As the number of healthcare interoperability initiatives continues to grow, tracking and assessing interoperability standards, government regulations, and the various consortiums, alliances, workgroups, and associations becomes a challenge. But undoubtedly, interoperability is the lynchpin to the future of health IT, and has been made a main priority by the federal government.
On November 17, at the New York eHealth Collaborative's (NYeC) 2014 Digital Health Conference, a panel of interoperability thought leaders provided an insider’s view of which efforts are gaining traction, which challenges present the biggest barriers to success, and how these obstacles will eventually be overcome to enable a future of connected health. On that panel was: Kenneth Kleinberg, managing director, The Advisory Board; Brian Ahier, director of standards and government affairs, Medicity (Salt Lake City, Utah); Anuj Desai, vice president of market development, NYeC; Matt Quinn, managing director, East Coast, healthcare and life sciences, Intel Corporation; Jacob Reider, M.D., deputy national coordinator, Office of the National Coordinator for Health IT (ONC); and Mariann Yeager, executive director, Healtheway. Below is an excerpt of the panel discussion, which was moderated by The Advisory Board’s Kleinberg.
Q: Obviously, we’re moving towards need for greater interoperability. But there hasn’t been as much progress as we would have liked. Why is that so?
Ahier: There is a lot going on, so it’s a complicated answer. There are a lot of initiatives underway to help promote interoperability for care coordination. I don’t know if I agree that interoperability is a failure to any extent. We do have a long way to go, but there is a great deal of interoperability that is taking place now. We do have challenges, but it’s because of the success we’ve had that we have these challenges. Five or six years ago, there weren’t so many doctors using electronic health records (EHRs), especially the ones that have standards for interoperability. We’ve seen EHR adoption move the needle so interoperability can be possible. The biggest roadblock is the business case—if your business model is to afford your data and keep a walled garden approach, then that’s what you’ll do, as it makes the most business sense. Now there is an incentive to share information about patients who you’re caring for, so you can improve that care. When you’re a large clinician network, you care very much about what’s happening outside of your four walls. There is still competition for market share, but more of a need to communicate.
Reider: I agree with Brian's core hypothesis. I was one of founding members of the Hixny Health Information Exchange (HIE) [in northern New York]. I remember one of our first board meetings, when a CFO in the community realized the numbers of millions of dollars of revenue his organization would forego by being part of this HIE. So they bit that off, and said begrudgingly that he’s in. I’ve spent time in private sector, so I know that if there is no margin, there can be no mission. So when the market as a whole—not fragments—are motivated to share information, that will be the tipping point.
Quinn: We need to get the word out of good examples and package that in a way that is understandable and consumable by others. Probably the biggest health IT thing that will happen in next few years is the Department of Defense (DoD) and the U.S. Department of Veterans Affairs (VA) investing in health IT infrastructures that I hope will take us into the future. Our soldiers and veterans have systems that are interoperable to the extent that we can use that as levers that could accelerate us and move us forward. That is one where the case for interoperability is solid—its financial as well as its moral.
Q: So you have this new environment that is pushing the exchange of information, but there is also the retail revolution and competition amongst healthcare systems. How does this get reconciled?
Ahier: If you’re still in the fee-for-service world, then yeah, that is a problem. Shared risk drives shared information though, that’s the bottom line.
Reider: This is healthcare; we're not making potato chips. We need to work together, not against each other. We need to keep people healthy, and organizations need to recognize that we're working towards the same goal. It never made sense to me that we compete in healthcare. Maybe that’s naive of me.
Q: Are vendors dragging their feet?
Reider: First off, folks who make software that creates better healthcare are health IT software developers to me, not vendors. So you’re talking about shared risk. These developers are in this, and interested in sharing risk and benefit. If these developers became part of sharing success, instead of just selling services and stuff, what if we could share the developers? Better health equals better payment. That would be cool.
Yeager: We see vendors as motivated to get their systems interoperable. The challenge they have had is in having a high-level national testing program. We're working on dual programs to connect and harmonize our specifications and test cases to support that. Once that exists, they will see the opening, but it’s costly for them to maintain their interfaces, as they’re getting an earful from customers.
Desai: We will see vendors coming forth, but they’re getting mixed messages from customers. There are different ways of doing things. Vendors will tell customers that they will do their thing, but different people are asking for different things. Let’s use the standards out there rather than create our new set. We need to educate providers on what that means, but once that happens, we'll start to see more exchange.
Q: We're asking vendors to create interoperable systems, but do we want to pay more for that?
Ahier: Anuj's point is important, as they have done the necessary testing to be certified. But within that standard, there are too many options. If there are 17 things inside a standard, it’s not really a standard. The biggest challenge isn’t so much that the systems can’t communicate with each other—we’ve made progress in that. It’s the content, not the transport.
Quinn: It’s about changing the nature of competition. As a large employer, Intel can say that we want to buy healthcare that is different. So you guys, multiple providers, need to work together. That’s changing the nature. Today we have 2,500 some odd certified EHR vendors. People are asking and wanting different things for different needs. We have all these systems, and some are good at some things, some are good at others. As we architect these next generation systems, what can be standardized and collaborated to facilitate interoperability, plug-and-play apps, and user interfaces?
Ahier: Competition can drive people to excellence. But in healthcare, we're competing for the wrong things. If we were competing for quality outcomes, and there was transparency for that, then that could drive change.
Q: There have been patient matching challenges. Have we solved this problem?
Ahier: My answer to this is call your Congressman. Congress has decided we won’t have a national patient identifier. As long as they hold that position, it will be difficult to make anything happen. We can do a pretty good job now of powerful algorithms of data points that will identify people.
Reider: I disagree with Brian. I don’t think that Congress said we can’t have a national patient identifier. Congress said 20 years ago not to spend money on creating one from the federal government. We can work on a voluntary national unique patient identifier—nothing is preventing that from happening. If you look at the countries that have this, they still have patient matching problems. Having one unique ID doesn’t solve all of these problems.
Ahier: I agree; it’s not a panacea. I think we're moving beyond this with technology, though.
Yeager: We can do more to make current patient matching approaches consistent. We did a study and have data to back up actual match results and changes that occur based on variation. More could be done—there is interest in a voluntary patient identifier.
Q: What’s emerging when it comes to open application programming interfaces?
Ahier: The JASON task force recommended to ONC the notion of using public APIs and a new standard called fast healthcare interoperability resources (FHIR). People think this replaces document-level exchange, but it doesn’t. It does give data-level access so you could have an API that would just query a medication list and allergy list, for example, or lab results without getting a 70 page document with irrelevant information.
Reider: I want to temper some of expectations that were set forward by JASON task force. We asked them to think outside the box and not be constrained by the current architecture and infrastructure in healthcare, but rather what health IT ought to look like. The report generated interest, but also concern from developers. The gap was vast. This is a problem, because they are saying something that doesn’t align with reality. Do we have this universal API that your apps will suck out bits of information from? Maybe, but we need to be thoughtful about the today and how we traverse this gap between today and tomorrow. [Epic] is a master of tight integration, as is Apple. If you look at what is successful in markets, it’s tight integration
Q: Any last thoughts on where we will go from here?
Ahier: Again, we're not doing as badly as it may seem. There is a lot of interoperability happening. Challenges exist but we need to celebrate our successes also.
Desai: We’re seeing industry groups created, so hopefully in the next year or so we will see more collaboration.
Reider: I would challenge each of you to think about what you can do in your community to improve the quality of care. Don’t focus on interoperability for interoperability’s sake, but do what you can to improve care. Pick one thing and go from there.
Quinn: This isn’t magic where you can sprinkle fairy dust onto something. This has been a tremendous amount of work being done, but you need to figure out how to accelerate going forward. We should focus on opening up systems that allow you to deconstruct and decouple, so we could make progress. Once we win the users, the rest will follow.
Yeager: There has been substantial progress, as we're seeing the pace of change increase. There are different types of care providers that we have never worked with before coming forward. It has evolved over the last several years. We need to come together—it’s the only way that we'll make dramatic progress.