Ending healthcare’s square peg – round hole interoperability problem

Last summer the physician Congressman Phil Gingrey (GA) held hearings to highlight the unacceptable lack of interoperability among electronic medical record systems.

Gingrey said: "Congress has spent, as we all know, something like $24 billion over the past six years buying products to facilitate interoperability, only to have...closed platforms. Do you believe the federal government and the taxpayers are getting their money's worth subsidizing products that are supposed to be interoperable, but they're not?" (Gregg, 2014)

Further in his remarks he referenced a RAND report that cites a lack of interoperability as one reason why EHRs have not yet reached their full potential. He went on to say,

"If the June 2014 RAND report is true, we have been subsidizing systems that block information instead of allowing for information transfers, which was never the intent of [the HITECH Act]. ... It may be time this committee takes a closer look at the practices of vendor companies in this space, given the possibility that fraud may be perpetrated on the American taxpayer." (Gregg, 2014)

Although Gingrey focused most of his anger on a single EHR vendor, all participants in the EHR space deserve some scolding for their lack of focus on interoperability.

The problem of poor interoperability did not suddenly appear in the hot Washington summer of 2014. It has existed for several years; I called it out in an article published in the Journal of Patient Safety and Quality Healthcare at the end of 2013:

"The lack of interoperability among HIT systems represents a substantial barrier to utilizing innovative information technology tools. If we spoke the same HIT language we could accomplish great things." (Chaiken 2013)

The RAND report (Garber et al., 2014) referred to by Gingrey, also referenced the impact of interoperability on the effectiveness of EHRs:

"Rapid adoption of EHRs has been hindered by a variety of factors, including a fragmented marketplace, changing federal incentives, provider uncertainty about the regulatory landscape, and the striking lack of interoperability between systems.

One feature that many current systems lack is interoperability. HITECH's language clearly indicated that Congress wanted HIT systems to be interconnected and interoperable so that they can readily share data between providers."

According to Garber et al., the rules for Meaningful Use payments watered down the requirement for interoperability and connectivity: "The practical effect was to promote adoption of existing platforms, rather than encourage the development of interconnected systems."

Although 20:20 hindsight may seem unfair, the impact of a Meaningful Use strategy that failed to foster true interoperability saddled our health IT infrastructure with high-priced systems that will prove both difficult and expensive to update to full interoperability.

While the opportunity existed to drive innovation and the potential benefits of shared medical information, provider organizations focused on implementing systems to secure incentive payments funded by HITECH. The government committees that promoted the Meaningful Use rules put in place by the Office of the National Coordinator focused on the current state of technology rather than encouraging the development of new capabilities.

Systems designed before HITECH never valued interoperability as a product feature. In fact, the lack of interoperability significantly raised switching costs, something that served the interest of EHR vendors.

In addition, the rush to deploy EHRs after did not allow these systems to include the health information exchange features that facilitate efficient and complete interoperability. Instead, health information exchange and interoperability became future functionality while systems lacking these capabilities became embedded in provider organizations. The difficulty and expense associated with large system upgrades doomed these provider organizations to many years of crippled clinical systems.

Information Interoperability Problem

Although physicians often address clinical problems without a complete patient's medical record, optimum care is achieved only when all patient information is available to the treating clinician. Complete records reduce the probability of unnecessarily repeating tests and procedures, and prescribing contraindicated or duplicative medications.

Building complete patient records across the continuum of care presents a very difficult challenge to provider organizations. As a first step, most organizations deployed integration software to facilitate the transfer of individual HL7 messages among various clinical systems. As part of Meaningful Use Stage 1, the U.S. Healthcare Information Technology Panel (HITSP) selected the Continuity of Care Document or CCD as a standard method for organizations to exchange health data on patients. Unfortunately, EHR vendors implemented this CCD format differently leading to the inability of many EHR systems to exchange patient data.

These problems led to the development of the updated Consolidated Clinical Document Architecture (C-CDA) standard now utilized by all EHR vendors. This standard allows the exchange of patient data including name, sex, date of birth, ethnicity, preferred language, smoking status, problems, medication, medication allergies, laboratory tests, laboratory values/results, vital signs, care plans, procedures, and team members. In addition, encounter diagnoses, immunizations and referral reason and discharge instructions may also be included.

Although the C-CDA seems to solve the data interoperability problem, it fails to solve the information interoperability problem. EHR vendors can electronically "ingest" C-CDA data but offer no consistent way across vendors in how they present the ingested data.

EHR vendors present barriers to entry for data that is not directly created within their own EHR. With the data kept outside the normal EHR data structure, C-CDA patient data is presented to clinicians using various visualization schemes. This leads to the data falling outside the usual clinician workflow reducing its usefulness in patient care. With clinicians pressed for time, activities that fall outside the normal workflow often get ignored, meaning important patient data may fail to reach the clinician.

As provider organizations broaden their focus from episodic care to care provided across the entire care continuum, they must focus on implementing a data interoperability architecture that allows for the viewing of a complete patient record. This includes robust data integration, data aggregation and data visualization. EHR vendors currently do not provide the necessary level of interoperability to deliver to clinicians the patient information required to provide high quality, efficient care. Therefore, organizations are encouraged to begin building the infrastructure necessary to offer clinicians a complete and accurate view of individual patient data and workflow friendly views of patient records.

Barry P Chaiken is the chief medical information officer of Infor. With more than 25 years of experience in medical research, epidemiology, clinical information technology, and patient safety, Chaiken is board certified in general preventive medicine and public health and is a Fellow, former Board member, and Chair of HIMSS. As founder of DocsNetwork, Ltd., he worked on quality improvement studies, health IT clinical transformation projects, and clinical investigations for the National Institutes of Health, UK National Health Service, and Boston University Medical School. He is currently an adjunct professor of informatics at Boston University's School of Management. Chaiken may be contacted at barry.chaiken@infor.com.

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