It was about 25 years ago when John Zaleski, Ph.D., began researching and ushering to market medical devices and products to improve healthcare. Back in the 1990s, Dr. Zaleski, who is the named inventor or co-inventor on seven issued patents related to medical device interoperability—and is now executive vice president and chief informatics officer at Bernoulli, a Milford, Ct.-based medical device integration vendor—assumed that by 2016 medical devices would be able to be integrated seamlessly. “We have come a long way, and we have made improvements, but I would have thought that this [interoperability] problem would have been solved by now,” says Zaleski.
Zaleski is far from alone; while “true” interoperability is taking place in certain pockets of U.S. healthcare, many healthcare leaders, as well as outsiders, are questioning why more progress hasn’t been made given the significant investment put in. As such, provider organizations are collectively—but also individually—embarking on their complex interoperability journeys, and they continue to face several core challenges including but not limited to: insufficient data standards for electronically exchanging information; cost concerns, the lack of a universal patient matching solution; and complex privacy and security challenges.
John Zaleski, Ph.D.
Nonetheless, Zaleski classifies himself as a “glass half full” person when it comes to how far healthcare has progressed in becoming an interoperable industry. “We have come a long way and have made definite improvements, but to achieve the types of data access that are necessary for really doing intelligent action and analytics, we’re still too busy about being worried about the dial tone of getting the data versus having the data and being able to do the really important things such as identifying patients at risk,” he says.
Progress Has Been Made
At the Healthcare Information and Management Systems Society (HIMSS) conference in Las Vegas in February, John Halamka, M.D., CIO of Beth Israel Deaconess Medical Center in Boston, looked at how health IT has evolved over the years, assigning grades to various different industry segments. Halamka gave interoperability a C+ grade, noting that healthcare has made reasonable progress pushing payloads from place to place, but have not built the enabling infrastructure to support pull. “We are better than we have been before, but about half of clinicians feel that data isn’t available when and where they needed it. Maybe the data was there but they were not able to integrate it. So we have work to do,” Halamka said at HIMSS.
John Halamka, M.D.
Indeed, much of the work that needs to be done falls on two sides that directly impact one another—the technology vendors that develop the software and the clinical end users of those products. Both sides would agree on the core goal to help physicians access the patient data they need when they need it. But how they get there—and what it costs to get there—remain significant issues.
To this end, also at HIMSS16, Sylvia Mathews Burwell, the U.S. Secretary of Health and Human Services, announced a major federal initiative that has gathered together industry leaders to advance data-sharing, consumer access to healthcare data, and interoperability. Indeed, companies that provide 90 percent of electronic health records [EHRs] used by hospitals nationwide as well as the top five largest private healthcare systems in the country have agreed to implement these three core commitments, which, if acted out, should have the impact of creating a more open healthcare system.
Similarly, earlier this year, five major health IT vendors—athenahealth, Epic, eClinicalWorks, NextGen Healthcare and Surescripts—signed on to be the first to implement Carequality’s framework for interoperability and data sharing principles. Carequality, a Washington, D.C.-based public-private collaborative and an initiative of The Sequoia Project, released its interoperability framework in December, which consisted of multiple elements, including legal terms, policy requirements, technical specifications, and governance processes. The Framework operationalizes data sharing under the previously-approved principles of trust—the policy foundation for connecting health data sharing networks throughout the U.S.
Until now, health information exchange was preceded by one-off legal agreements between individual data sharing partners, which involved lengthy and costly negotiation and inconsistent experience in quality and quantity of data exchanged. The collaboration between competing health IT vendors, particularly EHR vendors, may have been surprising to some, as Epic had previously declined to join CommonWell Health Alliance, a vendor-led interoperability initiative, of which athenahealth is a founding member.
Certainly, the Verona, Wisc.-based Epic Systems has had to fight off criticism about its lack of an open architecture. However, in an inaugural report from Orem, Utah-based KLAS Research last fall, Epic received high marks for its interoperability strengths from more than 200 healthcare professional respondents, though it should be noted that providers connecting with foreign EHRs from their own ranked other vendors, such as athenahealth and Cerner, as the easiest for that type of connection.
What’s more, leaders from a dozen major health IT vendors agreed to adopt a set of metrics to measure interoperability, a partnership that stemmed from a KLAS Keystone Summit in Utah last fall. Bob Cash, vice president of provider relations at KLAS, said that the research organization is in the process of evaluating interoperability progress through a questionnaire process that focuses on provider experiences with different vendors.
Cash, who is in charge of interoperability research at KLAS, says that 500 end-user evaluations is the goal, with various different use cases being presented in the survey, such as answering questions about the experience of trying to connect to someone outside who has the same vendor product. Other example questions/use cases are: how information comes in; in what format does it come in; ease of access; and being able to use the data for clinical decision making, Cash says. So far, based on the less than 200 evaluations that have been fully vetted to date, Cash notes that just locating the medical record has been a struggle for providers in many cases, as it requires moderate to significant effort, though Cash points out that “moderate” can be looked at as a positive or a negative.
So what does all this mean? Mostly, these are signs of collaboration and unification for a greater good, and proof that the marketplace’s key stakeholders are improving in terms of their commitment to healthcare interoperability. That being said, one of the main challenges that healthcare leaders point to is the lack of agreed-upon standards. To this end, at HIMSS16, Halamka noted that data standards have been “skinnied down some,” but they are still too challenging to navigate. “With Argonaut and FHIR [Fast Healthcare Interoperability Resources], they are simpler standards that take days, rather than months to implement, so our trajectory in that sense has been good,” Halamka said. “But they are still too complicated. You need a Ph.D. to [fully] understand HL7 [Health Level Seven]. However, there is FHIR work coming in the next year that will empower that,” Halamka predicted.
And, according to Zaleski, if you read the tea leaves, FHIR offers capability in terms of flexibility that has been problematic in generalized HL7 up to this point. “A flavor of HL7 for discrete data transfer is the norm, and will continue to be,” he says. “In the future what I perceive is that as medical devices become more embedded in the IT environment, as opposed to a standalone internet of things, I can see building out EHRs with individual APIs [application program interfaces] for specific pieces of data that could supplant HL7 messaging. But there is a long ways to go in terms of development there,” Zaleski says.
Going forward, healthcare experts agree that even more collaboration and effort than what exists today will be necessary for seamless clinical interoperability to finally become a reality. In a recent interview with Healthcare Informatics, Arien Malec, vice president of data platform and acquisition tools for RelayHealth (the Alpharetta, Ga.-based McKesson business unit that focuses on improving clinical connectivity) and former staffer at the Office of the National Coordinator (ONC), said the number one best practice is to “start getting involved in trying to improve the world if you don’t like how it exists.” He added, “If you’re a vendor organization, I would say join the Argonaut Project, join CommonWell, implement SMART [Substitutable Medical Apps, Reusable Technologies] on FHIR, or if not, do something to improve the state of interoperability. If you’re a provider organization, there are the same kinds of initiatives to participate in. A number of providers are participating in Argonaut offering to be demonstration sites and get technology up and running…Roll up your sleeves and get involved somehow.”
As such, the key question that is often asked about healthcare interoperability is, “How close are we?” Indeed, during a recent panel discussion at the Health IT Summit in San Francisco, sponsored by the Institute for Health Technology Transformation (iHT2, a sister organization to HCI under the Vendome Group corporate umbrella), attendees were asked: “On a scale of 1 to 10, with 10 being the most difficult, how difficult do you think it will be to achieve true, industry-wide interoperability in U.S. healthcare in the next five years?” Eight percent said “1”; 4 percent said “7”; 17 percent said “8”; 25 percent said “9”; and fully 46 percent said “10.” And if one were to take the top three most difficult choices—from 8 to 10 on a scale of 1 to 10—fully 88 percent of Health IT Summit attendees assessed the difficulty of achieving true interoperability in U.S. healthcare in the next five years as posing very significant difficulty, expressed as an 8, 9, or 10, on a scale of 1 to 10, as reported by Healthcare Informatics Editor-in-Chief Mark Hagland.
The panelists at iHT2 San Francisco agreed that while the foundation has been built, getting hospitals, medical groups, and vendors to collectively agree to actively participate in sharing data is still a huge roadblock. The hope is that the aforementioned collaborations will go a long way to combatting this challenge. To this end, Zaleski feels that in five years there will be more pockets that are integrated, but true industry-wide interoperability will “require a complete refresh and recognition by vendors to acknowledge that they have to do this because it’s in their business interest to do so.” He estimates himself that it will take “another five to 10 years” to achieve true interoperability.