Interoperability and Your EMR: 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. While there are many things to look for in an electronic medical record (EMR) system, interoperability is perhaps the most crucial element to consider when comparing home health and hospice solutions. 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 electronic health record (EHR).

What is Interoperability in Healthcare?

The Health Information Technology for Economic and Clinical Health (HITECH) Act was part of the American Recovery and Reinvestment Act of 2209 (ARRA) and was created in order to promote the adoption and support of progressive health information technology. Since 2009, much emphasis has been placed on better handling of patient transitions from one provider to another, from one level of care to another. Key to better transitions is the meaningful use of EHRs and comprehensive data sharing made possible by standards-based interoperability.

HIMSS (Healthcare Information and Management Systems Society) defines interoperability as the ability of different information systems, devices, and applications “to access, exchange, integrate and cooperatively use data in a coordinated manner within and across organizational, regional and national boundaries.” The twofold goal of interoperability: “to provide timely and seamless portability of information and optimize the health of individuals and populations globally.” HIMSS identifies four levels of interoperability—foundational, structural, semantic, and organizational, which together allow authorized clinicians and staff from across the healthcare continuum to securely access patient information.

Interoperability implies provider-to-provider communication among many simultaneous data partners: physicians and specialists, laboratories and pharmacies, hospitals and LTPAC (long-term and post-acute care) facilities. EHRs today conform to nationally recognized interoperability standards, and part of the certification process for any EMR vendor is proving their interoperability by demonstrating they can produce and consume (export and import) clinical data and summaries. This includes vital health and medical data such: 

  • demographics and medical history
  • admission, discharge and transfer notes
  • medications and immunizations
  • allergies and advance directives
  • diagnoses, care plans, and cognitive functioning
  • lab results and prescriptions
  • and much more

Why is Interoperability So Important for Hospice and HHAs?

Interoperability typically is geared to data exchange that supports care transitions, which in turn can translate into better medical care and better patient outcomes. Interoperability is of paramount importance in the home healthcare arena because LTPAC patients are more likely to have chronic conditions and comorbidities that necessitate frequent transition between multiple care providers.

Smooth transitions of care between LTPAC providers require access to the right patient information at the right time. An EMR system that incorporates a strategic, standards-based approach to interoperability and information exchange is essential to enabling the secure and timely capture, sharing, interpretation, and utilization of patient data among authorized healthcare providers across the care continuum. 

Interoperability has become increasingly critical for home health agencies (HHAs) 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 data comparison across all four LTPAC settings: home health agencies, skilled nursing facilities, inpatient rehabilitation facilities, and long-term care hospitals.

CMS (the Centers for Medicare and Medicaid Services) is steadily shifting its reimbursement model from quantity-based to quality-based, and corresponding initiatives like accountable care organizations (ACOs) are gaining solid ground. As a home health provider today, you may see your major source of referrals shifting from hospitals and physicians with whom you’re loosely connected to an organization or health system charged with the wellbeing of a defined patient population—an organization or health system to which you must be tightly connected at multiple levels, including data exchange. 

You will improve your odds of ACO participation by demonstrating that you can improve patient outcomes; that you can keep the ACO’s patients out of the hospital; and that you can connect – interoperate – with providers throughout the continuum of care. This is where Thornberry Ltd and NDoc® stand out. Most EMR systems tout their interoperability capabilities, but in reality, seamless interoperability among EMR vendor systems is rare. NDoc is built natively on the HealthShare™ interoperability platform, the market-leading engine for health information exchange, and is fully CCHIT Certified® 2011. 

Electronic Health Information Exchange (HIE)

HIE as a Process: The secure sharing of confidential patient data among authorized health care providers made possible through interoperability is referred to as electronic health information exchange. According to, HIE “allows doctors, nurses, pharmacists, other health care providers and patients to appropriately access and securely share a patient’s vital medical information electronically—improving the speed, quality, safety and cost of patient care.” 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 have found it necessary to connect with an ever increasing number of other providers. The ever-growing web of electronic communication has prompted a need for a more centralized approach.

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, efforts continued towards the creation of a secure and centralized repository—a central hub—for EHR data, giving birth to the HIE as an organizational framework. 

According to HIMSS, HIEs provide “the capability to electronically move clinical information among disparate healthcare information systems and maintain the meaning of the information being exchanged.” HIMSS identifies the goal of an HIE: “to facilitate access to and retrieval of clinical data to provide safe, timely, efficient, effective and equitable patient-centered care.”

There are many different types of HIEs. An HIE can be regional, statewide, or national; they can be 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. HIE interface capability can be leveraged for HHAs and Hospice agencies: post-acute providers with the technology in place to tie to an HIE can be more attractive to ACOs.

The NDoc EMR system has proven itself in the secure, seamless, and reliable transfer of clinical health data. NDoc data transfer includes demographics and clinical data for the Continuity of Care Document or CCD. A CCD is a concise electronic patient summary designed to communicate pertinent patient data from one provider to another in both human- and machine-readable formats. It contains the information deemed critical to continuity of care across the healthcare continuum, including patient demographics, problems, functional status, family and social history, allergies and alerts, medications, Advance Directives, and more. CCD data is secure: only registered patient providers have access to patient data, and HHA patients must give consent—either opting in or opting out—for their data to be shared/sent to the HIE.

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
  • KeyHIE (Keystone Health Information Exchange), one of oldest and largest HIEs in the US, serving 53 counties in Pennsylvania
  • HealtheConnections (formerly HealthlinkNY), a regional HIE serving 13 counties in New York
  • CarePort, a regional HIE in western PA
  • LIPIX (Long Island Patient Information eXchange; demographics feed only)

Benefits of Connecting to an HIE

Every HIE connection, at its core, is designed to give data visibility and usability to other HIE participants. An HIE facilitates the secure electronic transfer and utilization of patient records and health data in accordance with recognized standards, in order to provide safer, speedier, more effective, and more cost-effective care. 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.

Utilizing an HIE can greatly simplify the health information exchange process, and the benefits are numerous. An HIE can:  

  • improve the accuracy and completeness of patient records by giving all providers access to the same data for review and update
  • enable more accurate diagnosis by giving providers access to the necessary clinical decision support tools
  • facilitate coordinated patient care
  • help providers avoid medication errors
  • reduce redundant or unnecessary treatments and testing, which can help to avoid readmissions and costly mistakes
  • eliminate duplicative or unnecessary paperwork, which can improve workflow and lower costs
  • enable faster and more accurate medical billing
  • improve public health reporting and monitoring
  • facilitate the efficient deployment of emerging technology and health care services

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. According to CommonWell, “While future collaboration could touch on many different areas within healthcare IT, the immediate focus of the work between Carequality and CommonWell will be on extending providers’ ability to request and retrieve medical records electronically from other providers.” This 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. Thornberry is also working towards interoperability within the Carequality framework and is poised to help lead the charge in the post-acute care arena.