How Industry Collaboration​ Shaped the Carequality Interoperability Framework

Joe LamyOver the course of the last several years, industry has played an active role in accelerating the development and adoption of national and international standards for the secure exchange of health information. Through collaboration with industry developers, our organization was engaged to lead the efforts to create the Carequality Query-Based Document Exchange Use Case and Implementation Guide (“Guide”). This is a component of the Carequality Interoperability Framework whose public release was announced on Dec. 7. This article outlines some of the collaborative efforts that led to the creation of the framework.

Carequality was formed to enable seamless connectivity across all participating healthcare networks, including vendor-specific networks and existing health information exchanges (HIEs). The Carequality Interoperability Framework is an effort to bring together a vast number of critical stakeholders to systematically use a clearly defined process, identified standards and open access tools to enable that seamless connectivity throughout the healthcare ecosystem.

Carequality, a public-private collaborative initiative of The Sequoia Project, creates a standardized, national-level interoperability framework to link all data sharing networks. The Carequality Interoperability Framework is a collection of documents that are used to operationalize data sharing that include: the terms of the Carequality Connected Agreement (CCA), Carequality Connections (CCs) Terms, and a defined Dispute Resolution Process.

To facilitate collaboration in the efforts to achieve interoperability, Carequality has a set of guiding principles that include being:

  • Inclusive and transparent
  • Flexible and innovative
  • Clear and equitable in its oversight
  • Standards-based
  • Vendor neutral

In addition, in order to enable widespread connectivity without individual pre-coordination with each partner, Carequality has outlined three essential core elements:

Common rules of the road: In order for the varied participants to trust each other with health information, everyone needs to have a legal obligation to abide by the same rules.

Well-defined technical specifications: Shared rules are not enough; clear standards must be laid out in an implementation guide that all implementers can follow.

A participant directory: To connect using the common standards, systems must know the addresses and roles of each participant.


The Carequality Interoperability Framework

Key to the success of the Carequality Interoperability Framework was the enthusiastic participation of healthcare IT industry leaders and organizations and their collaboration with Carequality. This work was carried out under the guidance and direction of the Sequoia Project staff, with input from the Carequality Query Work Group and Trust Framework Work Group.

The Carequality Interoperability Framework is being driven by a diverse array of stakeholders, building on industry consensus regarding implementation of a core set of capabilities that enable connectivity among existing networks, including implementation-level functionality, standards-based technical and testing requirements, trust policies, and operational practices for inter-network connectivity. The initial implementers of the Carequality Interoperability Framework have focused on query-based exchange of clinical documents, laying the groundwork to support an unlimited variety of use cases.

Barry DickmanIndustry participation came from several leading organizations in this space., Inc. led the Query Workgroup in the analysis of the first Carequality query use case and wrote the technical requirements for the accompanying Guide. One of their key tasks was to pinpoint the interoperability pain points in the underlying specifications. The Workgroup followed a collaborative effort, leveraging AEGIS’ experience testing applicants to the eHealth Exchange, a mature, nationwide production exchange that utilizes the same underlying standards as Carequality,

The Query Workgroup, co-chaired by Cerner and Kaiser Permanente, was a unique grouping of subject matter experts and representatives from vendors, providers, and networks, such as ICSA Labs, all of whom contributed detailed review and discussion. Sequoia handled overall coordination of the Implementation Guide at a high level. A related effort, the Trust Framework Work Group, chaired by St. Luke’s Health System, and facilitated by Troutman Sanders, developed the Principles of Trust that serve as the foundation for Carequality’s operating structure.

The effort around the first Carequality use case culminated in an Implementation Guide which provides technical specifications and requirements, as well as additional business and policy requirements, for the initial Carequality Use Case of Query-Based Document Exchange. The Query-Based Document Exchange Use Case addresses the need for documents containing relevant healthcare information to be available upon request to appropriate parties across the healthcare ecosystem. For example, a hospital may need information held by a primary care physician, who in turn may need information from a specialist or emergency department. As a second example, a payer may need information from any of these clinical settings. And finally, Government agencies may need information from private sector organizations. The Guide provides for flexibility across multiple query purposes and healthcare settings.

The Guide specifies how query between and among networks is enabled for Simple Query and Record Locator Services, which are defined as follows:

  • Simple Query: The ability to request and receive one or more documents from any known node (e.g., network, location, individual EMR, HIE, system) using IHE document exchange profiles, starting with a known set of patient identifying data.
  • Record Locator Service: The ability to identify the presence of patient records across nodes, as a service, to facilitate electronic exchange.

Both services are built upon the Integrating the Healthcare Enterprise (IHE) XCPD and XCA standards for patient discovery and document exchange, as well as myriad web services and security standards from WS-I, W3C, OASIS and others.

The Query-Based Document Exchange Use Case describes the actors, transactions, and requirements to enable the exchange of health information between and among networks for simple query and RLS. The Use Case focuses on desired functionality (e.g., the user goals and how system actors meet them), highlighting the information that flows and the variations allowed by the existing specifications.

Carequality continues to seek participation from its membership (e.g., Health care organizations, HIE Network providers & Health IT vendors). Representation from current members in the implementation of the Carequality Interoperability Framework includes:

In addition, Eric Heflin, the Chief Technology Officer of the eHealth Exchange (formerly known as the Nationwide Health Information Exchange), is participating in the Query Work Group as a subject matter expert.

The ultimate benefits from active participation and adoption of the Carequality Interoperability Framework enable organizations to:

  • Achieve accelerated, less costly health data sharing agreements, because they no longer need to develop one-off legal agreements between individual data sharing partners.
  • Leverage (in the case of HIEs) existing networks and business relationships to rapidly expand.
  • Establish data sharing partnerships quickly and uniformly, making better use of existing networks and business relationships, according to the group.
  • Jump start to providing this functionality to clients and prospects
  • Demonstrate interoperability testing across networks

5 Major Health IT Leaders Adopt the Framework

The release of the Carequality Interoperability Framework was shortly followed by the announcement that five major health IT vendors are implementing the Framework. The five companies, athenahealth, eClinicalWorks, Epic, NextGen Healthcare and Surescripts, have agreed to provide health information exchange services for their customers under the comprehensive Framework. That includes legal terms, policy requirements, technical specifications, and governance processes.

“The adoption of the Carequality Framework represents a major leap forward for nationwide interoperability,” explained Dave Cassel, director of Carequality. “By these organizations committing to unified Rules of the Road, they are simplifying system-to-system connections to make data exchange easier for a significant portion of the healthcare ecosystem.”

One of the examples presented by Carequality is that of small physician offices. According to their announcement, "most physicians already have access to a small network through a technology vendor or a health information exchange (HIE). These existing health data sharing opportunities will dramatically expand to include additional providers, payers, government agencies, and others as the Carequality community grows."

Doran Robinson, Vice President of Network Integration for athenahealth said that “athenahealth believes that physicians should be allowed to focus on patients, not the hassles of coordinating care.” He emphasized “We’re thrilled to join other major players in reducing the legal and regulatory barriers that impede the development of a national health information backbone that connects care settings, regardless of vendor or service provider.”

The initial implementers will focus first on query-based exchange of clinical documents, but the Framework was developed to support an unlimited variety of use cases.


Updated 2/8 3:20 PM EST-Article was updated with additional news content.