What it will take to encourage EHR vendors to develop truly interoperable EHRs.
Two of the most significant potential advantages that we all hope to see from continuing electronic health record (EHR) adoption in the United States will be the ability to instantly connect providers across organizations with up-to-date patient information and the ability to aggregate that medical data. Imagine the benefits of a primary physician, cardiologist, neurologist, anesthesiologist, lab, and pharmacist who are all able to share medical data instantaneously. Such an elevated level of integration would enable not only highly efficient clinical care, but also foster the development of a holistic medical profile at both the patient and population levels. Other subsequent advantages of sharing and aggregating medical data will be densely populated disease registries and highly effective decision support. While fully connectable EHRs populated with universally normalized data sounds great in theory and the technology exists to support such an initiative, EHR vendors remain hesitant to invest in that level of interoperability.
When it comes to the development of truly interoperable EHRs, vendors, including myself, face a real quandary. Most EHR vendors tout an organizational mission statement focused on improving healthcare and helping patients and providers, and to the best of their ability operate accordingly. However, the reality of an extremely competitive marketplace can often pull vendors in the opposite direction. So far, there is little financial incentive to support true interoperability, and if anything, many vendors see some level of proprietary distinction as desirable — creating barriers to customer defection.
In keeping with the tradition of the first healthcare information technology czar, Dr. David Brailer, his successor, Dr. Farzad Mostashari, has chosen to focus on interoperability as an ultimate goal of EHRs without setting specific standards. The recently proposed Stage 2 meaningful-use rules are a testament that the Centers for Medicare and Medicaid (CMS) and Dr. Mostashari recognize the value of EHR interoperability in the marketplace, but also the government's determination to stay out of the standard-setting business. The real question then is what challenges will need to be overcome to encourage EHR vendors to work toward the development of truly interoperable EHRs?
While there are seemingly well-intentioned groups such as HL7 who are dedicated to the development of healthcare IT data standards, even they suffer from a fundamental flaw. HL7 is comprised of various commercial entities, including EHR vendors, who much like political lobbyists need to give the impression of working toward the “greater good” but are, at the same time, keen to advance their own agendas. Even though I don't have a seat on a standards board, I could understand being more supportive of standards that my solution could easily comply with regardless of whether those standards are necessarily what's best for the industry as a whole.
Perhaps strong leadership from groups such as ONC, HIMSS or MGMA can help to curb private interests and advance an effective reporting standard. While initially an all-encompassing standard would likely be difficult for all vendors, it would ultimately be in the greater interest of the industry as a whole. Regardless of where the motivation comes from, the bottom line is that in order to move things forward, vendors will need an incentive to design highly interoperable solutions.
While Dr. Mostashari seems content with the model set forth by ex-czar Brailer of not getting into the business of standards creation/enforcement, I don't believe it is outside the realm of possibility that the government would take it upon itself to offer EHR vendors incentives to subsidize the initial impact of opening up their solutions. Perhaps another scenario that could advance EHR interoperability would be the emergence of a solution or solutions that are generally accepted as the industry standard. As soon as one or two truly well-designed and highly interoperable EHR solutions emerge as the bellwether by which others are compared, there would be little value to an EHR solution that is unable to communicate with them. The question then becomes how quickly can the other EHR vendors take the plunge?
Both the federal government and the free market have potential to contribute to the advancement of interoperability, but perhaps the most likely path to true EHR interoperability begins with health information exchanges (HIEs) at the state or regional level. While currently many states have conflicting definitions of interoperability, and rates of progress vary greatly, there are some states that seem to be emerging as leaders in HIE development. While we may never see the “holy grail” of a unified national HIE, I think that the main driving force likely to advance true EHR interoperability will be continuing progress in adoption of state HIEs. State or regional HIEs represent an ideal path toward interoperability; however, the path will not necessarily be easily traveled and will require a certain degree of trial and error.
There are undoubtedly kinks that need to be worked out of EHRs, and interoperability represents a top priority and significant challenge. That being said, it is important not to forget that in the big scheme of things, we are still very early in the process of EHR adoption and development. If the EHR initiative was a baseball game, we would only be in the top of the second inning, and anyone familiar with baseball knows how much can change from the second inning to the ninth. I believe that ultimately, ongoing advancement in adoption of state HIEs will provide the foundation necessary to advance true EHR interoperability. Regardless of how interoperability is ultimately achieved, it is a very exciting prospect and will result in a substantial advancement in the quality of healthcare in the United States.
About the author
Arjen Westerink is director of business development at VitalHealth Software. Westerink assisted in architecting the VitalHealth EHR designed with Mayo Clinic. For more on VitalHealth Software, go to www.vitalhealthsoftware.com.