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Suggested Citation:"Front Matter." National Academy of Medicine. 2018. Procuring Interoperability: Achieving High-Quality, Connected, and Person-Centered Care. Washington, DC: The National Academies Press. doi: 10.17226/27114.
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THE LEARNING HEALTH SYSTEM SERIES

PROCURING
INTEROPERABILITY

ACHIEVING HIGH-QUALITY, CONNECTED,
AND PERSON-CENTERED CARE

Peter Pronovost, Michael M. E. Johns, Sezin Palmer,
Raquel C. Bono, Douglas B. Fridsma, Andrew Gettinger,
Julian Goldman, William Johnson, Meredith Karney,
Craig Samitt, Ram D. Sriram, Ashwini Zenooz,
and Y. Claire Wang, Editors

Image

WASHINGTON, DC
NAM.EDU

Suggested Citation:"Front Matter." National Academy of Medicine. 2018. Procuring Interoperability: Achieving High-Quality, Connected, and Person-Centered Care. Washington, DC: The National Academies Press. doi: 10.17226/27114.
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NATIONAL ACADEMY OF MEDICINE • 500 FIFTH STREET, NW • WASHINGTON, DC 20001

NOTICE: This publication has undergone peer review according to procedures established by the National Academy of Medicine (NAM). Publication by the NAM signifies that it is the product of a carefully considered process and is a contribution worthy of public attention, but does not constitute endorsement of conclusions and recommendations by the NAM. The views presented in this publication are those of individual contributors and do not represent formal consensus positions of the authors’ organizations; the NAM; or the National Academies of Sciences, Engineering, and Medicine.

Certain commercial software systems are identified in this report. Such identification does not imply recommendation or endorsement by the National Institute of Standards and Technology (NIST), the Office of National Coordinator of Health Information Technology (ONC), the Department of Veterans Affairs (VA), or the Department of Defense (DoD); nor does it imply that the products identified are necessarily the best available for the purpose.

Accordingly, the information in this document is illustrative and does not constitute legal advice. Because laws and regulations vary by jurisdiction and can change quickly, the National Academy of Medicine and JHU/APL do not warranty the adequacy of the information for use in a specific RFP and expressly disclaim any liability for their use. It is anticipated that in adapt-ing RFPs to individual circumstances, organizations will do so with the full engagement and guidance of their IT, contracting, and legal counsel.

Support for this publication was provided by the Gordon and Betty Moore Foundation, which fosters path-breaking scientific discovery, environmental conservation, patient care improvements and preservation of the special character of the Bay Area.

Library of Congress Cataloging-in-Publication Data

Names: Pronovost, Peter J., editor. | National Academy of Medicine (U.S.), issuing body. Title: Procuring interoperability : achieving high-quality, connected, and person-centered care / Peter Pronovost [and 12 others], editors.

Description: Washington, DC : NAM.EDU, [2018] | Series: Learning health system series | Includes bibliographical references.

Identifiers: LCCN 2018041809 (print) | LCCN 2018042655 (ebook) | ISBN

9781947103139 (E-book) | ISBN 9781947103122 (pbk. : alk. paper)

Subjects: | MESH: Medical Informatics Applications | Purchasing, Hospital | Systems Integration | Software Classification: LCC R855.3 (ebook) | LCC R855.3 (print) | NLM WX 26.5 | DDC 610.285--dc23 LC record available at https://lccn.loc.gov/2018041809

Copyright 2018 by the National Academy of Sciences. All rights reserved.

Printed in the United States of America.

Suggested citation: Pronovost, P., M. M. E. Johns, S. Palmer, R. C. Bono, D. B. Fridsma, A. Gettinger, J. Goldman, W. Johnson, M. Karney, C. Samitt, R. D. Sriram, A. Zenooz, and Y. C. Wang, Editors. 2018. Procuring Interoperability: Achieving High-Quality, Connected, and Person-Centered Care. Washington, DC: National Academy of Medicine.

Suggested Citation:"Front Matter." National Academy of Medicine. 2018. Procuring Interoperability: Achieving High-Quality, Connected, and Person-Centered Care. Washington, DC: The National Academies Press. doi: 10.17226/27114.
×

“Knowing is not enough; we must apply.
Willing is not enough; we must do.”

—GOETHE

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Suggested Citation:"Front Matter." National Academy of Medicine. 2018. Procuring Interoperability: Achieving High-Quality, Connected, and Person-Centered Care. Washington, DC: The National Academies Press. doi: 10.17226/27114.
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Suggested Citation:"Front Matter." National Academy of Medicine. 2018. Procuring Interoperability: Achieving High-Quality, Connected, and Person-Centered Care. Washington, DC: The National Academies Press. doi: 10.17226/27114.
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ABOUT THE NATIONAL ACADEMY OF MEDICINE

The National Academy of Medicine is one of three Academies constituting the National Academies of Sciences, Engineering, and Medicine (the National Academies). The National Academies provide independent, objective analysis and advice to the nation and conduct other activities to solve complex problems and inform public policy decisions. The National Academies also encourage education and research, recognize outstanding contributions to knowledge, and increase public understanding in matters of science, engineering, and medicine.

The National Academy of Sciences was established in 1863 by an Act of Congress, signed by President Lincoln, as a private, nongovernmental institution to advise the nation on issues related to science and technology. Members are elected by their peers for outstanding contributions to research. Dr. Marcia McNutt is president.

The National Academy of Engineering was established in 1964 under the charter of the National Academy of Sciences to bring the practices of engineering to advising the nation. Members are elected by their peers for extraordinary contributions to engineering. Dr. C. D. Mote, Jr. is president.

The National Academy of Medicine (formerly the Institute of Medicine) was established in 1970 under the charter of the National Academy of Sciences to advise the nation on issues of health, health care, and biomedical science and technology. Members are elected by their peers for distinguished contributions to medicine and health. Dr. Victor J. Dzau is president.

Learn more about the National Academy of Medicine at NAM.edu.

Suggested Citation:"Front Matter." National Academy of Medicine. 2018. Procuring Interoperability: Achieving High-Quality, Connected, and Person-Centered Care. Washington, DC: The National Academies Press. doi: 10.17226/27114.
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Suggested Citation:"Front Matter." National Academy of Medicine. 2018. Procuring Interoperability: Achieving High-Quality, Connected, and Person-Centered Care. Washington, DC: The National Academies Press. doi: 10.17226/27114.
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STEERING COMMITTEE

NAM Staff

Development of this publication was facilitated by contributions of the following NAM staff, under the guidance of J. Michael McGinnis, Leonard D. Schaeffer Executive Officer and Executive Director of the Leadership Consortium for a Value & Science-Driven Health System:

Consultant

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Suggested Citation:"Front Matter." National Academy of Medicine. 2018. Procuring Interoperability: Achieving High-Quality, Connected, and Person-Centered Care. Washington, DC: The National Academies Press. doi: 10.17226/27114.
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REVIEWERS

This special publication was reviewed in draft form by individuals chosen for their diverse perspectives and technical expertise, in accordance with review procedures established by the National Academy of Medicine. We wish to thank the following individuals for their contributions:

The reviewers listed above provided many constructive comments and suggestions, but they were not asked to endorse the content of the publication, and did not see the final draft before it was published. Review of this publication was overseen by Y. Claire Wang, Senior Program Advisor, NAM; and J. Michael McGinnis, Leonard D. Schaeffer Executive Officer, NAM. Responsibility for the final content of this publication rests entirely with the editors and the NAM.

Suggested Citation:"Front Matter." National Academy of Medicine. 2018. Procuring Interoperability: Achieving High-Quality, Connected, and Person-Centered Care. Washington, DC: The National Academies Press. doi: 10.17226/27114.
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Suggested Citation:"Front Matter." National Academy of Medicine. 2018. Procuring Interoperability: Achieving High-Quality, Connected, and Person-Centered Care. Washington, DC: The National Academies Press. doi: 10.17226/27114.
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ACKNOWLEDGMENTS

We would like to thank Drs. Jennifer Lee and Brook Watts, formerly with the US Department of Veterans Affairs, for contributing to earlier drafts of this publication, as well as Dr. Marianne Hamilton Lopez for her service as Project Director through July 2017.

We would also like to thank Daniel Bearss with the National Academies of Sciences, Engineering, and Medicine for contributing to the development of this publication through fact-checking assistance.

Suggested Citation:"Front Matter." National Academy of Medicine. 2018. Procuring Interoperability: Achieving High-Quality, Connected, and Person-Centered Care. Washington, DC: The National Academies Press. doi: 10.17226/27114.
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Suggested Citation:"Front Matter." National Academy of Medicine. 2018. Procuring Interoperability: Achieving High-Quality, Connected, and Person-Centered Care. Washington, DC: The National Academies Press. doi: 10.17226/27114.
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FOREWORD

The National Academy of Medicine (NAM) and the Gordon and Betty Moore Foundation are pleased to partner in the development and release of Procuring Interoperability: Achieving High-Quality, Connected, and Person-Centered Care. As medical knowledge, diagnostic tools, and treatment options grow at an unparalleled pace, and as digital technology offers a platform to transform delivery of care, the potential for improving health and health care is enormous. At the same time, an equally vast gap separates what we know should be possible through digital technology and the results we actually achieve.

Economic incentives have driven the evolution of a health system that is fragmented, inefficient, and ineffective in matching identified needs with available resources. The result is health care expenditures that are highest in the world coupled with system-wide performance that ranks far below most other countries with similar economic profiles.

In no arena is fragmentation more blatantly exposed than in the pervasive lack of interoperability in the digital health and health care infrastructure. Connected care is the goal; disconnected care is the reality. Despite the fact that the use of certified electronic health records grew in less than two decades from nearly non-existent to 2016 levels of more than 95 percent in hospitals and 75 percent in ambulatory care settings, actual interoperability is very limited for most digital tools, including health records, devices, and mobile applications.

Multiple devices used in the care of a single patient often operate on different platforms. Even in a single organization, different units often cannot seamlessly access needed health information and virtually absent are functional digital exchange capacities among different organizations and systems. Efficiency is defeated when too many records can be shared only in hard copy form, too many monitors operate independently, too many clinicians spend too much time processing and rectifying paperwork, and too many patients and families cannot access the information they need.

Clinicians are thus hampered in the delivery of the coordinated care both they and patients desire, and they are frustrated. Uncoordinated care and the delays, misdirections, and omissions it produces, lead to avoidable harm to patients.

Suggested Citation:"Front Matter." National Academy of Medicine. 2018. Procuring Interoperability: Achieving High-Quality, Connected, and Person-Centered Care. Washington, DC: The National Academies Press. doi: 10.17226/27114.
×

The 1999 Institute of Medicine (now National Academy of Medicine) publication, To Err is Human: Building a Safer Health System, alerted the nation to striking safety and quality shortfalls in health care, prompting important, lifesaving initiatives through better infection control, surgical protocols, medication management, and health care environmental engineering. Today, the increasing complexity in health care, the need for more seamless interfaces among clinicians, patients and families, and the increasing urgency of linking health care with social service interventions for high-need patients, has made digital interoperability even more essential across clinicians, care units, facilities, and systems. The absence of digital interoperability is no longer acceptable.

Although interoperability has been a topic of national health policy discussions for more than a decade, the pace of progress has been handicapped by limited agreement on requisite standards, divergent incentives and agendas among vendors, and notably, by disparate and inconsistent characteristics in user purchasing strategies, practices, and emphases. When it comes to procuring digital services for health and health care systems, interoperability is simply not yet an effectively structured component of either the supply or the demand equations, nor of the links between the two.

This publication, Procuring Interoperability: Achieving High-Quality, Connected, and Person-Centered Care, provides a summary of a project commissioned by the Gordon and Betty Moore Foundation to explore procurement approaches health care systems can use to activate system-wide demand for interoperability in health care, and to work together for its accomplishment. Experts representing various core health and health care stakeholders—clinicians, health systems, health insurers, informatics, standards organizations, government health systems—were engaged by the NAM to undertake that exploration through consultations, public meetings, literature reviews, and frequent conference calls. An important element of the consultations was a January 2018 NAM convening of more than 70 leaders from the stakeholder communities to review a preliminary summary of the findings and to offer insights on the most prominent issues and priorities moving forward. Drawing on those conversations, supplemented by comments solicited from a number of additional experts and reviewers, this NAM Special Publication has been developed as a summary of the issues and approaches. Most importantly, it presents elements of a roadmap for moving forward.

We would like to convey the gratitude of both the NAM and the Gordon and Betty Moore Foundation to each of the editors and contributors to this work, in particular to steering group co-chairs Peter Pronovost, Michael Johns, and Sezin Palmer. We would also like to acknowledge the project directors Drs.

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Suggested Citation:"Front Matter." National Academy of Medicine. 2018. Procuring Interoperability: Achieving High-Quality, Connected, and Person-Centered Care. Washington, DC: The National Academies Press. doi: 10.17226/27114.
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Marianne Lopez Hamilton and Claire Wang for their leadership in shepherding the development that so nicely sets the stage for follow-on progress.

The potential for progress is extraordinary. Our emerging digital world offers the prospect of revolutionary transformation in the pace and accuracy with which problems are identified, and in the precision with which solutions are targeted. The technology exists, and is improving daily, to build the needed, seamless digital platform. Now is the time for clinical providers and other purchasers to ensure that each digital tool purchased for use in health and health care can seamlessly interface and cooperate on behalf of people everywhere. If each health care leader works to realize that aim, they will greatly benefit the health of everyone.

J. Michael McGinnis, MD, MPP Harvey V. Fineberg, MD, PhD
Leonard Schaeffer Executive Officer President
National Academy of Medicine Gordon and Betty Moore Foundation
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Suggested Citation:"Front Matter." National Academy of Medicine. 2018. Procuring Interoperability: Achieving High-Quality, Connected, and Person-Centered Care. Washington, DC: The National Academies Press. doi: 10.17226/27114.
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Suggested Citation:"Front Matter." National Academy of Medicine. 2018. Procuring Interoperability: Achieving High-Quality, Connected, and Person-Centered Care. Washington, DC: The National Academies Press. doi: 10.17226/27114.
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PREFACE

Our health care delivery system requires unprecedented access to health information in order to effectively and efficiently provide the best care to individual patients and entire populations. Access to relevant and useful data that allows clinicians to meet the demands of modern health care becomes essential for building a continuously learning health system that supports new models of care, outcomes-based reimbursement, and personalized medicine. Such achievement will depend on the degree of interoperability among all the component systems of the health care system and medical devices. While health care has made great strides in recent years with the proliferation of electronic health records, the establishment of regional health information exchanges, and the development of data exchange standards and interfaces, true interoperability remains an elusive goal. True interoperability is the ability to seamlessly and automatically deliver data when and where it is needed under a trusted network without political, technical, or financial blocking.

Leading health care organizations are beginning to recognize that future sustainability and competitive advantage will be driven by their ability to deliver safe, efficient, and economical care—and comprehensive data interoperability is absolutely crucial to this transformation. In contrast to many other industries, the purchasers of health care technology have not fully leveraged their individual or collective purchasing power to require interoperability from the health technology marketplace. With better procurement practices, supported by the establishment of shared interoperability platform and architecture, health care systems can prepare themselves to advance much more rapidly into the person-centric health care environment of the future.

This National Academy of Medicine (NAM) special publication convenes a multistakeholder group of experts to examine the state of health care technology purchasing and to chart a path toward achieving large-scale interoperability through strategic acquisition of health technology, medical devices, and software applications. Over the course of eighteen months, the steering committee and NAM staff developed the goals, framework, and change agents that will be required in the journey to realize an interoperable health system. With the

Suggested Citation:"Front Matter." National Academy of Medicine. 2018. Procuring Interoperability: Achieving High-Quality, Connected, and Person-Centered Care. Washington, DC: The National Academies Press. doi: 10.17226/27114.
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assistance of the Johns Hopkins University Applied Physics Laboratory, the Center for Medical Interoperability, the Office of the National Coordinator for Health IT, and other industry consortia, this assessment reviews requirements for interoperable data exchange at three levels: facility-to-facility (macro-tier), intra-facility (meso-tier), and at point-of-care (micro-tier).

This publication outlines a tangible process to progress from the current state of health care systems with limited interoperability to the envisioned future state of health care systems with fully interoperable systems. Through the diverse perspectives brought to the discussion, we identified a multistep process, along with supporting details in the Technical Supplement, to assist health care organizations in establishing a process to ensure interoperability. The recognition that leading health care organizations will be best served by agreeing to a common approach that can be more broadly shared across institutions is also highlighted. The analytic framework employed considers key characteristics of information exchange involved in the three tiers of interoperability and focuses on the nature of the requirements for functional interoperability in care processes, the mapping of those requirements onto prevailing contracting practices, the specification of the steps necessary to achieve system-wide interoperability, and the proposal of a roadmap to use procurement specifications to engage those steps.

On January 30, 2018, the NAM convened a one-day meeting and discussion involving nearly 70 health care delivery system leaders and related stakeholders with the goal of eliciting perspectives and experience from the field. The valuable feedback from this meeting provided critical insight that was incorporated into the final version of this publication. Meeting participants stressed the need to support consumer- and patient-centered care delivery in a cost-effective and equitable manner and highlighted the fact that health technology procurement power is only one of many factors at play. Regulations, incentives, and other market forces must align and converge to truly move the needle.

In moving ahead, the fundamental responsibility lies within the cooperation among health care system leaders, as they guide progress within their own institutions, establish the organizational priority, marshal the expertise, and shape relevant acquisition strategies and interoperability requirements for purchases of digital technology. This cooperation requires solid and active commitment to collaboration that yields a multi-institutional strategy to develop and align on common contracting requirements to move toward the next generation of interoperable health systems.

Health care delivery and its technology infrastructure are approaching a critical juncture. Standards development and electronic health records adoption over the past decades have laid a fertile ground for an era of data liquidity where key

Suggested Citation:"Front Matter." National Academy of Medicine. 2018. Procuring Interoperability: Achieving High-Quality, Connected, and Person-Centered Care. Washington, DC: The National Academies Press. doi: 10.17226/27114.
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information flows across the care continuum—and across the life cycle—helping clinicians to make better decisions at the right time for the right person. In the marketplace, it is also a critical time to ensure that competition among health care providers and technology vendors is focused on quality and value, rather than on exclusivity and proprietorship of data.

Strategic procurement holds exciting potential to move the health system toward true interoperability, especially when combined with the right policy and market incentives. It takes strong leadership and negotiation from many stakeholders, including health care providers, health technology vendors, societies and associations, standards organizations, federal agencies, and payers. Most importantly, clinicians and patients must be part of the process in order to improve patient safety, reduce burden, and enable learning and transformational care delivery models. The learning health care system that we envision is not possible without interoperability, and we have an obligation to improve health care so that future generations will have better lives. The time is now to realize the true potential of health information technology.

Peter Pronovost Michael M. E. Johns Sezin Palmer
Johns Hopkins University Emory University Johns Hopkins University
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Realizing the promise of digital technology will depend on the ability to share information across time and space from multiple devices, sources, systems, and organizations. The major barrier to progress is not technical; rather, it is in the failure of organizational demand and purchasing requirements. In contrast to many other industries, the purchasers of health care technologies have not marshaled their purchasing power to drive interoperability as a key requirement. Better procurement practices, supported by compatible interoperability platforms and architecture, will allow for better, safer patient care; reduced administrative workload for clinicians; protection from cybersecurity attacks; and significant financial savings across multiple markets.

With funding support from the Gordon and Betty Moore Foundation, this National Academy of Medicine Special Publication represents a multi-stakeholder exploration of the path toward achieving large-scale interoperability through strategic acquisition of health information technology solutions and devices. In this publication, data exchanges over three environments are identified as critical to achieving interoperability: facility-to-facility (macro-tier); intra-facility (meso-tier); and at point-of-care (micro-tier). The publication further identifies the key characteristics of information exchange involved in health and health care, the nature of the requirements for functional interoperability in care processes, the mapping of those requirements into prevailing contracting practices, the specification of the steps necessary to achieve system-wide interoperability, and the proposal of a roadmap for using procurement specifications to engage those steps. The publication concludes with a series of checklists to be used by health care organizations and other stakeholders to accelerate progress in achieving system-wide interoperability.

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