A follow-up article on barriers to interoperability and lessons learned from those who’ve been there before.
Back in March, my colleague published an article titled “Getting EHR vendors speaking the same language,” which described one of the most critical advantages of electronic health records (EHRs) – the ability to instantly and seamlessly share patient data with multiple providers, across multiple organizations, across the country. In addition to the more obvious fact that sharing patient information across PCPs and specialists all treating the same patient helps to coordinate care (which ultimately leads to better outcomes), the secondary benefit of such integration is that it enables the aggregation of medical data at the population level, fostering richer disease registries and more effective disease management. However, as discussed in the aforementioned article, in order to fully reap the benefits of sharing data among EHRs or other healthcare information technology (HIT) systems, the systems must be interoperable, which requires standardization across the multitude of EHRs and other related systems in the market. In this article, I would like to further examine what it takes for HIT, EHRs specifically, to be truly interoperable, and will share some examples of how standardization has worked for other technologies in the healthcare space.
Integration vs. competition
Interoperability is the key to success of any HIT initiative; it simplifies and standardizes the way electronic health information is collected and shared across disparate HIT systems. However, in order to achieve true interoperability and integration among systems, they need to “speak the same language,” meaning they must operate using a common set of standards. While many vendors have contributed significantly to standards development and adoption in order to provide interoperability to their customers, the EHR marketplace is competitive – without robust and mandatory interoperability standards requirements, there are examples of vendors who intentionally or unintentionally create proprietary systems that do not work well with others.
However, with mandated interoperability standards emerging in the EHR world as a result of the meaningful-use requirements propagated by CMS and ONC, we will see all EHR vendors building standards-based systems that play nice with others. Today, there are many health IT standards, but few that have been harmonized industry-wide, with some developed independently and in isolation, and therefore in conflict with one another. A notable exception is the herculean effort that resulted in HITSP’s adoption of the Continuity of Care Document (CCD) standard, now evolving in the C-CDA standard under meaningful use. Because of the thought, effort and sweat equity invested in the development of competing standards, and differences of opinion between clinicians and IT folks, it was a highly charged, protracted and complex process. In order to ensure smoother and easier adoption of next-generation EHR interoperability standards and enable medical information sharing to be easier, faster, less expensive, more predictable and more error-free, we need to take a more holistic, meta approach to standards prioritization, selection and harmonization.
Standards adoption: The tide that lifts all boats?
Adoption of standards has established precedent to show that it is the tide that lifts all boats, so to speak. A great example of effective standardization in healthcare is the Digital Imaging and Communications in Medicine (DICOM) standard, for over a decade now the most widely used healthcare IT standard for distributing and viewing any kind of medical image, regardless of its origin. Prior to the existence of the DICOM standard, there were multiple conflicting proprietary standards in the imaging space, which created a huge barrier for interoperability as vendors were able to offer a complete, “one-stop shop” system that contained everything from image acquisition to storage to display functionality, with no possibility for modular add-ons from other vendors. This resulted in vendor lock-in and ultimately led to customer dissatisfaction because many of these “complete” systems were actually weak in one area or another (e.g., a healthcare organization may purchase imaging technology because of its grade-A image acquisition functionality, even though its display functionality was subpar). Once the DICOM standard emerged and was embraced by all vendors, it actually enabled a much larger market, the multi-billion-dollar PACS market, to emerge. It truly was the tide that lifted all boats.
We see a similar problem occurring in the EHR space today: Vendors are attempting to provide complete, end-to-end solutions that do not enable the possibility of integrated modules and add-ons from other vendors, which puts customers at a disadvantage as they have no way to assemble a custom, flexible, “best of breed” solution. I am hopeful, though, that the next evolution of the EHR will follow in the footsteps of imaging and PACS systems in that first the proprietary solutions will begin to adopt widely accepted standards, and in turn inspire the development of “best of breed” solutions.
Perhaps the best example of a successful approach to EHR interoperability standards selection and synchronization is the one developed by Integrating the Healthcare Enterprise (IHE), a global organization created by healthcare professionals to improve the way computer systems share health information. IHE promotes the coordinated use of established standards to address clinical needs in support of optimal patient care. The organization has had great success in enabling the implementation of functional interoperability projects worldwide. Systems implemented in accordance with IHE profiles are able to communicate with one another better, are easier to implement and enable care providers to use information more effectively – again aligning with the ultimate goal of EHRs.
Which came first, the standard or the policy? With standards come policy, and we need to have both in place in order to facilitate complete EHR adoption. We need to know how to technically share information, and we need policy in place to tell us how to formalize the who, where, when, why and how of sharing clinical information in order to ensure compliance. The U.S. Department of Health and Human Services (HHS) has developed Federal Advisory Committees (FACAs) to oversee standards and policy, and there are many private-sector projects working at the same time to identify and establish best practices for achieving standards-based interoperability.
Though we are still in the early stages of achieving true EHR interoperability, the EHR community is eager to absorb the lessons learned from – and benefits realized by – other sectors of the industry in order to maintain a focus on the end goal of achieving such a feat: Better clinical outcomes at both the individual and population level.
About the author
Blair Butterfield is president, North America, VitalHealth Software. For more information, go to www.vitalhealthsoftware.com.