Julia Adler-Milstein on Interoperability Issues: Change the Business Incentives for Healthcare Stakeholders | Healthcare Informatics Magazine | Health IT | Information Technology Skip to content Skip to navigation

Julia Adler-Milstein on Interoperability Issues: Change the Business Incentives for Healthcare Stakeholders

March 30, 2017
by Rajiv Leventhal
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How can interoperability progress be made? A health IT policy expert has some ideas that policymakers may want to consider

Last month, a piece in NEJM Catalyst from healthcare researcher Julia Adler-Milstein, Ph.D., caught the attention of many health IT contingents. In the commentary, titled, “Moving Past the EHR Interoperability Blame Game,” Adler-Milstein, an associate professor at the University of Michigan’s School of Information with a joint appointment in the School of Public Health (Health Management and Policy), argued that while most people tend to focus on who’s at fault for the lack of healthcare interoperability progress, it’s far more useful to learn from missed opportunities and create a path forward that all sides can agree to.

Perhaps the most important takeaway from Adler-Milstein’s piece was her last line in which she wrote, “Once the business case for interoperability unambiguously outweighs the business case against it, both vendors and providers can pursue it without undermining their best interests.” This is where much of the discourse in health IT circles lies—both vendors and providers want to “do right” for the sake of better healthcare, but there also needs to be a business incentive for them to go down that path. To discuss her take further, Adler-Milstein recently spoke with Healthcare Informatics Managing Editor Rajiv Leventhal, digging deeper into one of health IT’s core issues. Below are excerpts from that interview.

You have done a heck of a lot of work when it comes to health IT research over the years. When you look at where the industry started, and where it is today, how would you characterize the rate of progress?

I think there has been a lot of progress and a lot of it has to do with where expectations were set, relative to reality. A lot of the discussion has been around HITECH [the Health Information Technology for Economic and Clinical Health Act], the money spent [by the government], and the benefits of EHRs [electronic health records] as they would [soon become] interoperable. The discussion was almost that they would be basically be one and the same—you put in EHRs and they are interoperable, and they can share data, but anyone who has seen interoperability up close knows that couldn’t be farther from the truth. It was clear from the start that these would be different problems to solve. For EHR adoption broadly, there are a narrow and a specific set of barriers that needed to be addressed, and those were essentially money and making sure that the systems were of good quality. But on the other hand, the barriers to interoperability are broad, diverse, and all difficult. So you are solving different problems and we didn’t put enough muscle behind the harder problems. That being said, we have made progress on interoperability; there is a lot more data exchange going on today than in 2009. So it is frustration for people who work on this every day to be told that no progress is being made, but can we be further along today had we done things differently? I think the answer is yes.  

Julia Adler-Milstein, Ph.D.

You mentioned in your piece that most observers blame vendors for the lack of interoperability, but you seem to have come to their defense more than others have. Is that fair to say?

I think we have to distinguish what feels ethically right from what a rational business decision is. It clearly feels that vendors should be doing more, and we all wish they should have done more. They talk about their mission being to improve healthcare, but if that is your mission, you should have thought about interoperability differently. But at the end of the day, these are for-profit companies, and that’s how they’re behaving. If we were the heads and CEOs of these companies, would we have done anything differently? So I don’t think it’s fair to ask these vendors to act like for-profit companies, but also to act like mission-driven not-for-profit companies. You can’t be both. I wish they had made different decisions in the past, but it’s not fair to point fingers at them for these decisions they have made.

For me, the key takeaway of your piece was that the business incentives for vendors and providers need to change. That’s something that I think most people would agree with. But the vital question is, how can this happen?

I think what I tried to set up in the piece is that it’s a cost-benefit equation. Right now it’s the worst of both worlds where the benefits of being interoperable are perhaps ambiguous at best, and the costs are very high. So if you are going to solve that problem, you can do it either by making the benefits less ambiguous, or by bringing the costs down, or ideally by doing both.


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