Health IT leaders discussed and debated the different trends and challenges around interoperability, and what the future holds at the IHT2 Health IT Summit in Atlanta on Dec. 2.
The panel session, “Driving Interoperability Across Systems,” at the iHT2 Health IT Summit (the Institute for Health Technology Transformation is a sister organization to Healthcare Informatics under the joint umbrella of the Vendome Group, LLC), was moderated by Denise Hines, CEO of Georgia’s eHealth Services Group and executive of the Georgia Health Information Network (GaHIN). Joining Hines on the panel were: Donna Lynch, vice president, clinical informatics, Covenant Health (Knoxville, Tenn.); David Dull, M.D., chief medical officer, St. John’s Health System in the greater Detroit, Mich. area; Jeff Gartland, vice president at RelayHealth (the Alpharetta, Ga.-based McKesson business unit which focused on clinical connectivity); and Steve Rushing, director of health initiatives, Enterprise Innovation Institute, Georgia Tech. Below are excerpts of the panel discussion on interoperability at the Omni Atlanta Hotel at CNN Center, with the questions being asked by Hines.
What are your definitions of interoperability?
Lynch: To me, interoperability means you have a patient-centric tool and process so you can provide the right information to the right provider at the right time so they can make intelligent decisions to improve care. The key is that the patient has to be at the center of it. We have disparate systems and we need to get that information aggregated for the clinical decision support aspect. Whoever that healthcare professional may be, they need the information to improve care.
Gartland: We call it person-centered interoperability. The information needs to follow the patient and the care team regardless of what system they’re in. It’s not about any one system or a given interface or standard. It’s about ensuring that you drive that outcome and empower the patient.
Dull: When I look at interoperability from a clinician’s [standpoint], it has a different nuance. It has to meet the needs of the patient, but as clinician, I need to have all the information in a way I can look at. All of the relevant information to care for the patient needs to be in a form that is usable, functionable, and easy for whoever is the caregiver at that time. When we had paper records, I would get information faxed to me on a form that looked pretty good and was standardized. The quality wasn’t great, but at least it was on a sheet of paper 8.5 x 11. Now, the [other organization] most likely doesn't have a fax machine, and if it does, it's poor quality. The state of interoperability is actually worse than it was when we were on paper.
How are these definitions being applied to your organization’s infrastructure?
Rushing: Id love to see a day when we stop talking about interoperability, but instead intra-operability. There are new organizational enterprises focused on patient-centered care. There is a future in which you might be wearing a part of your clinician's clinic. We are doing work at Georgia Tech where wearables are real, and we are turning that into information that's vital. You cannot afford to buy everyone like we have been doing over past six or seven years. How do we get that intra-operability working in a fashion where we can improve quality and cost?
Gartland: When we succeed in this space, conversations won’t be about the bits and bites of interoperability, but about outcomes. You look at the World Wide Web as an example—that wasn’t an overnight success. You don’t think about standards, protocols, or other things going on behind the scenes when you call Uber, look at a website, or send an email. We will get there.
When you talk about FHIR [Fast Healthcare Interoperability Resources], it’s a model past the one of sending around meaningful use-era type documents. It actually gets into granular detail. Using CommonWell as an example since they leverage FHIR: you don’t have to leave your EHR [electronic health record] or RIS [radiology information system]—it’s within the workflow. The complication is that the package in between those workflows is a meaningful use-level document, which most people don't want to hunt and peck through. If you want a medication list only, you don’t want to hunt through all that other stuff. FHIR lets you grab the information that’s important. We had Cerner, athenahealth, and McKesson working together to demonstrate the ability to pass those granular FHIR resources. This way, you can send just the problem or medication, for example, from one system to another.
Lynch: One of the things I hear frequently from our clinicians, as we moved into the EHR world, was that they lost the story of the patient. They don’t know what happened on the last shift. The data is there, but they have to really dig through it. Often they have to ask nurses, who are all overworked anyway. As a result, we’re doing interesting things with natural language processing at Covenant.
Rushing: We are huge supporters of FHIR; we use it in our lab in several projects. It breaks down the barrier of usability that’s been present for so long. It enables people to go back to best-of-breed. We spent a lot of time in the early days doing best-of-breed, and then moved to enterprise systems. Now, when you look at start-ups and around the academia world, we are starting to see best-of-breed. We need to stop thinking about hospitals being walls and quarters—that’s the old economics of scale. Now, its how can we use data to improve outcomes. EHR vendors need to function in that new world.
Dull: What I hear about FHIR is encouraging. For 15 years we have forced all physicians into a square hole and it doesn’t work. Customizing data for physicians’ needs is encouraging. Losing the story of patient is due to two things: a lack of interoperability since all you see is the hospital data if you’re in the hospital; and also due to the way data is displayed. We have forced everyone to look at Excel spreadsheets, and that’s not where the story is.
How can health information exchanges (HIEs) thrive?
Rushing: The issue is how do we move information between health systems? That will require an HIE-like entity. Someone has to the do hard work of aggregating what the value propositions will be to stakeholders. The challenge will be the ones HIEs have already had—creating a sustainable business model at that point in time.
Dull: We had an HIE in Detroit and it worked horribly No one used it. There is so much competition in the Detroit market for patients and physicians. In Colorado Springs, it works well; people tell me they can get 85 percent of what they need from the HIE. In Colorado Springs, there is good collaboration between the two hospitals in town and not a tremendous competition between hospitals. When that competition happens, HIE will be incredibly difficult to implement. If there is not that fierce competition, they have great potential to work well. But the cost has to be driven down.
Gartland: To that point about cost, I run a business that sets up private HIEs, yet we started CommonWell while we owned that business because we believed in driving the cost down to zero. Those that find value propositions will be able to create sustainability. You can’t compete against free.
Rushing: There is a value proposition beginning to emerge. With HIE, you can think about how to create a big data platform that can feed back some interesting value propositions such as real clinical decision support. You can start making population health actually mean something. Forward-thinking HIEs will think about how to join forces, put down their competitive guns and knives, and then you will get real clinical decision support back.
What’s the role of the patient in interoperability?
Gartland: I believe patients have rights over everything. I’m a big proponent of them having power. We have found that in an opt-out scenario, less than 3 percent of patients will opt out to having their data shared. We have to empower the patients so we don’t create scenario like banking industry using LifeLock.
Dull: From the patient’s point of view, I love the idea of having control over my data. It has to be an opt-out model, and it also has to be about patient education. If I am thinking about my data as a patient, there might be information in there that I don’t want to share, and without education, I won’t understand the health implications of not sharing that data. Really important data could be embarrassing, so you need that education piece.
Also, there is the issue of the patient's right to contribute to his or her medical record. Interoperability will be key to that. This is an important aspect of health information that gets ignored. As we move forward with interoperability and patients’ full access to their data, it's also about the education of clinicians. It’s not their private journal to document their secret thoughts. We need to re-educate providers on how to document.
What will interoperability be in 5-10 years?
Rushing: We won’t be talking about interoperability in five or 10 years. It will just be what it is and the way it is.
Gartland: I feel the same way. We won’t be talking about it.
Dull: As a clinician, I hope you’re right!