Six Barriers to Interoperabilty

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?

  1. 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.
  2. 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.
  3. 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.
  4. 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.
  5. 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.
  6. 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.

Comments welcome…

The information presented in this article is the opinion, unless otherwise stated, of its author, Michael Stearns, MD.





ACO Survey – Interoperability and Cost of HIT are “Burdens”

This article (link below) reports findings from a survey of 62 accountable care organizations (ACOs) reported by the eHealth Initiative and Premier, Inc. 90% reported that the cost of HIT and its return on investment had become “crippling concerns.”  Areas that were seen as underutilized or underserved included:

  • Patient engagement tools
  • Referral management tools
  • Telemedicine
  • Remote monitoring
  • Personal health records
  • Smartphone applications
  • Data interoperability
  • Data quality
  • Health information exchange strategies
  • Analytics
  • Patient reported data mining
  • Unstructured data mining
  • Revenue cycle management
  • Master Patient Index (MPI)
  • Risk management

Improvements were seen in outcomes, cost, efficiencies, quality of care, reductions in hospital admissions/readmissions and ED visits, although they were modest.

Commentary:  This article provides very useful information and identifies the need to remove barriers to access to information.  The majority of ACOs reported they are  “facing significant obstacles in integrating and blending data from disparate sources.”  At this time a lack of implemented standards and success with removing business disincentives towards interoperability are threatening to compromise the success of accountable care initiatives.  Patients may be the only stakeholders with the legal and political clout to successfully promote cost-effective reform in this space; but as of yet they are relatively unengaged.

Article Link: The Landscape of Accountable Care and Connected Health: Results from the 2014 National Survey of Accountable Care Organizations.

EHRs and the ICD-10 Transition: Planning for 2015

This article (link below) was published by AHIMA and reprinted with permission by Physician’s Practice.  It details recommendations regarding how EHRs users and vendors should approach the transition from ICD-9-CM to ICD-10-CM.  EHR vendors that are transitioning to SNOMED CT before the October 1, 2015 deadline for using ICD-10-CM will be able to offer a relatively smooth transition.  In some cases EHR users maintain local ICD-9-CM codes (e.g., templates, pick lists for diseases, etc.).  These individuals will need to work with their EHR vendors to identify where in their EHRs locally maintained ICD-9-CM codes may reside, and the steps needed to update them to ICD-10-CM.

Article Link: EHRs and the ICD-10 Transition: Planning for 2015

Author of article (and this post): Michael Stearns, MD, CPC

Adoption of HIE and Patient Engagement Low in Practices

The August 2014 edition of the Journal “Health Affairs” published the results of a survey conducted by representatives from AHRQ, ONC, Harvard and the University of Michigan.

The article is titled “Despite Substantial Progress In EHR Adoption, Health Information Exchange And Patient Engagement Remain Low In Office Settings.”

Key findings of this 2013 survey:

  1. EHR adoption continued to increase, with 78% of practices reporting the adoption of some type of EHR and 48% had the features needed for the use of a “basic EHR.”  Providers in solo practices and non-primary care specialties has the lower rate of adoption.
  2. Only about 14% of providers share data electronically with other providers outside of their organization.
  3. The survey found that 30% of physicians routinely used secure messaging capabilities with patients.
  4. It also found that 24% routinely provided patients with the ability to view online, download, or transmit their health record.

Editorial Comment*:  This is an excellent and informative article about the state of health information exchange (HIE) and patient engagement in the U.S. in 2013.  HIE is plagued by limitations related to the cost of interfaces, lack of adoption of required technologies, business disincentives, privacy concerns, a lack of implemented standards, and challenges associated with reconciling data from disparate sources.   Patient engagement represents another challenging area of healthcare as patient have not traditionally been taking advantage of patient portals and PHRs.  A lack of interoperability, requiring patients to manually enter data in PHRs, would benefit from greater levels of health information exchange.  As the authors note in the discussion of this article, greater attention needs to be paid to policies that will facilitate the broader adoption of HIE and patient engagement tools.

Link to full article (requires subscription to Health Affairs): “Despite Substantial Progress In EHR Adoption, Health Information Exchange And Patient Engagement Remain Low In Office Settings”

The abstract is available here.

Author Affiliations:

1. Michael F. Furukawa ( is a senior staff fellow in the Center for Delivery, Organization, and Markets at the Agency for Healthcare Research and Quality, in Rockville, Maryland. He was director of the Office of Economic Analysis, Evaluation, and Modeling at the Office of the National Coordinator for Health Information Technology (ONC) in the Department of Health and Human Services when this article was written.
2. Jennifer King is chief of the Research and Evaluation Branch in the Office of Economic Analysis, Evaluation, and Modeling at the ONC.
3. Vaishali Patel is a senior adviser in the Office of Planning, Evaluation, and Analysis at the ONC.
4. Chun-Ju Hsiao is a health scientist administrator in the Center for Quality Improvement and Patient Safety at the Agency for Healthcare Research and Quality.
5. Julia Adler-Milstein is an assistant professor in the School of Information and the School of Public Health, University of Michigan, in Ann Arbor.
6. Ashish K. Jha is a professor of health policy and management at the Harvard School of Public Health, in Boston, Massachusetts.

Citation: Michael F. Furukawa, Jennifer King, Vaishali Patel, Chun-Ju Hsiao, Julia Adler-Milstein and Ashish K. Jha, Despite Substantial Progress In EHR Adoption, Health Information Exchange And Patient Engagement Remain Low In Office Settings, Health Affairs, no. (2014): doi: 10.1377/hlthaff.2014.0445

* The Editorial Comment represents the opinions of Michael Stearns, MD.

Challenges with the use of digital healthcare data

While healthcare institutions are busy collecting terabytes of data the vast majority of digital information captured has no secondary use value. Information is created by proprietary systems using non-standard terminologies or it consists of claims data that may or may not truly represent what transpired during clinical care.   However, if information could be captured from systems in a manner that maintains it integrity the value to patient care, clinical research, and the business of medicine would be enormous.  Efforts to require systems to record all data in standardized formats need to continue and to be accelerated.

While this does seem like something that should not be that difficult to resolve, no community in the world has overcome barriers to complete interoperability.  There is a tremendous opportunity for talented individuals to acquire a deep understanding of the life cycle of data, including how the following entry and usage points:

  • Its point of capture in an EHR, patient oriented device, billing application etc.
  • The use of standard terminologies (e.g., SNOMED CT, LOINC, others)
  • Its local storage for primary uses (e.g., documentation for patient care, clinical decision support, etc.)
  • Its method of storage locally (level of detail captured, data/time stamps, post-coordination, etc.)
  • How it is exported and in what vehicles(e.g., HL7 messages, CCD, cCDA, etc.)
  • How data in imported from other systems

Dr. Michael Stearns