Year-End Review: Health Data Interoperability

Although there were perhaps no major transactions or policy proposals announced in 2022 related to health data exchange, there was steady progress on several fronts. Perhaps most importantly, the Office of the National Coordinator for Health IT’s Recognized Coordinating Entity, the Sequoia Project, continued on the path of creating a national network of networks.

This fall, when the Sequoia Project released a finalized Qualified Health Information Network (QHIN) application document, several organizations such as the CommonWell Health Alliance announced their intention to apply to become one of the first QHINS as part of the Trusted Exchange Framework and Common Agreement (TEFCA).

“TEFCA has the potential to increase the level of empowerment by individuals and their care providers by enabling them to get the data they need to make the best care decisions—something CommonWell has been focused on since day one,” said Paul Wilder, executive director of CommonWell Health Alliance, in a statement. “CommonWell is more than prepared to transition to QHIN status, help build TEFCA, and take the nationwide exchange of EHI to the next level.”

Currently, stakeholders often must join multiple networks to get the information they need to support coordinated patient care, CommonWell noted. With TEFCA, joining a HIN that participates in the network created by the Common Agreement will enable access to and exchange of information from varied sources.

Mariann Yeager, chief executive officer of The Sequoia Project, said that with the recent release of the application and standard operating procedure (SOP) documents, the RCE is moving into the operational phase of TEFCA. “Since the release of the Common Agreement in January 2022, we’ve been working toward hitting our promised timelines while seeking input from the community,” she said. “The feedback we received has been invaluable as we worked toward finalizing the SOPs and application.”

Earlier in the year ONC director Micky Tripathi was asked if there was any planning around incentivizing participation in TEFCA. He said it is too early to talk about carrots or sticks related to TEFCA participation. “But we are working with federal agency partners about how they may have use cases that would benefit from being able to be TEFCA- enabled — with the CDC, for example, from a public health perspective, and with CMS for a wide variety of use cases. Those are active discussions, because we think there's a tremendous amount of benefit for the public at large and for making the federal government more efficient and more effective.”

The TEFCA HL7 FHIR Roadmap outlines how the use of the FHIR standard will become an established part of TEFCA-based exchange over time as the capabilities of the market mature. A revised QHIN Technical Framework (QTF) in 2023 will make network-facilitated FHIR-based exchange available as an option under TEFCA, while a planned revision to the QTF in 2024 would require FHIR.

California Data Exchange Framework

The State of California also made significant strides toward interoperability in 2023. The California Health and Human Services Agency (CalHHS) has awarded the first round of awards from the state’s new $50 million Data Exchange Framework (DxF) grant program.

California is establishing a Data Exchange Framework to improve how health information is shared across the health and social services systems. Among the goals are protecting public health, improving care delivery, and guiding policies aimed at caring for the whole person, while maintaining patient privacy, data security, and promoting equity.

The Framework includes a single data-sharing agreement and a common set of policies and procedures that will govern and require the exchange of health information among large healthcare entities and government agencies by Jan. 31, 2024. (Smaller provider organizations will have until 2026 to comply.)

The community information exchange movement

Another evolution taking place is involving more community-based organizations in health information exchange. The 2-1-1 San Diego Community Information Exchange (CIE) is a pioneer in connecting community-based organizations and health systems. Now, with 2-1-1 San Diego’s support, the CIE movement is spreading to other regions. For instance, HealthierHere is launching a CIE in King County, Wash., following up on its work in the Accountable Communities of Health program.

San Diego’s CIE platform shares client-level data and has participating organizations use a common risk rating tool. The CIE also facilitates community case planning, and care team communications to better address the social determinants of health.

The HealthierHere team spoke about the governance model under development for the CIE during a recent webinar put on by the Office of the National Coordinator for Health Information Technology’s (ONC) Social Determinants of Health (SDOH) Information Exchange Learning Forum.

This year, the Oregon Health Authority also launched a CIE workgroup tasked with providing recommendations on strategies to accelerate, support, and improve CIE across the state.

Merger of interoperability organizations

Two nonprofit organizations focused on health data exchange — DirectTrust and the Electronic Healthcare Network Accreditation Commission (EHNAC) —announced an agreement to merge effective Jan. 4, 2023.

DirectTrust is an industry alliance that was created to support secure, identity-verified electronic exchanges of protected health information. There were more than 208 million Direct Secure Messages sent and received within the DirectTrust network during the third quarter of 2022, an increase of just over 9 percent compared with the same period last year. That brings Direct exchange transactions since DirectTrust began tracking transactions in 2014 to nearly 3.5 billion at the end of the third quarter; an average of more than 73 million transactions per month.

EHNAC accredits organizations that electronically exchange healthcare data, including accountable care organizations, data registries, electronic health networks, e-prescribing solution providers, and health information exchanges. The commission is an authorized HITRUST CSF Assessor, making it the only organization with the ability to provide both EHNAC accreditation and HITRUST CSF certification.

With EHNAC’s incorporation into DirectTrust, DirectTrust anticipates bringing to fruition new accreditation programs, with a program focused on Credential Service Providers related to consumer access and use of health data as an early target. (EHNAC recently announced it was working with the CARIN Alliance on a code of conduct accreditation program in an effort to support additional levels of trust related to consumer access to health data.)

Feeling Gravity's pull

Another group that made considerable progress in 2022 is the Gravity Project, an HL7 FHIR accelerator that is developing standards for the collection of data related to food security, housing stability, and transportation access.

Among other things, it was announced this year that a Gravity Project Pilots Affinity Group was launched to support the work of putting the Social Determinants of Health Clinical Care FHIR Implementation Guide into practice.

Organizations working on pilots include Oregon-based OCHIN, AllianceChicago, and The University of Texas at Austin. Use case activities include validating coded terminology sets, exchanging the data capture using Gravity terminology value sets and established content and transport standards, and implementing Gravity SDOH Clinical Care FHIR standards.

The affinity group is envisioned as a peer-to-peer learning forum for entities participating in the real-world testing of Gravity terminology and technical standards. Each participating pilot serves as a feasibility study or experimental trial launched on a relatively small scale to help an organization learn how a large-scale project might work in practice.

Testing Gravity standards includes everything from using Gravity social risk terminology for the care of patients and clients across four primary care activities — screening, diagnosis, goal setting, and interventions — to exchanging social determinants of health (SDOH) information across the health and human services ecosystem.

Collaboration between SNOMED, LOINC

Finally, a new collaboration agreement announced this year paves the way for coordinated use of SNOMED CT and LOINC by both SNOMED International and Regenstrief, with each retaining editorial control of its respective standard.

LOINC was created in 1994 at the Indianapolis-based Regenstrief Institute in an effort to facilitate interoperability in healthcare. Today, the LOINC coding system contains almost 100,000 terms for everything from a serum alpha 1 antitrypsin level to a zygomatic arch x-ray report. For each concept, LOINC includes many other rich details, such as synonyms, units of measure and carefully crafted descriptions. Maintained at Regenstrief Institute, the system is free to users.

Owned and governed by 43 global members, the nonprofit SNOMED International determines standards for a codified language that represents groups of clinical terms.

In addition to promoting the adoption of practices to facilitate use and interoperability of the terminology standards produced by both organizations, the new agreement targets reduction of current and potential duplication. The goal is to standardize terminology and enhance clinical system interoperability while providing support for providers and users who implement different combinations of both standards.

The new agreement lays the foundation for development of a LOINC extension that aligns with the SNOMED CT model, enabling SNOMED International and Regenstrief to distribute LOINC and SNOMED CT content together to their respective users. The extension will create both SNOMED CT and LOINC codes for all concepts that are shared between the terminologies, making it easy for implementers to have a unified approach to implementing both standards and to meet clinical and regulatory requirements globally.

The 2022 agreement extends a relationship, inaugurated in 2013, which linked the rich clinical semantics of SNOMED to LOINC concepts, enabling the identification, exchange and collection of data across health systems. The COVID-19 pandemic has highlighted and further emphasized the importance of coordinated standards to support interoperability, the organizations said.

“Opportunities to support robust interoperable health information exchange, nationally and globally, are vital to providing the best quality healthcare,” said Marjorie Rallins, D.P.M., M.S., executive director of LOINC Health Data Standards, in a statement. “The strategic and diplomatic value in Regenstrief and SNOMED working together should not be underestimated.”