Interoperability and connecting to an HIE

Our world is getting smaller, and the healthcare arena is no exception. As healthcare options continue to expand and the number of providers a patient interacts with continues to grow, the focus is increasingly on interconnectedness, communication, and convenience. From acute care to long-term care, home care to hospice, electronic medical records (EMR) are no longer a choice, but a necessity. While there are many things to look for in EMR software, interoperability is perhaps the most crucial element to consider when comparing healthcare software solutions.


An EMR is defined as a digital version of a patient’s chart within a single medical practice or healthcare organization. The EMR record includes the medical history and other patient information recorded by clinicians and staff within that organization. Usually incorporating point of care documentation using web-based or cloud-based software on a mobile device, EMRs allow authorized users to create, manage and extract the data as necessary.

Interoperability is what differentiates an electronic health record (EHR) from an EMR. HIMSS (Healthcare Information and Management Systems Society) defines interoperability as the ability of different health information technology (HIT) systems to connect within and across organizational boundaries in order to cooperatively exchange and utilize data. EHR products conform to nationally recognized interoperability standards. An EHR system includes patient records from across the healthcare continuum, thereby offering a broader, more inclusive view of a patient’s health and medical history than an EMR. EHR patient data can be created, managed and extracted by authorized clinicians and staff from all of a patient’s providers and organizations, including laboratories, pharmacies and specialists.

Is “Interoperability” the same as “Interface”?

In the world of health information technology, interoperability and interface both refer to the electronic transfer of patient data from one health record system to another. Perhaps the easiest way to distinguish the two is this: Interoperability relates to the transfer of information or data from one healthcare provider or organization to another; interface relates to the transfer of data from software vendor to software vendor. You need an EMR software vendor that does both… well.

An EMR system with limited and/or ineffective interoperability is not an EMR solution, because it does not enable a patient’s electronic medical record to become part of their broader EHR. Home health software vendors have been interfacing with partner vendors for years. NDoc® has been interfacing for over two decades with HIT systems such as hospitals, laboratories, medication administration, DME and supplies, coding, telehealth, telephony, transcription, benchmarking, and patient satisfaction (CAHPS). Interoperability is much more complex, involving many more layers of communication.

Why is interoperability so important?

HIMSS identifies four components of interoperability—foundational, structural, semantic, and organizational—which allow authorized clinicians and staff from every health care provider to securely access, share, interpret and utilize a patient’s vital medical information. Interoperability means that authorized providers across the healthcare continuum will have access to patient data such as medical history and contact information; admission, discharge and transfer notes; medications and immunizations; allergies and advance directives; care plans and cognitive functioning; and much more.

Interoperability is of paramount importance in the home healthcare arena, since long-term and post-acute care (LTPAC) patients are more likely to have chronic conditions and co-morbidities that necessitate frequent transition between multiple care providers. Interoperability has become increasingly critical since the implementation of the Improving Medicare Post-Acute Care Transformation (IMPACT) Act, a bipartisan bill passed in 2014. The IMPACT Act requires that assessment data be standardized in order to facilitate coordinated care and enable assessment data comparison across all four LTPAC settings: home health agencies, skilled nursing facilities, inpatient rehabilitation facilities, and long-term care hospitals.

Smooth transitions of care between LTPAC providers require access to the right patient information at the right time. This is best accomplished by an EMR system that incorporates a standards-based approach to interoperability and information exchange, enabling the secure and timely capture, sharing, interpretation, and utilization of patient data among authorized healthcare providers. Part of the certification process for any EMR vendor is proving their interoperability by demonstrating they can produce and consume (export and import) clinical summaries.  NDoc is built natively on the HealthShare™ interoperability platform, the market-leading engine for health information exchange, and is fully CCHIT Certified® 2011. NDoc connects to acute, post-acute, and ambulatory EMRs; and to post-acute referral networks.

Electronic Health Information Exchange (HIE): the next step in interoperability

HIE as a Process: Interoperability is a crucial component of any EMR solution. The secure sharing of confidential patient data among authorized health care providers made possible through interoperability is referred to as electronic health information exchange. describes three forms of health information exchange: directed, query-based, and consumer mediated. Directed exchange is the form most applicable to home health and hospice. It is used to easily and securely send patient information from one healthcare provider or organization to another, and allows seamless access to the information required in order to more comprehensively understand and address patients’ health needs.

HIE as a Framework: As patients maneuver throughout the healthcare continuum, provider organizations are finding it necessary to connect with an ever increasing number of other providers. The ever-growing web of electronic HIE communication has prompted a need for a more centralized approach, giving birth to the HIE as an organizational framework.

The first attempt towards centralization of data began in 1990 when the Community Health Management Information Systems (CHMIS) program was formed by the Hartford Foundation. Although ultimately unsuccessful, the program marked the birth of the HIE philosophy, and efforts continued towards the creation of a secure and centralized repository—a central hub—for EHR data. The goal of the HIE is to facilitate the secure electronic transfer and utilization of patient records and health data among authorized providers/organizations in accordance with recognized standards, in order to provide safer, more effective care.

There are many different types of HIEs. An HIE can be regional or statewide, private or not-for-profit. The terms HIO (Health Information Exchange Organization) and RHIO (Regional Health Information Organization) are often used interchangeably with HIE. According to HIMSS, however, an HIO is an organization that performs oversight and governance functions for HIEs according to nationally recognized standards. The protection of confidential patient data is a central part of all interoperability standards and, regardless of type, all HIEs/HIOs/RHIOs are required to have policies and procedures in place to ensure the confidentiality and security of patient health data exchange.

Some healthcare providers may need to connect to multiple HIEs, and your EMR software vendor should be able to accommodate your HIE interoperability needs. Thornberry’s NDoc EMR currently partners with:

  • Healthix, a key partner in the Statewide Health Information Network for NY (SHIN-NY) and the largest public HIE in the nation
  • HealthlinkNY, a regional HIE serving 13 counties in New York
  • KeyHIE (Keystone Health Information Exchange), one of oldest and largest HIEs in the US, serving 53 counties in Pennsylvania
  • NC HealthConnex (coming soon), North Carolina’s state-designated HIE

What are the benefits of HIE?

Utilizing an HIE can greatly simplify the health information exchange process, and the benefits are numerous. An HIE allows participating providers to quickly access and confidentially share a patient’s medical history, current medications, and other vital health data—no matter where the patient receives care. An HIE can improve the safety, speed, cost, and quality of care by:

  • improving the accuracy and completeness of patient records by giving all providers access to the same data for review and update
  • enabling more accurate diagnosis by giving providers access to the necessary clinical decision support tools
  • facilitating coordinated patient care
  • helping providers avoid medication errors
  • reducing redundant or unnecessary treatments and testing, which can help to avoid readmissions and costly mistakes
  • eliminating duplicative or unnecessary paperwork, which can improve workflow and lower costs
  • enabling faster and more accurate medical billing

According to, connecting to an HIE may even increase market competitiveness, expand referral networks, and enhance payment for LTPAC providers.

The trend towards nationwide centralization

HIEs are becoming increasingly collaborative. This is not surprising, as the geographic mobility of the US patient population highlights the need for an ever more centralized solution. CommonWell Health Alliance is a nonprofit trade association founded in 2013 by a handful of health IT companies, with the mission to enable secure, reliable interoperability across the nation. Carequality, also a nonprofit entity, was founded as a national interoperability initiative by The Sequoia Project in 2014.

One of the most recent steps towards nationwide centralization came with the CommonWell/Carequality connection, which was first announced in December of 2016 and became generally available in November of 2018. This new interoperability connection allows more than half a million participating health care providers from across the U.S. to connect and exchange patient health data. The majority of these are acute and ambulatory care providers. There are currently few hospice or home health participants.

Interoperability will be increasingly vital as healthcare options continue to expand. An EMR system can be an EMR solution only if it offers secure, seamless, certified interoperability with acute, post-acute, ambulatory care, and other provider organizations. HIEs are an imperative part of the interoperability equation in our ever-shrinking world, where the trend is toward centralization on a national level. Thornberry already offers interoperability with some of the largest regional HIEs in the nation. Although not yet part of the CommonWell-Carequality collaboration, Thornberry is working towards interoperability within the Carequality framework and is poised to help lead the charge in the post-acute care arena.