With all the discussion industry-wide around the subject of interoperability, the topic is clearly top-of-mind for many healthcare leaders these days. With that in mind, attendees at the Health IT Summit in Miami, being held at the Ritz-Carlton Coconut Grove Hotel, and sponsored by the Institute for Health Technology Transformation (iHT2—a sister organization to Healthcare Informatics under the Vendome Group corporate umbrella) heard a wide-ranging first panel discussion on Monday, under the heading, “Interoperability: Beyond the Buzzword.”
Gary Ozanich, Ph.D., senior research associate and professor in the Center for Applied Informatics in the College of Informatics at Northern Kentucky University, led a distinguished panel of industry leaders in a very broad and probing discussion of the topic. With him in discussion were William H. Morris, M.D., associate CIO, Cleveland Clinic; John Santangelo, senior director, information technology, Cleveland Clinic Florida; David C. Kibbe, M.D., president and CEO, DirectTrust; and Karl Norris, CTO, founder, DUOLARK LLC.
(l. to r.) panelists Ozanich, Santangelo, Morris, Norris, Kibbe
Among the numerous subtopics discussed, early on, discussion emerged around how much real progress is being made towards interoperability in the U.S. healthcare industry right now. Dr. Morris of Cleveland Clinic said, “Certainly, we’re seeing advances with Smart on FHIR. On the geek side, which I oversee, there are definitely exciting things happening. But clinically, operationally, it still feels pretty glacially slow,” he conceded.
Santangelo of Cleveland Clinic Florida, immediately responded, “What he said! You know,” he continued, “we as a healthcare community are figuring out ways to interact with each other, to exchange information. HIEs [health information exchanges] are not the answer, obviously. Based on the transition of our healthcare organizations, we’re finding ways to make interoperability work around HIEs and other infrastructures that really aren’t working. I think we’re definitely making progress, but it’s not going to be run by the state or government, it’s going to be run by ourselves.”
Ozanich asked his fellow panelists, is the attempt to exchange patient record summaries and to be able to move away from having to exchange very large patient record data sets, becoming real yet?
“Things are getting better,” Dr. Kibbe testified. “I recently had an appointment with my internist in a rural place in North Carolina. And I asked, can you get my records from Mayo Clinic? I recently received care there. And they said, ‘Sure, what’s their DIRECT address?’ And this was not an IT person asking that question. And my CDA went the next day. So it is happening,” he said. “ But there are problems. Neither FHIR nor APIs have fully worked out standards. But it’s doable; we’ve done it with DIRECT exchange.”
Meanwhile, Kibbe said, “There are two other FHIR problems. One, if you’re pushing (data), you know someone’s address, but there are problems you have to deal with. First, there’s the patient matching issue: am I getting the right patient? Second, do I have the right consents in place? And once you’re beginning to do server-to-server exchange, you won’t have the people to help facilitate those issues. That’s one of the reasons we’ll see much more intra-exchange inside patient care organizations before we see much inter exchange.”
Norris noted that, “Here in South Florida, what we’ve done is to design a method to communicate downstream, from the hospital to the SNF [skilled nursing facility] to long-term care. A lot of the time, it’s just paper records. And we basically set up a way to get all these different organizations to be interoperable, using tools like FHIR as a standard but also normalizing the way people do business and track the encounter. Within CJR, each provider gets reimbursed. And the first year, it’s all designed for benefit. We’re making sure that information on a patient tracks down through all these different entities for quality control and cost management. We have to track the individual, the episode, the encounter, and the cost, so these folks get reimbursed. And 67 metro areas across the US are mandated on this for knee replacements,” he said, referring to new mandates coming out of the Medicare program around joint replacement procedures. “And by year three, if you don’t use this system, by year three, I believe, you’re cut out of Medicare payment. So those kinds of developments are moving things forward.
Later in the discussion, the subject turned to the development of APIs, and whether that ongoing evolution would help the U.S. healthcare industry move forward on interoperability. “APIs are a tool,” Cleveland Clinic’s Morris said. “They’re not a panacea. With regard to what David [Kibbe] said about the evolution of how you use these tools, a couple of points. We need not be so innovative; we can be imitative, and look to [the developers of tools at individual, pioneering organizations], to see how to use tools appropriately. Internally, there are plenty of opportunities to get your feet wet with APIs and with FHIR. Internally, as we move from volume to value in our organizations, how do we use predictive models?”
Critically, Morris said, “Physicians are seeing that their computers can be not just repositories of records, but rather, that they can help guide them in patient care delivery; and that’s what we need. Using predictive models is one great concrete example; another is visualization. That’s all really centered around how you take data and make knowledge.”
Norris said, “It’s complex. And so we need to take care of that complexity behind the scenes. Look at how Amazon uses APIs to drive business.”
When the topic turned to the issue of how the CDA (clinical document architecture) is evolving forward, Kibbe noted that “The CDA is not very standardized. Probably the biggest mistake CMS [the federal Centers for Medicare & Medicaid Services] made was not allowing PDFs and Word documents to be exchanged initially.”
The nature of healthcare geography can also prove challenging, Norris noted. “In South Florida, we have a lot of folks who come down from the north and spend the winter here. So having an integrated solution is very important. And most of the folks who come down here are older, and have more health issues. When the patients start to see the value” in data exchange and messaging and other communication tools, he said, “then they want to participate as patients. So, having information available, and seeing people use it effectively, helps.”
Later still in the discussion, Ozanich asked panelists, “What do you see as the cultural barriers to adoption” when it comes to the shift towards interoperability?
“It still feels sometimes that IT is still being done to you, rather than with you,” Cleveland Clinic’s Morris stated. “And John [Santangelo] brings up a great issue. Yeah, it’s great you’ve got the widget, but it’s 40 clicks away and you can’t get to it. So having technology folks side by side with clinicians, is important. And it’s great to have knowledgeable informaticists talking to clinicians—because there still needs to be operational ownership. And having difficult conversations and being transparent, is key. I do think we’re seeing an evolution away from informatics as a back-office service, and driving towards patient safety and outcomes,” he added.
“It’s about developing relationships, it’s about developing trust,” Santangelo asserted. “And IT has to be at the table and also have relationships, and it’s about the physicians trusting the IT folks and the IT folks trusting the physicians. And we can’t have business plans developed and laid out and have the people who came up with the business plan then suddenly coming to IT and saying, now we need your help to make this work.”
How does all of this connect to issues around vendor selection?
“Five years ago, best-of-breed was frowned upon,” Cleveland Clinic’s Morris noted, “as everyone was moving towards a monolithic experience. I am so happy that we’re moving towards something that works for the patient. So I’m so happy we’re moving towards driving the best clinical care at the best cost for patients, so now the technology folks get to figure out how to make things work best for patient care. So the pendulum is swinging back away from single-source solutions, and that’s a good thing, because what gets me going as an IT person is not just being a vendor champion, but doing what’s best for our patients.”
At a more fundamental level, Kibbe said, “We all want to connect deeply. And we have this really strong sense that we’ve got to reestablish human communications in healthcare, because that’s what makes it work. And interoperability is sometimes held up as a kind of talisman for this idea that we’ve lost the soul of medicine, and interoperability can help us regain that.”
Towards the end of the panel, when asked how quickly panelists see the industry moving forward towards true interoperability, Santangelo said that, “Short-term, it won’t change a whole lot, but we’ll continue to make baby steps and progress. And as things transition, the incentive needs to be around solving problems. Meaningful use helped us all progress towards EHRs [electronic health records], especially some of the smaller groups that need that, but how much resource financially was spent chasing meaningful use for some of the wrong reasons? So that incentive needs to shift towards solving the interoperability problem and making sure that as a patient, no matter where you need care, that critical information is available to any provider anywhere in the country,” he said. “Once we’ve solved that problem, we’ll go a long way towards where we need to be.”
And Morris added that “I think what you’re seeing in 2016 is a shift, and we’re seeing this coming out of Washington, the voice of the clinician saying, it’s happening to me not with me. It’s not helping me with my patients. The patients aren’t seeing the benefits, or me. Are we just turning paper records into electronic ones, or are we moving towards technology becoming a guide and mentor to us as physicians? So I’m optimistic that things are moving in the right direction for us as clinicians. And in terms of FHIR and other areas, I think people will be experimenting, and a tipping point will be reached. And in terms of Cleveland Clinic, why should what we’re doing be limited to northeast Ohio? What we’re doing at CC shouldn’t be limited to us. It shouldn’t involve hardwiring over and over and over in different places; it should just work. So you’ll see at HIMSS all sorts of homegrown solutions that were birthed in one organization but then spread everywhere, and that’s good.”