In a recent piece for the New England Journal of Medicine, two Boston Children’s Hospital informatics researchers, Kenneth Mandl, M.D. and Isaac Kohane, M.D., make the argument that EMR and EHR vendors are holding back innovation in the health IT industry. Many vendors, the duo insists, have failed to adopt basic Internet-era sources for their systems such as private cloud-based storage and secure communication protocols, as well as modern consumer technologies such as word processing and search engines.
Mandl and Kohane say the lack of interoperability and standards with these systems have put the industry’s innovation in a standstill. Instead of constraining physicians, they suggest that more open systems with diverse functionality would drive improvements in patient engagement, care coordination, and overall create better care quality, which in turn would reduce costs.
In a two-part interview, HCI Associate Editor Gabriel Perna recently spoke with Mandl, who is the director of the Intelligent Health Laboratory at the Boston Children's Hospital Informatics Program as well as an associate professor at Harvard Medical School, about his somewhat controversial opinion, why he says EHR vendors are afraid of interoperability, and why they shouldn’t be. Below are excerpts from the first part of that interview.
Kenneth Mandl, M.D.
What was behind the article and what kind of research did you put in? And how did you come to this conclusion?
This article is really based on over 20 years of experience in the health IT field. Myself and Isaac Kohane are both in the Boston Children’s Informatics program, which has 23 faculty members and has had a very strong focus on innovative approaches to EHRs, PHRs, and analytics in healthcare. We’ve worked in the area of all of those things. For example, if you look at a website called smart platforms, that describes our $15 million federal grant from the Office of the National Coordinator for Health IT (ONC) to develop an app store for health. In other words, to re-imagine EHRs as apps platforms for supporting innovative applications that can access medical data in ways software developers can understand. It’s about a competitive marketplace for health innovation and rapid diffusion of those innovations. We come at it having worked in health IT and being very involved. We think there is enormous innovation to do.
Our concern is that many of the EMR products are overly specialized for healthcare in ways that are unnecessary and that ultimately constrain the end-user to confine them to a toolkit that is below the market standards.
Talk about some of the obvious examples, in your opinion, of innovations that lack in the health IT market?
The text editors in EMRs are substantially poorer than the most basic version of Microsoft Word, and there’s no spell check. Other technologies that we are used to using in our consumer lives, like Google search [are also lacking]; there’s no search [function] in EMRs. I can’t put in a keyword and find 20 patients that I saw who are on a particular medicine or physical exam finding. The databases that are used are propriety and not optimized for retrieval of data. The communication tools in EMRs are an afterthought. Also, because there are 700 EMR vendors, and because the tradition has been to create environments that are complete and have full functionality, each of these vendors has to reinvent these components. In our consumer lives, we use different software for different functions. We use Twitter for micro-blogging, but we don’t expect it to be our email client. There are now very mature approaches in and our consumer technology to getting these functions that we need in healthcare. Most of these functions do not need to be overly generic for healthcare. Healthcare does not need its [proprietary] database system; it can use existing systems. There are data types, and some standards, some processes that are specific to healthcare. But the idea of maintaining privacy of information is an industry-wide problem, not just limited to healthcare.
There’s also a myth we feel is propagated by EMR vendors that it’s unsafe to integrate EMR technology with a specific third-party technology. We take the opposite perspective. If you look at the smart platforms site, we are capacitating third party applications to run on EMRs, even proprietary EMRs through APIs [application programming interfaces]. And also if one needs to tab over to a web-browser to handle one’s functionality and leave the EMR environment to potentially access the same data warehouse, that’s okay. It’s okay to have innovative functionality that is able to fuse and spread on its own, not necessarily within an EMR product. If we wait for business cycle integration of new technologies into 700 vendor products, it’s very unlikely that a good technology like a Twitter could take hold within the healthcare system because it’s so compartmentalized right now. If we don’t change our approach, we’re in danger of [creating] a system that doesn’t promote innovation and progress in support of health reform and cost reform. It’s a very important issue I think for the bottom line of healthcare.