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Can Middleware Technology Solve Healthcare’s Interoperability Problems?

May 20, 2015
by Rajiv Leventhal
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In February, Black Book Research’s annual health information exchange (HIE) stakeholder survey concluded that the current state of operative HIEs in the U.S. can best be described as “persistent unpredictability,” and the industry appears a ways away from achieving meaningful interoperability.

The survey revealed that while some simple healthcare information is being exchanged among parallel electronic health record (EHR) systems in pockets of communities, 94 percent of America’s providers, healthcare agencies, patients and payers persist as meaningfully unconnected in Q1 2015. Outside of their garden walled EHR networks, providers are dropping HIE as a priority, as evidenced by a 5 percent drop in regional connectivity from last year, the data showed.

What’s more, the federal government and healthcare stakeholders seem to be at odds when it comes to addressing interoperability issues. To this end, Donald M. Voltz, M.D., department of anesthesiology and medical director of the main operating room at Aultman Hospital in Canton, Ohio, says there is an answer that solves healthcare’s interoperability problems that other vertical markets such as retail, banking, and transportation have shown to work—middleware. Middleware is software that is used to connect one or more different software applications; it has been simplified as the glue or plumbing used to pass data between applications. It is currently being used to connect completely unrelated software into a single user-friendly interface, and also to connect legacy and emerging technology that have been developed using different designs, data models, or architecture, Voltz says.

A board-certified anesthesiologist, researcher, and medical educator with more than 15 years of experience in healthcare, Voltz has been involved with many facets of medicine. He has performed basic science and clinical research and has experience in the translation of ideas into viable medical systems and devices. “I wanted to try to solve these interoperability problems, but implementing processes that work both on the administrative hospital and health system side, and the clinical side, is almost impossible,” he says. “We’re constrained by whatever platform it is, be it a single EHR or multiple EHRs, based on what they bring to the table. You need to build systems that operate but also bring action to the data on the clinical side.”

Donald M. Voltz, M.D.

Voltz says that EHRs are not smart systems, but are more about collecting data right now. They are still at the database level, he says. “We talk about putting business logic on top of them, but we’re not there yet in the sense that we haven’t addressed the needs of how we interact with the system or what kind of information can be collected from an ambient type interaction,” he says. “In anesthesia, there are issues with what am I documenting, when should I be documenting, and what’s being tracked in the EHR Open loops are putting us at risk from a medical legal standpoint but they are also blocking my ability to communicate with other providers that are taking care of the same patient.”

As such, middleware technology can connect to various pieces of information and develop on top of those connections without having to move or duplicate all of the data around it, Voltz says. Specifically, for the last several years, Voltz has been using software from the San Jose, Calif.-based Zoeticx, whose platform’s architectural design has been successfully used to link data from multiple databases, irrespective to the database platform or where the database is located, Voltz says. Essentially, it is a padding layer between EHR systems that provides interoperability, he notes. Voltz says there aren’t many “true” middleware solutions on the market today— the ones that are out there are more attempts at middleware but fall short as full platforms, and are thus more like messaging systems, he says. “They’re worried about interconnecting data but not addressing the problems in healthcare,” Voltz says. Nonetheless, earlier this year, the Plymouth Meeting, Pa.-based consulting company ECRI Institute dubbed middleware as one of 10 key technologies that healthcare CIOs need to be watching.

One of the problems that actually isn’t complained about by physicians, because they don’t know the term of it, is the concept of data provenance, Voltz continues. “I don’t know care where the data resides, but I need to know that it’s accurate or I’ll end up duplicating it,” he says.  Another problem, he adds, is not knowing who on the care team has addressed an issue—or if anyone even did. “As a surgeon for instance, I don’t even have access into the flow of an EHR system. So I don’t know who has looked at the information or what new information has bubbled to the top of an EHR system, whether that’s a consultant, a nurse putting in a concern about a patient, or a lab value that just came back.  So as an anesthesiologist, I’m sitting in the middle of this trying to orchestrate and coordinate not only the patient but how I allocate resources in the OR and how I respond to issues in the ER. There’s no way to do that well with an EHR system,” Voltz says