accelerating interoperability in healthcare · challenges of interoperability..... 4 the...

This white paper describes and explores interoperability of healthcare in the United States, particularly with reference to tactical problems surrounding the transition from paper-based information transmission techniques—fax, in particular. We also describe a new player in the information exchange marketplace that helps solve the tactical problems and bridges the gap between current-day practices and the future world of electronic interoperability.

Accelerating Interoperability in HealthcareBridging the gap between traditional fax and Direct Messaging

Table of Contents

Introduction. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3

Defining Interoperability in Healthcare . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4

Challenges of Interoperability. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4

The Long-Standing Standard: Faxing in Healthcare . . . . . . . . . . . . . . . . 4

The Emergence of Meaningful Use and the Direct Standards . . . . . 5

Bridging Fax and Direct for Interoperability . . . . . . . . . . . . . . . . . . . . . . . 5

Challenge 1: Implement Direct without Changing Workflows . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 6

Challenge 2: High Costs of Direct . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 6

Challenge 3: Communicating with Late or Non-Adopters of Direct Messaging . . . . . . . . . . . . . . . . . . . . . . . . . . 6

RightFax Healthcare Direct Accelerates Interoperability to Direct . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 7

E N T E R P R I S E I N F O R M A T I O N M A N A G E M E N T 3

ACCELERATING INTEROPERABILITY IN HEALTHCARE

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Introduction

Interoperability is the “ability of a system or a product to work with other systems or products without special effort on the part of the customer”1. This ability is also one of the key problems facing health information exchange today. The problem is a complex one that includes consideration of not only the documents, information systems, and document transmission methods of one hospital, but those of every community partner with whom they want to establish true interoperability.

Internally, hospital managers who are responsible for interoperability in healthcare have to take numerous things into consideration, including:

• Value – What is the real value of interoperability and how it will improve efficiency, patient care and relations with community partners?

• Regulations and Standards – What future changes in regulations or de facto standards are likely to impact requirements around interoperability?

• Technological Advances – What available vendors and applications can help meet the growing demands of electronic document exchange? What are their costs, how quickly and how easily can they be implemented? How disruptive will these solutions be to the established workflows within the organization?

• Limited Resources – What is the easiest, least expensive, and least disruptive path to get from the present to the future?

Hospital managers must also consider external community partners who can pose other challenges, such as:

• Adoption – If community partners represent a “weak link” in the interoperability chain, what can organizations do to encourage the purchasing, implementation and leveraging of applications that enhance electronic document exchange?

• Diversity of Technologies - Does the diversity of technologies and Health Information Service Providers (HISPs) used by my community partners represent a technical barrier to all of us taking steps toward each other and true interoperability?

1 IEEE. “Standards Glossary.” Retrieved from: https://www.ieee.org/education_careers/education/standards/standards_glossary.htmlw



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Defining Interoperability in HealthcareHealth Information and Management System Society (HIMSS) is a global, cause-based, not-for-profit organization focused on helping medical institutions achieve better health services through information technology. HIMSS leads efforts to optimize health engagements and care outcomes using information technology.2

HIMSS defines interoperability as “the ability of different information technology systems and software applications to communicate, exchange data, and use the information that has been exchanged.”3 Particularly, “Data exchange schema and standards should permit data to be shared across clinicians, lab, hospital, pharmacy, and patient regardless of the application or application vendor.”4

The above definitions contain references to two very different components: the first refers to data and documents (to provide a “language” of interoperability) and the second refers to applications, vendors and partners (to provide a technical and social construct for interoperability). To use a human analogy, for communication to occur, people need a language such as English to be able to articulate thoughts; they also need vocal chords (or paper, etc.) and someone to communicate with.

In the marketplace, and thanks to the Office of the National Coordinator (ONC) and organizations such as HIMSS, there is broad consensus and a straight road ahead around the communication characteristics5:

1 Foundational Interoperability: Standards for how messages should be exchanged and transmitted.

2 Structural Interoperability: Standards for how the messages should be formatted.

3 Semantic Interoperability: Standards for how the data in the relevant documents should be structured and codified.

The standards are complex, but reasonably well-defined.

Challenges of Interoperability Unfortunately, there is no consensus around the technical and social construct required for interoperability. The road towards interoperability is not straight and can often seem like an endless journey. The challenges can be daunting—from multiple applications to integrate and multiple Electronic Medical Record (EMR) vendors who have difficulty finding a place to start, to community physician partners who may not be willing to adopt major technology advances that can help them connect or exchange clinical documents.

Because the interoperability chain is only as strong as its weakest link, if any segment of the industry is not able to participate fully in the interoperability communication circle, then no real sustainable progress can be made. Buy-in and investment from major stake-holders and adoption from users and participants is mandatory for success.

The Long-Standing Standard: Faxing in HealthcareA de facto interoperability standard already exists: paper-based transmission, or fax. Over 70 percent of healthcare organizations continue to use fax as their primary method of clinical document exchange6. Even as a primary method of document exchange, health-care providers are increasingly concerned about the risk of using fax machines to send and receive protected health information.

Today, however, fax software and fax cloud services virtually eliminates this risk, delivering faxes in a paperless manner to the recipient’s desktop or their inbox.

2 http://www.himss.org/aboutHIMSS/

3 HIMSS Dictionary of Healthcare Information Technology Terms, Acronyms and Organizations, 2nd Edition, 2010, Appendix B, p190. Original source:

“What is Interoperability?” found at http://www.himss.org/library/interoperability-standards/what-is-interoperability

4 American Academy of Family Physicians (AAFP), Center for Health IT, 2013.

5 National Committee on Vital and Health Statistics (NCVHS) Report on Uniform Data Standards for Patient Medical Record Information, July 6, 2000, pp. 21-22

6 Source: IDC InfoBrief, “Clinical Document Exchange, the Need for a Simple, Secure, Cost-Effective Solution” from April 2015.



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Because fax delivery points—either through software, services, or fax machines—are ubiquitous in healthcare organizations, and because the transmission standards are well-defined, a rival interoperability ecosystem already exists. The combination of regulatory and native market forces must be strong enough to move customers from that document transmission ecosystem to the electronic ecosystem.

The Emergence of Meaningful Use and the Direct Standards

The American Recovery and Reinvestment Act (ARRA) provides incentives for “meaningful use” of EMRs and advanced messaging technologies through the Health Information Technology for Economic and Clinical Health (HITECH) Act. Meaningful Use is defined as using certified EMR technology to improve quality, safety, efficiency, and reduce health disparities, engage patients and family, expand care coordination, and improve population and public health, and maintain privacy and security of patient health information7.

The purpose of Meaningful Use is to encourage participants—namely, hospitals and physicians— into the social construct of the interoperability evolutionary path.

Meaningful Use, Stage II, includes a measure that relates directly to clinical document exchange between healthcare providers. This measure requires that acute care hospitals and physicians send 10% of their summary of care documents in a manner that corresponds to the standards set up by the Direct project. (This percentage will likely increase under Meaningful Use, Stage III rules, to 50% of outbound summary of care documents and 40% of inbound summary of care documents to be sent compliantly.) These standards, in brief, ensure the confidentiality and integrity of the content of Direct SMTP messages through the use of S/MIME encryption and signatures, and the authenticity of the message’s sender and receiver through X.509 digital signatures.

Meaningful Use impacts vendors and their technologies indirectly, requiring support for customers who may attest to the measure that calls for 10% of summary of care documents to be sent via the Direct standard. Although Meaningful Use encourages vendors and applications to consider and invest in interoperability, more can be done.

Bridging Fax and Direct for Interoperability

According to a survey performed by HIMSS8, the top three challenges of implementing Direct standards are:

• Changing workflows;

• High costs; and

• Convincing non-adopters to interface with Direct.

With constant pressure to decrease costs and improve efficiency, implementing new technology can be perceived as a monumental task.

OpenText, the leader in Fax Solutions, is bridging the gap between the current method of communication (fax) to the new ecosystem of electronic document transmission (Direct messaging). With an innovative offering, OpenText™ RightFax Healthcare Direct, organizations can expand beyond fax to Direct messaging with very little disruption.

7 http://www.healthit.gov/providers-professionals/meaningful-use-definition-objectives 8 http://blog.himss.org/2015/06/22/current-market-view-of-the-usage-value-and-future-of-direct-messaging/



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Challenge 1: Implement Direct without Changing Workflows

OpenText™ RightFax solutions have a long history of proven integrations with many EMR systems. Many healthcare organizations already rely on EMR integrations with RightFax to send protected health information (PHI), including referrals, notes to specialists, summary of care documents, and a multitude of other documents, notes, letters and patient information.

RightFax allows users to fax content from within their EMR system. With RightFax Health-care Direct, users can use their existing RightFax and EMR integration to send secure clinical documents not as a fax but, instead, as Direct messages directly from the EMR application with no change to the user’s workflow. Users do not need to learn new processes or steps. Outgoing “faxes” from the EMR system are simply converted to Direct messages when a Direct address is available for the recipient. Additionally, users have access to a national directory with fax number-to-Direct address lookup, which eliminates the need to look up Direct addresses that may not be known. RightFax Healthcare Direct automatically references a cloud-based address book to see if there is a Direct address for the outgoing fax number.

While EMR systems should logically be the direct source for outbound Direct messages, many users of EMR systems still find it difficult to seamlessly send Direct messages from within these systems. According to the HIMSS survey, only 28% of respondents’ EMR systems include an integrated directory of providers, making it difficult for users to determine if there is a Direct address available for the recipient.

With RightFax Healthcare Direct, users can easily send Direct messages within their EMR system and have access to the largest HISP provider directory in the industry. OpenText has partnered with Surescripts, expanding the reach of RightFax Healthcare Direct to nearly every care setting and provider in America. As a member of the Direct Trust, Surescripts relies on collaboration and neutrality, which allows RightFax Healthcare Direct to easily communicate with other providers outside their community regardless of the Health Information Service Provider (HISP) technology used on the receiver’s end.

Challenge 2: High Costs of Direct

New technology can be disruptive to budgets and resources, especially when organizations need to invest in multiple point solutions. RightFax Healthcare Direct is a forward-thinking way to bridge the gap between faxing and Direct messaging—quickly and easily—by combining the two in a single solution.

Using an existing RightFax and EMR integration, RightFax Healthcare Direct does not require new system applications, work-arounds, or extensive IT commitments to start sending and receiving Direct messages. By combining fax and Direct messaging in a single solution, organizations can exchange clinical patient documents quickly and easily to improve efficiency and increase the quality of patient care.

Challenge 3: Communicating with Late or Non-Adopters of Direct Messaging

When launching new technology in any industry, growing pains are expected and need to be overcome. There are early adopters who forge the path before the masses and there are skeptics who hesitate to take the plunge. How do you communicate with other providers who are not ready to interface with Direct? How do you bring all providers in the community together into an ecosystem where everyone can communicate via Direct, regardless of their stage of adoption?

RightFax Healthcare Direct addresses this concern in a number of ways.

Firstly, RightFax Healthcare Direct includes a failover technique that ensures valuable patient information is delivered to the intended recipient whether the Direct address is available or not. For example, when a user “faxes” content from the EMR system, RightFax Healthcare Direct accesses the provider directory of America’s largest HISP, determines if there is a Direct address associated with the outgoing fax number, and if so, sends the content in a Direct message. However, if the recipient is not a participant of Direct messaging or does not have a Direct address in the Surescripts provider directory, the content is faxed via RightFax.



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Secondly, RightFax Healthcare Direct is equipped with tools to help other providers quickly and easily get onboard with the new technology. RightFax Healthcare Direct enables providers to:

• Notify their community of their Direct address. This allows recipients to capture the sender’s Direct address for future communications via Direct.

• Invite others to register their existing Direct address in the nationwide address book. This “Join the Directory” tool allows recipients to key their Direct address into the provider directory. Once the address has been verified, the cloud address book is updated, thus allowing future sent faxes to be converted and sent as Direct messages.

• Invite others to obtain their own Direct address(es) along with a platform for exchanging Direct messages. This service is provided by OpenText partner Inofile and provides an easy-to-use, cloud-based application for sending and receiving clinical documentation using Direct, called Kno2TM. In fact, with Kno2, up to 3 users can be configured to receive Direct messages along with the ability to create an unlimited number of Direct addresses.

Expanding the reach of Direct messaging will not only improve an organization’s ability to send Direct messages, it will also increase an organization’s ability to easily receive Direct messages in their EMR system. Receiving Direct messages with RightFax Healthcare Direct involves a two-step process:

1 An incoming Direct message will be matched to patient identification information gathered from HL7 data inside the hospital. This patient identification information will be added as metadata to the relevant files downloaded from the message.

2 The file is exported in a format configured to be easily imported by the recipient’s EMR.

The more providers are able to expand Direct within their community and within the circle of providers with which they communicate on a regular basis, the wider the reach of Direct. For recipients who are still not ready to interface with Direct, RightFax will continue to send and receive faxes with those providers.

RightFax Healthcare Direct Accelerates Interoperability to Direct

RightFax Healthcare Direct is an innovative method for hospitals and their community partners to grow the technical side of the social construct with minimal changes to their workflows. The value is realized in more efficient clinical document processing and less likelihood of error in patient identification. In addition, RightFax Healthcare Direct customers will have the satisfaction of knowing that they are helping to advance the ONC interop-erability objective, which is to: “leverage health IT to increase healthcare quality, lower healthcare costs and improve population health.” Indeed, because one of the guiding principles for the ONC interoperability roadmap is to “build upon existing health IT infrastructure,”9 RightFax Healthcare Direct is one of the few solution that builds upon the ubiquitous presence of fax in U.S. healthcare and provides a bridge from current paper-based information transmission methods to the future of electronic transmissions.

9 “Interoperability Roadmap: Early Draft Material, Joint HITPC and HITSC Meeting” presentation, Oct 15, 2014, Erica Galvez, presenter.

W H I T E P A P E RACCELERATING INTEROPERABILITY IN HEALTHCARE

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Interoperability is just the beginning of benefits that organizations will realize by implementing a seamless solution like RightFax Healthcare Direct to expand Direct messaging capabilities. Other tangible benefits include:

• Increase quality of patient care: Ensure patients receive optimal care including acute illness management, chronic disease management, and preventive care.

• Increase coordination of care across providers: Increase the ability to communicate and coordinate patient care across multiple health settings and multiple physicians/providers and reduce the number of duplicate testing across the patient care continuum.

• Reduce the risk of readmissions: Health information exchange between the hospital and the follow-up provider serves as one of the most important exchanges in healthcare. The more effective and efficient this communication, the higher quality of care for the patient, thus reducing the risk of readmission.

• Reduce missed or delayed diagnosis, medical errors, and medication errors: Decrease delays in patient record exchange, reduce the time for content to reach EMR systems, and exchange richer electronic, clinical information between providers.

• Increase employee productivity: Reduce the impact of Direct on employees by implementing solutions that provide interoperability without changing user workflows.

• Be prepared for Meaningful Use: Many organizations who have already attested to Meaningful Use, Stage II are already worrying about Meaningful Use, Stage III, which increases the intensity of Direct message exchange. Attaining Meaningful Use objectives and requirements does not have to be a painful and disruptive process.

RightFax Healthcare Direct accelerates interoperability and improves patient care in the healthcare industry by allowing healthcare providers to easily and securely send Direct messages, a secure way to send encrypted health information directly to authenticated recipients over the Internet. RightFax Healthcare Direct helps organizations expand beyond fax to Direct messaging in a single solution to easily and securely share and communicate patient information across an entire network of caregivers.

RightFax Healthcare Direct works without users changing their existing workflows. And it comes equipped with tools to help anyone they communicate with quickly and easily get onboard with the new technology, OpenText opens the door to allow the entire healthcare community interface with Direct: both in your city and across the entire United States.

accelerating interoperability in healthcare · challenges of interoperability..... 4 the...

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