner, CareEvolution, Allscripts made available in their test environments or their sandboxes," Wilkins said. "We were looking at real patient data, but again demonstrating the feasibility that any of those FHIR endpoints could hypothetically be a clinic, or a doctor's office, or a hospital that a hypothetical patient could be seen at."
Although the demonstration at the conference proved that pulling information from several EHRs is possible, in the real world it is not happening today and more work needs to be done.
"Today, right now, a patient and any of those provider organizations may not be able to log in and make this happen," Wilkins said. "But these are real solutions and real servers and connections that have been built."
However, Wilkins believes that this initiative and demonstration were the "heavy lift" needed to get vendors to show that their FHIR servers can enable third-party access as well as enable patients to make requests.
"That's the heavy lift and so there's just more incremental steps as far as this coming to the point where you or I can go on the App Store and actually download the app to make this happen," Wilkins said. "But we're on the road and have interested organizations [that] want to see this through."
ONC sets interoperability standards for MACRA
lack of interoperability is main issue with EHRs
For the DoD, interoperability is non-negotiable