This year's Health Information and Managements Systems Society's HIMSS13 conference began with a shocker: The announcement that five leading electronic health record (EHR) vendors were forming a group called the CommonWell Health Alliance that would promote "seamless interoperability" of healthcare data.
HIMSS13 also saw the announcement of The CURE Project, an interoperability initiative started by New Health Networks to put to task the healthcare community, not vendors or the federal government, to help define interoperability standards for healthcare applications that capture, update, report and exchange information.
There's also the imPatient Movement, an effort among NoMoreClipboard.com, Microsoft HealthVault and Indiana Health Information Technology to encourage patients to use an interoperable personal health record and providers to use the data in that PHR to improve care.
With a lack of interoperability standing as an obstacle to improving patient care—and reducing the estimated $750 billion in annual unnecessary healthcare spending in the United States—will parallel interoperability initiatives help or hurt the industry?
Vendor Interoperability Pledge Met With Skepticism
While industry observers noted that an EHR vendor interoperability pledge is better than no interoperability at all, reaction to the CommonWell announcement was, in a word, skeptical. (It didn't help that Epic Systems, arguably an EHR market leader, is not part of CommonWell.)
- Consultant and blogger Anne Zieger referred to it as an interoperability scheme, though she admitted, "the more data sharing the better, particularly by major players with significant market share."
- Dr. Adrian Gropper, CTO of Patient Privacy Rights, called it a shame and a missed opportunity— a shame because "another program with opaque governance by the largest incumbents in health IT is being passed off as progress" and a missed opportunity because it doesn't involve physicians or patients.
- Dan Munro, founder and CEO of iPatient, expressed concern that publicly traded companies—with boards of directors and shareholders to please and quarterly objectives to meet—"don't make good candidates for lean, rapid and disruptive technical innovation."
- Jon Mertz, vice president of marketing for Corepoint Health, put it simply when he asked, what took so long?
That's why the men behind the CURE Project—Steven E. Waldren, M.D., senior strategist with the American Academy of Family Physicians and Robert L. Brown, vice president of professional services, Mosaica Partners—say interoperability will come only with what Brown describes as a "large-scale specifications development project."
Back in 2004, President George W. Bush called for widespread adoption of electronic health records. Rather than take the opportunity to recast the EHR system in the context of interacting with patients at the point of care, to make EHR less obtrusive and more efficient, the industry instead went full steam ahead, building hundreds of standalone systems the create and maintain EHRs, Brown says.
As a result, first vendors and then the federal government, through the meaningful use program, have defined what they want in healthcare IT systems—while providers, the ones actually paying for the systems, haven't had a say. It's time for that to change.
Define the Software Capabilities You Need
The CURE Project began as an "academic exercise" for the Agency for Healthcare Research and Quality that examined information models in the patient-centered medical home (PCMH), one of the cost-saving initiatives included in healthcare reform. Brown and Waldren had to define that information model, as there was no standard approach, and soon discerned that the model was missing nearly everywhere else, too.
Traditionally, healthcare IT systems have been designed in an iterative manner that focused on business process automation—namely, billing and documentation—and not care delivery. Now that government incentives encourage improved care, through the adoption of the PCMH and the accountable care organization, there are financial reasons to improve clinical applications, Waldren notes.
For this to happen, the industry needs to define the capabilities it needs, the software functionality that will make it happen and the common, open technical specifications—not the "insular and problematic and very proprietary" ones Brown says EHR vendors have used for so long—which can deliver these features.
"If we don't specify what we need to do as these new types of [healthcare] delivery models, or existing delivery models, we can't expect to get a usable, interoperable IT system to support them," Waldren says.
The CURE Project is taking a grassroots approach to defining these capabilities and functionality; its parent company, New Health Networks, will license the output via Creative Commons, and once that work is finished the CURE Project will turn the work over to an entity the community deems best suited to manage and oversee the specifications.
A grassroots approach is necessary because those definitions need to be specific. For example, Waldren points out, healthcare leaders say they want "population management" capabilities, but that's far too vague to build specs around.
The community needs to decide what patient care quality measures need to appear in a dashboard, what evidence can be brought in to change an individual patient's care plan and, on a broader level, what data will be used to determine which patients are at the highest risk of, say, developing diabetes. If that doesn't happen, he says, the emerging EHR backlash will only worsen.
EHR Interop Struggles of VA, DOD Point to Management Woes
Few scenarios better illustrates the difficulty of interoperability, and the source of that backlash, than the 15-year effort of the Veterans Affairs and Defense departments to get their EHR systems to talk to each other.
The departments represent two of the largest healthcare systems in the United States and two of the earliest adopters of EHR technology: VistA, launched in 1978, helps the VA treats 6.3 million veterans, while the DOD's AHLTA, which debuted in 1997, holds records for 9.6 million active duty service members.
Since the late 1990s, both Congress and the President have urged the departments to achieve varying measures of EHR interoperability. Planning has been absent virtually every step of the way, Valerie C. Melvin, director of information management and technology resources issues for the Government Accountability Office, testified before the U.S. House of Representatives Committee on Veterans' Affairs.
The testimony came after the VA and DOD first said they would abandon the effort to develop a joint EHR by 2017 and then backtracked, saying they were committed to integrated EHR systems rather than a shared system.
Melvin cited several specific examples:
- The 1998 Government Computer-Based Patient Record project to give each department an interface into the other's EHR suffered, as "basic principles of sound IT project planning, development and oversight" weren't followed and "accountability…was blurred across several management entities." The project was finished in 2005.
- A joint clinical health data repository, slated for completion in October 2005, was nearly one year late. This initiative, GAO said, lacked a project management plan and an architecture for describing the common interface.
- While a directive to develop six specific "fully interoperable [EHR] systems or capabilities" by Sept. 30, 2009 was met, the GAO saw none of the "objective, quantifiable and measurable performance goals and measures that are characteristic of effective planning." These were developed seven months after the functionality was in place.
- The Virtual Lifetime Electronic Record, a way to streamline how patient records move with a soldier who leaves active duty, began with successful pilot programs. However, without "identifying the target set of capabilities that they intended to demonstrate in the pilot projects and then implement on a nationwide basis," the VLER couldn't meet its goal of implementation at all domestic VA and DOD sites by the end of 2012.
- Lack of planning for an integrated, jointly funded federal health care center left the VA and DOD unable to "estimate the project cost or establish a baseline schedule." The total cost ballooned to $122 million—not including the workarounds resulting from delays in setting up single sign-on, single patient registration and physician order portability.
- Finally, the fate of the interoperable EHR remains in doubt, the GAO said, and "the extent to which the departments' revised approach to iEHR is guided by a joint health architecture remains to be seen." This in spite of a February 2011 GAO report that recommended putting EHR modernization efforts and IT investments in the context of common healthcare business needs.
These myriad initiatives, Melvin concluded, suffered from a "persistent absence of clearly defined, measurable goals and metrics" and "deficiencies in key IT management areas of strategic planning, enterprise architecture and investment management."
Government Seeks Interoperability Input
Interoperability, then, remains the biggest hurdle to efficient and effective use of healthcare IT. That's why Dr. Doug Fridsma, the director of the Office of Standards and Interoperability and the acting chief scientist in the Office of the National Coordinator for Health IT (ONC), says health IT interoperability is like designing a city.
Linking the disparate clinical, billing, administrative and email systems in use at the nation's medical centers, hospitals and independent practices isn't about individual building blueprints, Fridsma says. Since those organizations are, in effect, individual neighborhoods, it's about "zoning laws, roads and infrastructure, rules and governance, safety and protection," all of which must be implemented according to flexible standards that change incrementally (not radically) and emphasize usability and workflow.
To help build this city, during HIMSS13 the ONC released a request for information seeking ways to catalyze interoperability. Various government mandates, ranging from the meaningful use of EHR technology to the care coordination advocated in healthcare reform, depend on better health information exchange. Several avenues could be pursued, ONC notes, including Medicare, Medicaid and Children's Health Insurance Program pilot programs and an expansion of the popular Blue Button program.
With interoperability alliances, movements and projects emerging with increasing frequency, the ONC should be prepared to do some heavy reading—and, it is hoped, give the industry the guidance it needs to make data exchange easier.