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Interoperability: Someone has to lead!

July 8, 2012
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The industry needs initiators to step up and create interoperability between clinical systems and the EMR

Recently I blogged on why cardiology systems just can’t get along.  This blog was precipitated by a client situation involving interoperability between a cardiovascular information system and an EMR.
Well, now I have another client situation with almost similar circumstances!  It happens to be with the same EMR vendor, who has a strategy of being the “entry point for all clinical documentation.”  While I appreciate the objective, the consequence is what concerns me.  Some EMR vendors choose not to play in the data capture space, and expect documentation to be done manually within the EMR at the expense of similar information automatically acquired by data capture devices.

Case in point – consider hemodynamic systems which have classically been the primary point for documentation of cardiac and vascular procedures.  These systems have been designed to not only provide a running record of the hemodynamic data, but they have also evolved to provide the documentation point for the case.  The resultant report documents the pressures, supplies and medications used during the case, as well as a detailed time line of events for the actual procedure. 

In both these client situations, the likelihood is that a majority of the documentation will now have to be recorded in the EMR, but the hemodynamic systems will still be required for monitoring pressures.  The rationale?  Unless items such as medications are captured within the EMR, they won’t show up in the correct location!  So, in politics, it’s class warfare.  In healthcare information systems, it’s system warfare!  Why shouldn’t it be possible for an interface to properly pass the procedure log, medications, supplies, and pressures to the EMR where they can be correctly cataloged?  I’ll tell you why – because many EMR vendors have not implemented a standards-based means (HL7, DICOM, etc.) for doing so, and apparently, they are under no competitive pressure to do so!

Years ago when I worked for a major US equipment vendor, I committed modality heresy by suggesting that we publish the API to our modality workstations so that others had access and could develop supporting applications.  I stressed that it would be advantageous if users and competitors wrote applications on our workstation platform, since it would add extra functionality and value to the platform which we controlled!  It’s the Gillette razor/razor blade argument, or the Microsoft Windows argument.  Whoever controls the platform has the advantage. 
Hence, if I were the EMR vendor, I would want to publish the API to my application and encourage every vendor to comply.  That way, I don’t have to reinvent every data source, but would control the eventual solution in my favor.  Clearly, standards would be the best approach, and would level the playing field, but short of that, it just seems like good business practice to foster interoperability. 

I bet this particular EMR vendor would be much better received in the marketplace if instead of attempting to compete for the creation of each piece of data, it took the initiative to provide a mechanism that accomplished the same goal via interoperability.  Who knows – such an initiative could become the de facto standard!  Would this result in a competitive disadvantage for the EMR vendor?  I think not!  Again, more tales from my past – in the early days of engineering a mobile CT unit, there wasn’t room for the company’s multi-format camera for capturing images onto X-Ray film, due to the size of the camera.  Discussions with a 3rd party camera manufacturer were bogged down, and when I queried the company engineers, it was because they wanted a particular control circuit on the camera to adjust density, but they were reluctant to discuss with the 3rd party as it “would result in a better camera that would be sold to competitive CT manufacturers.”  I told the engineers to get back in the room and discuss it, since no one was going to make a competitive CT decision based on how good the film camera was!

The bottom line?  Same as my prior blog.  Someone needs to take the initiative to promote interoperability.  Healthcare providers should demand it by inclusion of interoperability in their EMR RFP’s.  Interested trade organizations such as HIMSS, or market savvy vendors who understand the advantages of fostering interoperability might also promote it. 

IT based interoperability, not manual entry holds the promise to improve the accessibility, quality and safety of healthcare information and to reduce the cost of patient care.  It can really be done.  Imaging IT vendors and Imaging Departments have demonstrated this since the Imaging Community implemented open connectivity standards like ACR-NEMA 2.0 in the 1980's, DICOM 3.0 since 1994 and interoperability frameworks like IHE since the late nineties.  When will the EMR community jump on a similar bandwagon?
As usual, comments are encouraged!



Our issue has been the monitoring vendor, not neccessarily the EMR/EHR vendor. I think one of the issue is that the vendors have their own EMR/EHR solution and do not feel obligated to share the key monitor information with a competing vendor's EMR/EHR.

Your point is well stated, that we all must stop taking the vendor's answers where they virtually say they aren't going to play in OUR respective multivendor sandbox, but rather dictate to us what will be done in the very sandbox WE own and what we'll integrate with them which is blatently counter to the IHE standard the vendors say they comply with when we are in negotiations with them.

Great comments! One can only hope that we learn from experience. The whole ACR/NEMA and DICOM experience should be a "lesson learned" for the marketplace. Initially vendors balked at implementing ARC/NEMA, and then DICOM, but user pressure for interoperability prevailed, and today, it is a given that a device supports the DICOM 3.0 standard.

If the rest of the industry can learn that supporting and promoting standards is not a bad thing, then perhaps some will take the initiative to promote solutions that support interoperability!

There is an effort to resolve these issues.

It's called Integrating the Healthcare Enterprise (IHE)

Here's the link:

If we can convince more vendors to participate, then there's
a real chance for devices, EMRs, etc. to pass information.
When the data is passed electronically, it limits the
risk for human error in data entry.

Paul Sherman, CCE, FACCE

Joe, great post, couldn't agree more. I couldn't agree more that interoperability is the key driver in Healthcare IT today. Be it medical imaging, related clinical content, reporting, or even summary information, it is always disappointing to me to see vendors attempt to take ownership of the data production and ownership and not think about the ramifications of such strategy.

I'm an advocate of creating the High Definition EMR, an EMR that has a complete view of all clinical content, bot summary information as well as bulk clinical content such as medical imaging, related content (wound care, ENT as an example), along with your example above around hemodynamics. I'd offer the consideration of an enterprise class clinical content management solution, one that is capable of offering data management yet not in control of data acquisition, one that offers data liquidity/mobility and interfaces to the EMR, in this fashion your EMR becomes HD!

On top of this the EMR itself should be encouraged to export bulk clinical content externally, after all how many EMR solutions do we know of that are good at data management?

Food for thought.

Shannon Werb
Acuo Technologies


I love the term High Definition EMR (EHR). What you're advocating is basically a digital EMR instead of an analog one. Fascinating.

Jeremy Bikman