Healthcare Interoperability: Who's The Tortoise? - InformationWeek
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11/21/2014
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Healthcare Interoperability: Who's The Tortoise?

Are EHR vendors or government committees leading the race to interoperability?

9 Healthcare Innovations Driven By Open Data
9 Healthcare Innovations Driven By Open Data
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Interoperability may not have gotten enough attention in the early days of Meaningful Use's electronic health records (EHR) gold rush, but it's now taking center stage as healthcare providers, government agencies, vendors, and committees consider how to support the exchange of data easily and securely.

It's about time, industry executives say. Enabling interoperability among disparate systems would have advanced healthcare IT more than any initiative the federal government actually implemented, Dan Haley, vice president of government and regulatory affairs at the cloud-based EHR vendor Athenahealth, told InformationWeek.

"In 2015, the notion you can have 'meaningful use' of information technology that does not enable interoperation is ridiculous. You could strip away all the other requirements and only require interoperation," he said. "The government is not going to mandate interoperability, and the government is not going to subsidize its way to interoperability. We'll get to interoperability when doctors demand the same interoperability as they demand from every other aspect of technology in their lives."

[How to get there? See: A Serious Proposal For Healthcare IT Interoperability.]

Patients and clinicians are starting to demand the same ubiquitous access to their data they receive in other industries. Patients are tired of completing duplicate forms; of unnecessarily repeating expensive, potentially harmful tests; and of ordering CDs or files of medical records -- if they can recall who treated them years ago. Physicians are fed up with getting faxed reports and then trying to locate the pertinent information, and practices must figure out how to communicate with payers.

Government agencies and facilities demand interoperability, too. Lack of standards is expensive: The Statewide Health Information Network of New York is a network of 10 nonprofit regional health information organizations (RHIOs) -- but many providers won't participate, because it costs up to $30,000 to create an interface between their EHR system and the RHIO, New York eHealth Collaborative director David Whitlinger testified in August.

There has been plenty of talk and planning. This year, the Office of the National Coordinator for Health IT (ONC) published its 10-year interoperability plan, and recently the eHealth Initiative unveiled its 2020 roadmap, which addresses interoperability. Both separately and within numerous committees, leading EHR developers, startups, health information exchanges, and others focus on ways to improve EHR interoperability, so physicians and patients can seamlessly and easily exchange, search, and access records.

Some blame certain EHR vendors for creating closed systems designed not to play well with others, said Dr. Charles Sawyer, chief health information officer for Geisinger Health System, which uses Epic. But that oversimplifies an extremely complex issue, he said.

"It's very easy to point fingers at folks. People underestimate how challenging this work is," Sawyer told InformationWeek. "I think the vendors are being cautious before spending lots of research and development money before a standard is more clearly defined."

Some EHR systems, like Epic, were designed long before cloud and APIs, executives said. Others leveraged newer technologies like cloud and APIs from the start. But clinicians and patients want them all to exchange files with one another -- just like financial firms, which enable consumers to withdraw funds from any ATM, regardless of bank. Or like Amazon, which lets consumers browse and order items from stores -- both Amazon and other sellers -- via one platform.

"We're often asked the question, 'Why don't these systems talk to each other?' We're long past the point in every other sector of worrying what platform they're on," Haley said. "In healthcare, it's all about what platform you're on. And that is because most of the information technology in healthcare is pre-Internet."

HISP steps
To further interoperability, as part of Meaningful Use Stage 2 and to try to end healthcare's reliance on faxes, beginning Jan. 1, clinicians must use a secure messaging method to file at least 10% of referrals. Called Direct, the protocol enables secure point-to-point messaging -- something "we've been doing in the regular email world since the 1990s," said Dr. Seth Flam, CEO of the cloud-based EHR developer HealthFusion. "But still, [Direct] is not free-flowing, and it's still an issue."

Under Direct, messages go through health information services providers (HISPs), which secure and send information between providers, after confirming senders' and receivers' identities. However, there was no mandate that different HISPs talk to one another, Flam said. As a result, physicians using one HISP might not be able to communicate with those using a different HISP.

"Now everyone is scurrying, but I'm a little skeptical that [on] January 1, the infrastructure will be there for doctors to meet the standard. And it's completely out of their hands," said Flam. Vendors "can't make HISP XYZ connect with another HISP."

Others are more optimistic.

"It was only a few years ago that Direct was a drawing on a whiteboard. Now it's a regulatory requirement in use by tens of thousands of physicians every day," said Dr. David McCallie, Cernersenior vice president for medical informatics, said in an interview. "These things happen, but you keep having to work at it. People underestimate how much good Meaningful Use has done."

Industry alliances
Rather than wait for mandates, stakeholders labor in organizations such as the CommonWell Health Alliance (whose members include Cerner, Allscripts, Athenahealth, Greenway, and McKesson, for example) and Carequality (which includes Epic, Siemens, Greenway, and Kaiser Permanente). They're trying to craft secure standards acceptable to all, hoping industry-driven initiatives will move faster than potential federal mandates.

Alliances, which often work with government agencies, seek voluntary and open standards for interoperability, Judy Faulkner, Epic's founder and CEO, told InformationWeek. But first, participants must agree on the definition of interoperability, a term that can mean many things to many members of the healthcare world.

"It goes from rather restricted -- which I hear used a lot, a Meaningful Use type definition -- to its full interpretation, where you can look at [data] and it's everything," she said. "There are a lot of standards. Reducing the number of standards in interoperability will be nice, too."

Alliances and consumer demand worked in other industries (VHS versus Betamax, for example), and healthcare executives hope their industry follows a similar path.

Extending interoperability
Given their increased financial burden and role in healthcare, consumers will demand more interoperability across the industry, said Lisa Maki, co-founder and CEO of PokitDok, a HIPAA-compliant, cloud-based e-commerce platform for healthcare purchases.

"There are patient records [and] patient information, but you also have interoperability about the business areas of health around consumer experiences, around booking and paying for their experiences," she told InformationWeek.

So, while the initial road to interoperability may take far less than the government's 10-year plan suggests, side roads could add to the journey's length and timeframe.

The owners of electronic health records aren't necessarily the patients. How much control should they have? Get the new Who Owns Patient Data? issue of InformationWeek Healthcare today.

Alison Diana has written about technology and business for more than 20 years. She was editor, contributors, at Internet Evolution; editor-in-chief of 21st Century IT; and managing editor, sections, at CRN. She has also written for eWeek, Baseline Magazine, Redmond Channel ... View Full Bio

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Alison_Diana
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Alison_Diana,
User Rank: Author
12/1/2014 | 10:14:40 AM
Re: Interop should start at home
You raise some very good points, @fpoggio600. To be honest, I don't want the government to set standards. I would MUCH prefer that the healthcare industry -- and I mean that in the broadest sense possible, across all components of the vast sector -- works together to come up with its own set of standards. From what I've seen, voluntary, industry-created standards typically are much better than anything mandated by the feds, and I cannot imagine it would be any different in the case of healthcare interoperability.

Just think about how the feds wanted EHRs to deal with Ebola: They asked EHR vendors to come up with tweaks to specifically address Ebola, rather than figure out ways for EHRs to quickly adapt to ANY situation, whether it's Ebola, swine flu, anthrax, MERS, a disease I haven't heard of, or a 200-car pile-up. That type of closed-minded, illness-specific thinking is contrary to everything any industry needs today, contrary to every type of software development or digital transformation -- yet policy wonks in DC are forcing EHR developers into this mold. For one, how many top developers will want to work in an industry that mandates this approach? Two, how much will this cost EHR developers? Three, how much will this cost healthcare providers, per illness (although I believe the Ebola "fix" was free)? Four, will anyone die while they await a specific EHR module? Five, what happens if multiple conditions arrive at the same time -- flu and a 200-car pile-up, for example? 
fpoggio600
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fpoggio600,
User Rank: Apprentice
11/26/2014 | 10:07:59 PM
Interop should start at home
Re: "Government agencies and facilities demand interoperability.."

BE CAREFUL WHAT YOU WISH FOR...
Many providers, journalists and bloggers call for the government to set a fixed standard for interoperability, just like the government set a standard in 1880 for the width of railroad tracks. Here's how that came about and where we are today.

The standard for the distance between railroad tracks is about 5.5 feet and has been for over 100 years. This width also determines the maximum height of a railroad car (via center of gravity) and the maximum width of the car. So why did the feds pick 5.5 feet? Well it goes all the way back to the width of ancient Roman roads. The Romans were the first real road builders and they set it at 5.5 feet because that was roughly the size of two chariots passing each other. That measurement was used to build roads around the world for 2,000 years. And in the 19th century it was adopted by some railroads, while others had larger or smaller widths thus causing untold 'inter-modal' problems. At the request of many railroads the government promulgated the 5.5 ft. into law over 100 years ago.

Today if we could increase the width by just one foot we could easily increase transportation productivity by 25% and reduce energy consumption. But alas we can't, we're locked into a nice tight government standard for infrastructure.

So if you want to really slow down information technology advances a good way to do that is have the government set a 'standard'. Be careful what you wish for!

And here's more real examples...

If you think commercial industry is a heaven of smooth interoperability, next time you are at the airport take a long look at the screen that comes up for the ticket agent. Believe it or not they still use 'character filled green screens' running under state of the art operating systems like Windows XP and then type in cryptic codes to get you a seat change. Then if you need to change flights to another carrier they actually have to PRINT out a ticket that you take to your new carrier. Now that's what I call interoperability! Why can't healthcare be more like that?

And if the government is so big on interop why did it take two weeks to bring up the Chicago FAA center when it was crashed by a crazed worker? Bet you do not know that you can't take an air controller from the NY Center and move him to Chicago or LA or any other FAA center without a 3 month retraining program!

So let's make sure we get ONC and CMS to define what interop should be...

Frank Poggio

The Kelzon group

Kelzongroup.com
Alison_Diana
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Alison_Diana,
User Rank: Author
11/24/2014 | 9:57:37 AM
Re: What is need to drive interoperability
Ah, but you forgot the patients' role here, @Gary-El! Now we -- consumers -- are paying more and more for healthcare, are accustomed to the Amazons, the myriad online travel sites, and other disruptive online/app tools available for practically every other industry -- there is a 'bubbling up' of demand from patients for the same treatment by their healthcare providers. Now these same healthcare providers are being forced to focus on population health, on engaging with patients when they are consumers (not sick patients), and this relationship demands a two-way street. So those providers that respect patients' time, that stop demanding forms in triplicate, that share information with other providers (specialists, second opinion doctors, physicians out of and in area, etc.) will - through word of mouth and rating sites - eventually reap the rewards of this openness. 

Will it happen tomorrow? Of course not. If I've been seeing Dr. T for years, am I going to stop, simply because she doesn't work well with others? No. But I will tell you, when I look for a new specialist, how they work with others and how they share information is part of the equation.
Gary_EL
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Gary_EL,
User Rank: Ninja
11/22/2014 | 10:13:17 PM
What is need to drive interoperability
I get all of my heathcare at Hospital A. Anything any practitioner from Hospital A does is immediately available to all my other providers at Hospital A. But, the info isn't available to any provider who isn't affiliated with Hospital A - even those providers that are fully contracted by my insurance company.

Obviously, Hospital A is in no big hurry to change this. Who wants competition?

So, this is one case where standards may not "bubble up." This is clearly a case for a government mandate.
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