Large institutions face problems with internal and external interoperability. Many, like the Cleveland Clinic, may have hundreds of systems that have to be coordinated in order for meaningful information to be shared amongst members of the same healthcare institution. The data is often fragmented and stored in databases using formats and codified terminologies that are highly proprietary. These challenges are difficult but can be partially managed with interfaces and when appropriate by choosing multiple products from the same vendor.
However, patients are typically seen at multiple locations. On average the severity and complexity of a given patient’s conditions are directly proportional to the number of different databases in which medical information about that patient are stored. Thus even an “ideal” institution that invests heavily in interoperability remains at the mercy of other systems with which they must communicate.
With perhaps the one exception being mediation reconciliation, there has been relatively little progression in interoperability over the past 30 years. This has occurred despite the many government and healthcare community initiatives that have been launched to make systems interoperable. Why is this so and what could actually be done to overcome barriers to interoperability?
- Physician Attitudes Toward Interoperability: Regarding the reasons for lack of interoperability, perhaps a leading consideration and one that is not spoken of very often, is a lack of understanding amongst physicians of the value of interoperability. Doctors are trained to be able to evaluated a patient who presents with no prior records, as this remains a common occurrence. Most physicians would agree that if the information was available in a format that was reliable and formatted in a way that it was directly relevant to patient care, then it would be very useful to have the full record of care. However, it may not be a high priority, and in some cases physicians may see access to a complete record as information overload creating additional pressure on the limited amount of time they have to provide patient care. If physicians felt that interoperability was essential, they would demand it from their institutions and be willing to making greater investments in health information exchange. Targeted educational initiatives that illustrate the value of interoperability to physicians, in particular when they impact patient safety, medicolegal risk, and reimbursement, may be of value if they encourage providers to demand access to complete medical records. However, the information that is obtained from other systems and shared with providers needs to be formatted in a manner that will allow for efficient reviewing. It will also need to be accurate and complete.
- Lack of Implemented/Mandated Standards: The lack of standards is often cited as a barrier to interoperability. However, numerous standards have been vetted and are available that would make a significant difference in improving the flow of information in medical communities. These include the CCD, cCDA, FIRH, HL7 V3, CDC requirements for immunization registries, numerous codified terminologies, and several others. However, many of these standards have not been mandated or when they are there are marked gaps in how the implementations may be “interpreted.” Thus, developing additional standards is not as important as taking the ones that have already been developed and creating incentives for their use, including common methods for working with them in live settings.
- Business Disincentives to Interoperability – Don’t Make it Too Easy to Leave: Healthcare institutions often do not have strong business incentives to invest in interoperability. They depend upon community physicians making referrals to their systems for labs, diagnostic procedures, surgeries, admissions and other revenue generating activities. Many have acquired physician practices or provided EHR software, training, hosting and technical support for affiliated physicians in their communities via the Stark Antitrust Exception. In general these systems encourage or require physicians who are employed or affiliated to use a single EHR platform. Since the hospital is providing software and technical support, it is in their best interest to invest in knowledge resources that fully understand a given single system. In addition, the cost of the EHR product and its support in the clinics are covered by the hospital (up to 85% of costs in the Stark Antitrust Exception) which may foster a form of IT dependency on the hospitals. In some cases, the hospital also owns the database that houses the medical records of the patients. Considering all these factors together, hospitals (and EHR vendors) have concerns about the impact of seamless interoperability on their retention rates. Physicians are largely dissatisfied with their current EHR platforms and if their ability to change to a new system were to relatively straightforward, they may opt to transition to another vendor platform. This may be one of the reasons that hospitals are in general not demanding low cost and low resource intensive interoperability from their EHR vendors, and their vendors also not business incentive to allow for their current customers to switch to a competitor. There may not be a straightforward solution to this barrier other than the institution of mandatory requirements for interoperability.
- Breach Concerns: Other concerns that are often cited include hospital and provider fears over the ramifications of a breach of protected information, as the covered entity has responsibility for breaches even if the breach occurred once the data was out of its hands. For example, if an HIE were to be breached the hospital that sent the data to the HIE would be required to contact all of the affected patients and possible penalties. Since breaches are increasingly common occurrences, the stigma associated with a breach in a setting where the covered entity has made every reasonable effort to be compliant with security requirements and protocols needs to be reduced. In addition, penalties should not be applied if the covered entity is compliant with reasonable breach protection requirements. Until the fear of breaches is addressed it may negatively influence the willingness of hospitals to engage and invest in interoperability.
- Competitive Marketing Analytics: A related concern that may give hospital management teams pause is their concern over how data exported from their systems will be used by their competitors. Hospitals often compete by stating that they have the lowest rate of complications in the community. A competitor will full access to data may be able to challenge marketing materials provided by another system once they “reanalyze” the data. This is another barrier that will be difficult to overcome short of the adoption of interoperability requirements.
- The Monetary Value of Data: Healthcare data has value in the industry and several companies have successful business models related to selling data to clinical and marketing research organizations. Once data is shared with other organizations its proprietary value may be impacted negatively, or it may enhance the value of a competitors data (e.g., if the data that was shared lead to a competitor having a larger cohort of patients with a disease that is being targeted by pharmaceutical research organizations). The ownership of data is under constant debate, and until there is legal precedent that establishes the ownership of data, including the patient’s right to their own healthcare date, this will be a difficult barrier to overcome. One approach might be to make it mandatory that organizations share data that is needed for patient care without restriction.
In summary, U.S. healthcare would have seamless interoperability today if it was a true priority. Until the business and other barriers are addressed interoperability is unlikely to be more that a discussion topic at HIT meetings for years to come. Perhaps the most promising change is the marked increase in the use of technology by patients, the principal stakeholders in healthcare. This will allow them to become more engaged in the process of sharing data. Also encouraging is that none of the 6 barriers to interoperability noted above are of great concern or interest to patients, and in most cases it is likely that they would want to see them removed as quickly as possible.
The information presented in this article is the opinion, unless otherwise stated, of its author, Michael Stearns, MD.