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by Dr. David McCallie
Published on December 4, 2017

At the Office of the National Coordinator (ONC) Annual Meeting, Dr. Don Rucker, the National Coordinator for Health Information Technology, highlighted the importance of the 21st Century Cures Act (the Cures Act) in improving interoperability. He also noted that application programming interfaces (APIs) can play an important role in driving consumer engagement and ownership of their health data. The Cures Act stipulates that EHRs provide APIs, with the expectation that these APIs will enable access to clinical data “without special effort,” enabling programmers to use standard tools to create innovative apps for consumers and providers.

In addition to discussions about APIs, ONC announced that drafts of the Trusted Exchange Framework and Common Agreement (TEFCA), which will address national-scale exchange and a roadmap for the scope for data access, are targeted to be released late December for public comment.

Interpreting the Cures Act

In an earlier blog post, we discussed possible interpretations of what is meant by the Cures Act language specifying the concept of “all electronically accessible health information.” A second constraint in the Cures Act specifies that this information should be made available “without special effort on the part of the user,” which raises additional need for clarification. By clearly defining an agreed-upon set of API and data standards, as well as the framework for network-based access, we believe it will be possible to dramatically reduce the “special efforts” that complicate current approaches to interoperability.

What standards should the industry focus on first? We believe that standards enabling service-based APIs is a good direction to meet the goal of reducing “special effort.” The ONC 2015 Certification Edition called for API access to the Common Clinical Data Set (CCDS) using a publicly available service-based API. Given this direction, our industry responded by creating the Argonaut group, which collaborated to settle on HL7’s emerging Fast Healthcare Interoperability Resources (FHIR) as the standards-based API specification that EHR vendors could all support. The Argonaut collaboration resulted in publication of FHIR profiles and implementation guides that now form the basis for HL7’s U.S. Core.

We believe that this process of iterative collaboration between ONC and industry groups like Argonaut is the most fruitful way to expand the scope of the FHIR U.S. Core to encompass the additional data domains including clinical, administration and financial data that we believe are implied by the Cures Act stipulation of “all electronically available” information. We also suggest that the HIPAA Designated Record Set should be considered as the eventual target for the scope of all data.

API-based interoperability

Connecting through APIs will enable data access and data exchange flows to show only the essential, contextually relevant data for each respective provider. This information could include transition of care, referrals and prescriptions. An emerging problem that health organizations face is that with improved interoperability, providers are now receiving redundant or potentially irrelevant information packaged into large documents, making it difficult to decipher or quickly locate clinically relevant information. Receiving unnecessary or redundant data can clog up clinicians’ workflows. If clinicians need to see more data, they should be able to request it as needed through the API-based services. We shouldn’t expect that sending “all electronic data” every time is useful, nor should we consider it as information blocking if all data is not sent each time a query is made.

However, API-based interoperability is not the only relevant form of data access and exchange. There are still use cases where it is appropriate to push data over existing document-centric exchanges, such as CommonWell, Carequality, Direct or even use HL7 V2. Formats or methods for transferring data will evolve over time, but C-CDA-based document exchange already serves a very useful purpose, especially as additional narrative sections are added to interchange expectations. Often the narrative part of the record contains important details of the patient’s story that cannot be captured by coded lists of diagnoses, medications and labs alone.

We believe that health organizations should be allowed to continue to use document exchange standards, such as IHE Cross-Community Access (XCA), to request and retrieve relevant patient medical data, even as we pursue implementations of FHIR-based APIs.

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Learn more about our recommendations for advancing nationwide interoperability with our regulatory consulting team. We’ll help you explore which practical principles and approaches for health care organizations to consider as the health care industry begins the implementation of the Cures Act.

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