Vendor Selection Criteria: Interoperability

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When selecting a vendor for EHR implementation, interoperability or functionality should be considered. In a 2015 publication, "What makes an EHR "open" or interoperable?" there were five cases where interoperability should be considered when selecting an EHR. The following should be considered:

  • Clinicians- essential to provide safe and effective care
  • Researchers- critical to advance and understand disease processes
  • Administrators - to reduce the dependence on one EHR vendor
  • Software developers- to develop interface and software
  • Patients- important to access personal health information

Widespread access to EHR information is important if the full potential of the electronic health care system is to be realized.[1]

The purpose of EHR is to provide access of patient information to the right people at the right time. Interoperability is the ability to exchange this information between different EHR systems and stakeholders. [2] There are standards considered by the Health IT and they are divided into 3 different categories: content, terminology and transport.[3] In addition, the exchange of information between systems is dependent on two entities: syntax and semantics. Syntax describes how the communication is put together. Semantics, on the other hand, describes what the communication means.[3]

In 2011, a majority of office-based physicians could exchange lab and medication data, and approximately one-third could exchange clinical summaries with patients or other providers; 55% of physicians had computerized capability to send prescriptions electronically; 67% had the capability to view lab results electronically; 42% were able to incorporate lab results into their EHR; 35% were able to send lab orders electronically; and, 31% exchanged patient clinical summaries with other providers. EHRs serve as a key mechanism by which physicians can exchange clinical data, though physicians' capability to exchange varies by vendor and by state. [4]

Importance of Interoperability

The communication, interoperability and analysis of Electronic Health Records (EHRs) is of growing global importance as the functionality and use of an EHR system increases. Longitudinal EHRs can improve the quality and safety of care to individuals, provide the knowledge needed to improve the efficiency of healthcare services and population health programs and accelerate clinical research.[5]

Interoperability is of significant importance for multiple reasons:

  • Security: low standards of interoperability can lead to security hazards
  • Behavior change in patient health habits may be affected
  • Interactions between multiple branches of systems in the health industry depend on the interoperabilty of systems [6]


  • Help deliver evidence-based health care
  • Help to improve safety by reducing errors and inequalities [5]

Patient Centered

  • Empower and involve citizens in their own health care.
  • Help to protect a patient's privacy. [5]


  1. Sittig, D.F., Wright, A. (2015). What makes an EHR "open" or interoperable? Journal of the American Medical Informatics Association.
  3. 3.0 3.1 Hoyt, R. E., & Yoshihashi, A. K. (Eds.). (2014). Health Informatics: Practical Guide for Healthcare and Information Technology Professionals (6th edition)
  4. Patel, V., Swain, M. J., King, J., & Furukawa, M. F. (2013). Physician capability to electronically exchange clinical information, 2011. The American journal of managed care, 19(10), 835-843.
  5. 5.0 5.1 5.2 Tapuria, A., Kalra, D., & Kobayashi, S. (2013). Contribution of Clinical Archetypes, and the Challenges, towards Achieving Semantic Interoperability for EHRs. The Korean Society of Medical Informatics, 19(4), 286-292.
  6. Kahn, J. S., Aulakh, V., & Bosworth, A. (2009). What it takes: characteristics of the ideal personal health record. Health affairs, 28(2), 369-376.

Interoperability Considerations

It is important to determine prior to selecting a vendor what type of data and devices a facility needs to exchange information. [1]

  • PACS Systems
  • Medical Devices (Monitors, Ventilators, Anesthesia cart, etc.)
  • Pharmacy
  • Laboratory Orders and Results
  • Critical Values Reporting
  • Electronic Health Records to other facilities and/or physician's practices

EMR needs to have interoperability specifications

  • Defined levels and mechanisms of desired semantic interoperability
  • Well-defined architecture and modularized interfaces to build transition plans for future upgrades
  • Patient data safety[2]

Ensure that Information Technology, Biomed and EMR vendor are engaged in all conversations to achieve desired interoperability level. [1]

Content Standards

There are mainly two types of contents in clinical data; 1. Structured Data, which is computationally tractable and used in Billing, Lab reports, problem lists and others and 2. Unstructured Data, which is usually physician dictations that is free text, this is not computationally tractable and requires Natural Language Processing. Data extractors likes cTAKES, METAMAP and MEDLEE are used to process free texts.[3]

Terminology Standards

"MEDCIN is a clinical terminology designed to support medical documentation entry into electronic health record systems. MEDCIN was initially developed as “an intelligent clinical database for documentation at the time of care.”(16) MEDCIN's producer, Medicomp, states that their software “makes capture of the encounter information fast enough, sufficiently comprehensive and rewarding to overcome physician reluctance.” MEDCIN has evolved to include more than 250,000 concepts since 1978, and has been installed in several EHR systems as an interface terminology for clinical documentation including AHLTA, the EHR system developed for the US Department of Defense." (Brown et al. 2007) [4]

Transport Standards

  • The transport standards consist of ELINCS, IEEE 11073, NCPDP and ASC X12.[3]

ELINCS stands for EHR-LAB Interoperability and Connectivity Standards enables messaging between laboratory and clinicians ambulatory EHRs, IEEE 11073 is the transport standard for medical device connectivity and data exchange, National Council for Prescription Drug Program (NCPDP) is for the exchange of prescription related information and Accredited standards Committee (ASC)X12 is for electronic data interchange or computer-computer business data exchange. Other transport standards include Script (V10.10) for physician pharmacist communication, OpenID Connect helps web-based, mobile to connect to an authentication server and IHE-PCD based on IEEE integrates the healthcare enterprise and patient care device. [3]

2015 Interoperability Standards Advisory

On January 30, 2015, the ONC released a document entitled “2015 Interoperability Standards Advisory.”[5]The 2015 Interoperability Standard Advisory was created for two purposes regarding the healthcare professionals and Health Information Technology Interoperability. First it was developed to provide a single point of reference regarding interoperability for professionals in the Health IT field. Second, it was developed promote awareness of the different interoperability standards and to provoke opinions and input regarding these standards. By fulfilling these two purposes, the 2015 Interoperability Standard Advisory makes it easy for Health IT professionals to identify necessary standards and how they are to be implemented. The advisory standards also allow for better management of standards, potentially identifying standards that can be met by fulfilling one standard versus several standards.[6] It is essentially a document noting many standards that are recommended for interoperability among EHRs. There are criteria for content standards, structure standards, and transport standards, among other notable standards for interoperability.[6] The document is subject to change as the ONC moves forward and also contains a section noting how changes to the document will take place.[6]

Section I

Section 1 of the 2015 Interoperability standards Advisory identifies the standard specifications for terminology and code sets. From allergic reactions to unique device identification and more, Section 1 specifies standards implemented by the Systemized Nomenclature of Medicine – Clinical Terms (SNOMED-CT), International Classification of Diseases, tenth edition, Clinical Modification (ICD-10-CM), and many more standards associated with the interoperability of Health IT.[6]

Section II

Section 2 consist of standards for how data will be collected and stored in a Health IT device such as an EHR. Like Section 1, different systems have different standards. An example of standards that would be found in section two of the 2015 Standard Advisory would be on the exchange of data collection forms utilized abroad different systems for a patient. You would also find standards on how data would be entered into an EHR. [6]

Section III

Section 3 lists the standards for the transport of data from data collection to database, from database to database, and database to computer. These standards are especially important due to the information being transported. Transporting Personal Identifiable Information (PII), Personal Health Information (PHI), or any other type of sensitive data can be risky. Failure to protect such information can result in hefty fines and or jail time. [6]

Section IV


  1. 1.0 1.1 Achieving INTEROPERABILITY: What's Happening Out There? Williams, Jill Schlabig; Jacobs, Brian, MD
  2. Interoperability Hufnagel, Stephen P, Phd
  3. 3.0 3.1 3.2 3.3 3.4 <Hoyt, R. E. Y. A. (2014). Health Informatics: Practical Guide for Healthcare and Information Technology Professionals (Sixth Edition) eBook: Robert E. Hoyt, Ann Yoshihashi: Kindle Store. Retrieved September 14, 2015, from>
  4. <Brown, S. H., Rosenbloom, S. T., Bauer, B. A., Wahner-Roedler, D., Froehling, D. A., Bailey, K. R., ... & Elkin, P. L. (2007). Direct comparison of MEDCIN® and SNOMED CT® for representation of a general medical evaluation template. In AMIA Annual Symposium Proceedings (Vol. 2007, p. 75). American Medical Informatics Association. Retrieved from:>
  5. Interoperability to help achieve better care, smarter spending, and healthier people
  6. 6.0 6.1 6.2 6.3 6.4 6.5 2015 Interoperability Standards Advisory