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Hospital CIO on Interoperability: With Current Technology, It Can’t Happen

August 12, 2014
by Rajiv Leventhal
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Health IT vet says recent comments that blasted interoperability in healthcare were “mostly fair”
Dick Escue, Valley View Hospital CIO

In mid-July, at a regulatory hearing over interoperability, members of Congress from the federal Subcommittees on Communications and Technology charged health IT vendors, such as the Verona, Wis.-based Epic Systems, with using closed systems.

Rep. Phil Gingrey, M.D. (R-GA) and Rep. Joe Pitts (R-PA) discussed the obstacles that are standing in the way of achieving the promise of health IT in discovering breakthroughs in medicine. In particular, they were concerned over the lack of integration between systems. 

Gingrey specifically expressed concern that the Office of the National Coordinator for Health IT (ONC) and the federal government overall have spent roughly $24 billion on products that are not interoperable and not compatible with anyone but the primary electronic health record (EHR) vendor. According to Politico, he mentioned Epic Systems by name, saying the company has collected millions in federal incentives but still operates on closed systems and doesn't allow information to flow from its systems. 

He also asked, “Are we getting our money’s worth subsidizing products that are supposed to be interoperable but they’re not? We have responsibility for ONC and the Health Information Technology for Economic and Clinical Health (HITECH) act. We’ve spent tens of billions on non-interoperable products. It may be time for us to look closer at the activities of vendors in the space, given the possibility that fraud is being perpetrated on the American people.”

Even more recently, Senate Democrats have joined Republicans in demanding an investigation into whether heavily subsidized EHR systems are blocking the free exchange of patient health information that was a major objective of the multibillion-dollar federal program. Federal health IT officials have been trying to prompt better health exchange among EHR systems and have made interoperability a central goal of their efforts over the next year.

Needless to say, the lack of interoperability in the healthcare industry has been getting blasted of late. However, according to Politico, Peter DeVault, director of interoperability at Epic, defended his organization by saying that Epic users exchanged 313,000 records with users of other systems last month alone. Ten thousands of those were with federal agencies like the Defense and Veterans Affairs departments, he said.


Dick Escue, CIO at the Glenwood Springs, Col.-based Valley View Hospital, with 25 years of healthcare IT experience under his belt, says that the criticism from the Congressmen has been mostly accurate. “If you look at the comment about $24 billion being spent to buy products to facilitate interoperability, yet failed, that’s fair. The systems that we have, that we are hamstrung with in healthcare, absolutely do not enable interoperability,” Escue says.  But he adds that it’s not fair to single out Epic. “[Those comments] apply to all of the hospital information system vendors,” he says.

Before getting to Valley View, Escue worked at the RehabCare Group, Inc., a New York City-based for-profit provider of physical, occupational and speech-language rehabilitation services in 46 states. There, the vendors that the organization worked with generally had written their software in the last five or 10 years and leveraged new tools that were web-based, scalable, and probably were delivered as a service, compared with hospitals being locked into contracts, Escue says.

But that was in the ambulatory space. In the acute care space, it’s been a different story, he notes. Having been a customer of a variety of big-name vendors throughout his healthcare career—including Cerner, McKesson, Meditech, and Epic—Escue says that generally, their software was written a long time ago and certainly none of it is what you would call “contemporary,” using modern tools, modern language, and modern techniques. “Anytime you want to do an [EHR] interface, you’re going to have to pay [the vendors], and even then it will be difficult, and even then, they might really drag their feet and not help you do it if they deem it’s not in their best interest. Really, the vendors have control of you.” And because the vendors have antiquated systems, new technology models that are the standard in other industries are not explored in healthcare, he says.




The published comments by Representatives Gingrey and Pitts are completely inappropriate. The software that the medical industry has today is that which was mandated by the government in the HITECH Act and subsequent HHS rulemaking. When the rules were being formulated in 2009 and 2010 it was apparent to anyone with IT experience who cared to notice that the fundamental assumptions were flawed, the 'social engineering' and cost savings that the rules intended to drive were, respectively, biased and unreasonable and that the general approach towards eventual interoperability was, please excuse the phrase, ass-backwards. ONC's approach was similar to designing a sport like football by beginning with the penalties assessed for infractions, without yet even knowing the size of the playing field - and that general approach has not really changed.

So, yes, the software we have is lousy, the whole notion of interoperability is a joke, and everything is in exact accordance with the dumbest bunch of rules ever applied to any complex human endeavor. There is a clear lesson here - take all the 'process', the 'subject matter experts', the conference rooms in Washington and the surrounding environs, the bureaucrats who inhabit those conference rooms, their meetings and forums and requests for public comment and revisions and self-justification, and throw the whole damn thing out the window. You cannot re-engineer one sixth of the American economy on the basis of the 'consensus' output of 1000 or 10,000 different self-absorbed and private-agenda-driven bureaucratic covens which often have no more subject matter expertise than the ability to formulate glamorous adjectives. The mantra of the early HITECH years was "process equals outcome"; we are today witnessing the ironic truth of that.

While we're at it, let's toss out the self-serving industry and media groups which led the cheerleading for the whole mess in hope of grabbing a slice of the large and expanding federal spending pie. Go read any 'leading' industry journal from 2009 or 2010 and see if you can find any article, anywhere, which contained the slightest shred of truth relative to the outcome of the health care fiasco we now have on our consciences. In that time period the expression of any doubt was censored, no argument against the government's party line was tolerated and anyone who dared criticize the process unfolding before them was roundly driven into oblivion by the screams of outrage arising from the PC crowd.

If our congressional representatives are concerned about fraud being perpetrated in the health IT field, they should direct their gaze to the VA and DoD. While it may be difficult to prove overt fraud at those agencies, it would be only slightly less difficult to find any signs of professional competence and/or leadership. After more or less a decade and who knows how many billion dollars, they can't stop their bureaucratic bickering enough to have even the most rudimentary agreements regarding interoperability - within an essentially closed government system!!! Where is the leadership there, and why hasn't Congress sorted out that problem? These agencies are the poster children for every argument against government health care; they are in equal parts frightening and embarrassing.

Congress should forget - literally and completely - about private sector healthcare IT and focus all of their considerable energy, attention and power on one goal - building a modern, functional, interoperable set of IT tools at DoD and subsequently at the VA, and do it from scratch. Forget Epic - let Apple take the lead and use IBM as a consultant, and see what they come up with.

This is a serious proposition. Apple has a history not of original innovation, but of a superior ability to take current technology and extract the maximum capability from it to make it work in what appears to be an excitingly innovative way. While Google has a wonderfully PC phrase - "Don't be evil" - Apple has a much more human and performance oriented, though non-PC, history of appealing to basic human nature - avoiding overt complexity, satisfying our greedy urges to be productive quickly and easily and applying enough 'cool' to make it all very attractive. IBM, meanwhile, has deep and broad experience integrating very large and complex entities in functional and reliable ways. Neither corporation has a perfect track record, but both bring to the table a history of performance and understanding of human and corporate behavior which is vastly different from the short-sighted, greedy, 'more pie for me' mindset of our current industry 'leaders'. If Congress can clamp down on the inevitable attempts along the way for Apple and IBM to inflate their contracts - a known government problem throughout human history - it is possible that a DoD/VA HIT example which the private HIT industry could then emulate could be built. Of course, the real trick is to keep congress and the government from interfering with private health care once the model is in place.

Finally, Mr. Escue's comments are only partially correct, mostly because of what he didn't say. Ultimately, it is indeed the fault of health care organizations that we're in the mess we're in because, as he points out, they bought the products. But he fails to mention the lack of alternatives; the intensity of the pressure/coercion from industry, from the press, from the government, and from peers and, finally, the absence of leadership from senior IT professionals in the face of clueless senior administrators. While it seems he may have made one or more bold stands against buying crap for the sake of appeasing all the pressure, it is clear that the majority of his peers lacked either his insight, his fortitude or both. Perhaps he is the man to lead an Apple/IBM consortium along the search for a path out of the deep dark woods in which we find ourselves.

Congress needs to look deeper into what and how industry is addressing interoperability. In our experience, we recognize a number of technical as well as organizational roadblocks to successful exchange of information.

We hope with that Congress, Chief Innovation Officers, CTOs and CIOs, Analytic Officers, Chief Data Officers, industry and the Federal procurement process will be promoting the importance of Testing. As both public and private sectors plan for current and future initiatives, it is important to recognize and mitigate the following risks:
• For those Large Federal Health Programs (focused on integration)
o Interoperability and conformance testing should be built into the entire software development lifecycle (agile)
o The importance of true independent (3rd party) testing
• For Health Systems and other Organizations
o Compliant Product (Vendors who prove “Continuous” Interoperability)
o Proven Technical Stacks (challenges)

Focus on the importance of testing for interoperability and standards conformance in the electronic exchange of information. The lists stakeholders in the first paragraph have the opportunity to mobilize the community to participate in the building and testing of standards-based, interoperability solutions while promoting innovation. Some proposed strategies to consider include:
• Support Automated Platform for Test Case Execution
• Encourage Best Practices for Audits and Work Flow Lifecycle of Testing
• Support an Environment for Re-Use of Testing Tools/Test Cases
• Promote Beyond “Happy Path Testing (peer-to-peer), ensure Negative Testing”
• Encourage the adoption and use of Standardized Test Data
• Support and enables Communities of Interest for a shared testing environment
• Promote Industry Reporting Metrics on how well their products and services ensure interoperability and not vendor lock-in.

Congress should advocates the following to ensure Interoperability:
• Support Test Driven Development (TDD)
• Promote putting the testing tools into the hands of the Developers during the development life cycle, do not test at the end it’s “Too Late”
o Proven by
• Believe testing should begin as soon as development
• Functional (Conformance) Testing alone will not ensure Interoperability with External Partners
• Support a focus towards testing Specifications, and ensuring forwards and backwards compatibility
• Promote Gateway-to-Gateway communications