Clearing Interoperability Roadblocks To Deliver Better Care

Compiled by Scott Westcott, Contributing Writer

Getting different IT and software applications to communicate and share data effectively remains a challenge as healthcare providers seek to achieve interoperability, but progress is being made.

There is likely no aspect of health IT that presents more of a challenge than interoperability. In simple terms, interoperability is defined as the ability of different information technology systems and software applications to communicate, exchange data, and interpret data and information that has been shared.

Achieving interoperability is often viewed as the Holy Grail when it comes to health IT, in that it represents leveraging and sharing data in ways that lead to better patient care and outcomes while creating significant cost and time efficiencies for providers.

Yet big challenges exist, both in facilitating the efficient exchange of information between many different technologies and the need to change the behavior and mindset of caregivers. Recently, Dr. Rasu Shrestha, chief innovation officer at UPMC and executive vice president at UPMC Enterprises, and Dr. Donald Voltz, anesthesiologist at Aultman Hospital and HIT consultant, shared their insights on the progress that has been made toward, and how to overcome barriers to, true interoperability.

Q: What obstacles are currently impeding interoperability?

Shrestha: We have been on the HIT interoperability journey for a decade now. It is time to wake up and realize HIT interoperability is not just a “nice-to-have” anymore — it’s a strategic imperative. One key impediment to HIT interoperability is, ironically, standards. We don’t need more of them; we need better discipline around embracing existing national standards for HIT interoperability. What we need is simplicity that facilitates a level of ease and reliability that is akin to plug and play around HIT interoperability standards.

Voltz: Technical barriers are often blamed as the main obstacle to the sharing of patient medical information, but this is really not the hurdle it is being made out to be. Th e most significant issue impeding interoperability stems from the EHR. When we look at EHRs from a high level, they are databases at the core, which unfortunately use proprietary formats to store the various pieces of patient and operational data. Big EHR vendors still refuse to embrace interoperability and continue to put patients and hospital systems at possible risk. Patient care depends on near real-time access and capturing the interpretation of data and how it fits with the patient, disease, and treatment plan. When you break apart the process of healthcare into individual events and data elements, its reconstruction can lead to gaps in understanding. If we shift our perspective to a system-level, patient-centric model of healthcare delivery, EHRs bring the potential to enhance patient care. Without connecting all the pieces, we lose context, a critical requirement to addressing quality, reducing duplication, and enhancing patient care with technology.

Q: Are clearer standards a necessity to ensure HIT interoperability?

Shrestha: Yes, we need clearer guidelines around standards, better discipline around adherence to core standards, and clear measures so we can hold vendors, providers, and payers accountable to ensuring HIT interoperability.

Voltz: Yes, standards would clearly improve the work required to transmit data between systems. Open technology standards such as middleware plug and play are one way to bring about interoperability. Emerging technologies, changing models, and new concepts will all continue to bring new insights and information, as they have done in other businesses. Even at the current state of EHR implementation across the country, access to a standardized view into EHRs, irrespective of the platform or vendor, is possible. I have helped work on such a platform and have successfully mapped the databases of the major EHR platforms. Interoperability, or access to patient and other healthcare data, can take place if EHR vendors and health systems want it. These barriers are relatively easy to cross, should we choose to enhance patient care by allowing such access.

Q: The government, HIT vendors, healthcare providers, payers, and patients all will play a role in interoperability, but which of these stakeholders will ultimately drive this effort forward?

Shrestha: The U.S. healthcare system currently has a high degree of dependency on HIT vendors. Indeed, vendors have not really been incentivized financially or otherwise in the past decade to enable real interoperability. They have, I would argue, been disincentivized to enable real interoperability. The past decade has seen the emergence of disparate ways to capture, store, and exchange data. But this is changing, and vendors who adhere to proprietary standards or are less interoperable with others will eventually lose out. Instead of relying solely on the HIT vendors to enable interoperability, healthcare needs to think outside the box and enable more of a patient-centric approach to interoperability. Perhaps we have been betting on the wrong horse all along. Perhaps, if we allow patients more freedom of access to their own data and enable them to be true arbitrators of their own data, we can truly make an impact and get at real interoperability.

Voltz: I really think the driver of interoperability will fall on the healthcare providers, as they have a great deal of skin in the game. Allowing two competing EHR vendor platforms to seamlessly interoperate is currently a bad business model as vendors jockey for broader market penetration. Physicians and other healthcare providers focus on the patient and remain connected to the needs of patients and have had to develop workarounds for the overall lack of workflow and user interfaces to support care delivery. I have been involved with vendors to address issues of interoperability by adding a layer of software on top of EHRs. This presents patient data in a format that supports healthcare interpretation, data flow, and an improved ability to understand a patient’s condition. I believe the next big phase of innovation in health IT will come from software that integrates with EHR databases. What is often not understood by providers is that EHRs are just databases, often with poorly designed user interfaces added on top of the data store to appear like enterprise applications. Unfortunately, the attempted design of EHRs in many cases does not meet the needs of the patient or the healthcare provider. What is needed is a customized application designed for a specific end with an interface that supports a limited scope of providers.

Q: What strategies have you found to be successful for implementing, adopting, and sustaining HIT interoperability to date at your facilities?

Shrestha: UPMC has been at the forefront of HIT interoperability for years now. We embraced interoperability as a strategy before it became fashionable to do so. The trend today is to go with one of the few major EMR vendors. At UPMC, we have a best-of-breed approach to clinical information systems, enabled by interoperability. We have invested heavily in not just syntactic interoperability, but have led the way in semantic data interoperability where data harmonization enables a more meaningful approach to interoperability and knowledge extraction.

Voltz: Given all of the frustrations and difficult rollouts many healthcare professionals have experienced, it is a difficult time to address new and novel solutions that will make things better. Remember, these were exactly the benefits touted for EHRs during the initial implementation. The best strategy moving forward is to use the previous pain and frustrations as learning points. We have come to appreciate some of the benefits of EHR technology, including remote access to patient information. With the glimmers of hope for a better healthcare environment, great opportunity exists in the development of user-understood patient-engaging and productivity-enhancing solutions. For these to happen, they need to be customized to address a niche of healthcare providers and demonstrate effective and aligned workflows with the real-world delivery of healthcare. It is a more difficult sale to get physicians, hospital administrators, and health IT professionals to buy into new technologies without acknowledging the issues of the past. But at the same time, the requirements to meet governmental and other payer policies, curb waste, improve the patient experience, and obtain buy-in from healthcare professionals keep us dependent on technology.

Q: Can we be true meaningful users or achieve true population health management without true HIT interoperability?

Shrestha: Interoperability is the bedrock for achieving better population health management, better analytics, and better usability. So to become true meaningful users requires continued movement toward true interoperability.

Voltz: The concept of an accountable care organization intimately depends on the sharing and access of patient data, irrespective of where the care is being delivered or the phase of a patient’s treatment. Anything short of real-time, continuous access to patient information will not work, leading to inefficiencies, errors, and waste.

Much of the impetus for widespread implementation of EHR systems came from the concept of population health management. Even the development of HIEs has been driven by population health. There is no question population health is an important issue to be addressed, but it must be tempered by the personalized delivery of care. These two concepts can, at some level, look to be competing with one another, but are critical to the success of any technology. The indices and data used to assess population health can be quite different from those of personalized care. HIEs have been designed to collect subsets of patient information to assess metrics of quality, care plans, reimbursement, and overall performance. Removing the context from the data or, conversely, including all of the data into each encounter leads to bloat and inaccuracies. The data needs to be placed in a context to complete the patient story. No matter where any single piece of data is collected, it must be available to other professionals who depend on it to make decisions and institute treatment. Without access to the various phases of assessment and treatment, the technology is not meaningful in the care of the patient.

Q: What are some methods of transforming care with interoperability?

Shrestha: It is critical to focus on a ground-up approach to data interoperability, with the goal of enabling better workflows and better decision making. The millions of dollars we invest in implementing clinical information systems become meaningless if usability goes down or if clinical workflow is impeded.

Voltz: Instead of trying to solve interoperability with a single solution, we need to look at different healthcare needs and how they can best be met and enhanced with technology. We can address sharing and access of data by building solutions on top of EHR platforms. As an anesthesiologist, I am responsible for ensuring patients are adequately risk-adjusted and medically optimized prior to undergoing an elective surgery. Th is area of medicine depends on the communication and sharing of patient health data obtained from multiple medical professionals including the surgeon, primary care physician, and other consulting physicians such as cardiologists or pulmonologists. Although a surgical procedure is often viewed as a single epoch of care, it is actually a small part of a larger continuum often beginning in a primary care office or emergency department when a surgical condition is discovered. Th e continuum of care continues after surgery and may involve intensive care physicians, hospital-based (hospitalists) and other specialist physicians, and other professionals such as physical therapists, dietitians, and social workers.

At each of these phases, information is gathered, care is delivered, and potential issues such as follow-up care may need to be completed. If the patient’s medical data does not follow each phase in this continuum, there is a critical break in information flow and communication with the possibility of unnecessary duplication of services or worse, missing an intervention.

Q: What technical challenges need to be overcome to achieve true HIT interoperability?

Shrestha: Loose standards need to be tightened up. Vendors need to be better disciplined to adhere to national standards. Perhaps vendors need to start first with enabling crosswalk capabilities between the core standards they adhere to and national standards around key data elements such as medications, allergies, problems, immunizations, and labs. Th ere also needs to be better synchronization in provider adoption of HIT interoperability standards.

Voltz: Technical specs and access to standardized application programming interfaces would go far in developing solutions that actually work. In addition, a change in the business model for health technology could go far in the adoption of solutions by healthcare institutions. The concerns of being financially chained to a given technology solution by the high cost of purchase, implementation, and ongoing service to these systems limits the choices available. Instead, technology success should be measured post implementation by assessing customer satisfaction, patient outcomes, and information exchange across the care continuum. This would provide a better indication of how well the technology solved the actual problem.

Q: What role, if any, does the public sector need to play in the effort to improve HIT interoperability?

Shrestha: Public HIEs have generally demonstrated less value over the years. Th ere has been a rapid emergence of private HIEs with tighter linkages between healthcare facilities that are aligned around patient fl ow geographically and economically. HIEs today primarily rely on sending and receiving continuity-of-care documents, and these are often not well-ingested and integrated into the clinicians’ workflows.

Voltz: I think the greatest impact the public sector can have in the improvement of HIT is to realize innovation is unlikely to arise from current players in HIT. This is not to say they are not doing a good job, but instead, that solving a problem as complex and wide-reaching as medicine requires a great deal of experimentation and creativity. Understanding this, the public sector can support and even drive initiatives to allow developers to tackle this challenging yet rewarding problem. The company that will be the greatest winner in the future of health IT will embrace the concept that access and use of data is more valuable than sequestering it for limited use. I am not suggesting we disregard security and regulate who has access to the information, but instead to open up our minds to different ways of solving the problem of interoperability.

Q: What advice would you share with other providers on how to optimize their HIT interoperability efforts today?

Shrestha: It is critical to understand that, regardless of the provider’s strategy around clinical information system implementation, interoperability should be a key consideration, even when purchasing a solution. It is also critical to comprehend that, even for organizations with a single-vendor strategy, there is never really just one vendor. Providers need to ensure a good level of stickiness across referring provider groups, across neighboring provider organizations, and often across state and national lines. Th is calls for both a stricter level of adherence to data standards and methodologies, as well as a broader need to really push their respective vendors to embrace national standards and having better discipline around adherence to core standards. Th ere are three top points to understand about interoperability: First, it’s really about the patient. Those who have endured frustrating challenges in their own care, or the care of their loved ones, understand this best. Second, interoperability is hard, but must be done. Third, at the end of the day, interoperability is less about the technology, and more about leadership. We need to rise to the occasion and show real leadership within our own organizations and more broadly to make this happen.

Voltz: Personally, I am engaged in the concept of expanding access to data through the use of middleware. As mentioned, I do not think data warehouses have much utility in providing access for clinical patient data and are likely to fall short in clinical care.

With the belief that we will continue to see innovation and adoption of new technologies in healthcare, we will need to have a way to interface and integrate the old with the new. As our data collection needs continue to climb, we cannot reformat legacy data to meet new formats. Instead, we need to look for solutions that have worked in other industries. Th e concept of a middleware platform, an integrator of sorts, has been shown to connect legacy systems with newly developed ones in many industries such as retail and finance. There’s no reason this type of middleware can’t work in healthcare.