Tackling interoperability

Two industry groups address the problems of health care’s complicated connectivity
One of the most frustrating things patients deal with when interacting with the health system is attempting to share medical information among new specialists or facilities. From filling out the same form multiple times to potentially life-threatening delays in treatment due to crossed wires on prescriptions or referrals, patients may not know interoperability by name. But they certainly know its impact.

A study conducted by medical research organization West Health Institute found that the American health system’s lack of interoperability resulted in excess of $30 billion in costs, which includes the tab for mistakes and inefficiencies contributing to poor results for patients. With dollars and outcomes on the line — and in an era during which even secure financial data can be transmitted wirelessly — patients and many of the providers who care for them recognize that a serious change is needed.

While there are technical and regulatory challenges to sharing medical information among providers, experts say the issue is less about creating the necessary technology, but more about breaking down the business barriers to implementation and scale.

“The technology components are there, and I believe the industry has proven, while not at scale, there is sharing that is occurring,” says Bob Robke, vice president of interoperability at tech giant Cerner Corp., which is on track to book more than $4 billion in annual revenues this year. “Most of our issues today are how we can scale that and make it an expectation of both providers and patients.”

To scale interoperable technology, the industry has to unite the software vendors and the providers who buy their products. The two groups have traditionally had a transactional relationship, but are now faced with coordinating toward a common achievement.

Two industry groups have sprung out of this dynamic. On the vendor side, there is CommonWell Health Alliance, an interoperability network for information technology companies. The group was founded in 2013 by five big players in the IT world — Cerner, McKesson and Allscripts among them. By September of this year, the group had grown to 33 members, including locally based Medhost.

On the provider side, the Nashville-based Center for Medical Interoperability was launched in April of this year. With five local executives and seven national health care leaders, the group represents a big chunk of the provider industry’s procurement power, which Center Executive Director Ed Cantwell calls “the most valuable asset” in the free market.

“We launched with the Nashville five — LifePoint, Community Health Systems, HCA, Ascension’s Saint Thomas and Vanderbilt University Medical Center,” Cantwell says. “What’s unique about those five is that they’re almost the surrogate for the entire nation. You have your prestigious academic, your rural hospitals and the national mega-presence of HCA. We don’t have to invent new technology. It’s more of developing the techno-economic model for these providers to say, ‘I’m just not going to tolerate the current system.’”

While interoperable technology exists, the real need is in developing standards for vendors to build on and for which hospitals can be certified. Presently, interoperability standards are built around “Meaningful Use,” the federal incentive program for providers to implement and use certified electronic health records.

But because Meaningful Use Medicare payments, for example, began in 2011 and end next year, certification has been oriented around existing standards. That’s a low achievement bar, according to Bill Stead, VUMC’s chief strategy officer and a biomedical informatics professor.

“Current standards do not require that the two parties or systems actually understand the information in a way that allows it to be used,” says Stead, who is pictured here. “It’s a bit like requiring the Postal Service to use standard envelopes and standard addresses and standard paper, but when you open it, it’s written in Chinese, and you need an interpreter. That’s the current level of interoperability built into the current regulations.”

The interoperability landscape includes all the technology involved in patient care, from medical devices to the electronic health records that hold a patient’s charts and medical history. Presently, none of these elements communicate with each other, causing expensive complications and inefficiencies. The Center for Medical Interoperability’s goal is to connect the nation’s network of devices and software by building a “plug-and-play” system that collects data in a standard, non-proprietary way.

Developing interoperability standards will improve certification processes, care coordination and product development, Stead says, with engineers able to compete on a standardized, rather than vendor-specific, playing field.

“That would be the first big win for the development community,” Stead says, “And also a big win for the government, because it makes interoperability certification scalable and doable.”

The provider-oriented center is more focused on connecting and standardizing medical devices, while the vendor-based CommonWell has spent more time building out the shared infrastructure of interoperable health records.

The splitting of that work was an unofficial, but natural, division of labor, according to Dr. Mike Schatzlein, center board member, and Ascension Health senior vice president. Many expect that as the health record industry continues to consolidate, it will be increasingly incentivized to solve its own interoperability challenges. Meanwhile, the much more fragmented medical device industry can be better impacted by the center and its provider expertise and awareness of connectivity needs in an acute-care setting.

But siloing software development is partially to blame for the nation’s current lack of interoperability, and leaders on both sides of the coin say they are ready and willing to share data and information as the process unfolds.

“We connect over 1,000 medical devices,” says John Gresham, vice president of Cerner’s DeviceWorks division. “That’s why the Center for Medical Interoperability and Cerner, that’s such an important relationship. The work we’ve done with medical devices has been in the absence of any standards, and if new ones emerge out of the Medical Interoperability group, we’ll look to adopt those standards as they occur.”

Nevertheless, tension remains between vendors and providers. There is a suggestion among providers — both implicit and explicit — that vendors are, at worst, purposefully blocking interoperability efforts and, at best, not actively contributing to their success. It is not profitable, some say, for vendors to make their systems communicate with competitors. It makes better business sense for them to bind users to their own network of products. And even in this move toward improved standards, some providers worry that certification represents an additional profit opportunity for vendors.

“We just don’t want the vendor community to think there is money to be made in selling standardization services,” Schatzlein says. “We’re standardizing to get the proprietary nature out of this information. If there’s a profit-making proprietary approach, that’s no different than the vendors making everything different on purpose.”

Naturally, the vendor community largely rejects that characterization. Misaligned incentives likely did contribute to technology fragmentation, but that glosses over the millions of dollars spent by health systems over many years to internally optimize non-interoperable technology. Did government regulations keep hospitals from demanding interoperable technology until now? Did vendors conspire to tap the brakes on development? Were providers wary to share patient data and slow to invest in technology that could do so?

Perhaps a better way to think about interoperability is as a co-morbid patient. There were many causes of the condition, and a coordinated response is the only cure.

“There are a lot of good organizations and good efforts in all aspects,” Stead said. “We’re doing pieces of what needs to be done, but we’re not actually doing it in a coordinated fashion. The real secret is to take those steps together.”

Developing CommonWell and the Center for Medical Interoperability pushes the vendor and provider industries toward breaking down their sector-specific competitive barriers to interoperability. Representatives from both groups note that a neutral, collaborative effort has been necessary to build a trust framework among sector peers. As that work evolves, the ultimate test will be whether the industry as a whole — health systems, vendors, individual physicians and others — can move forward in a coordinated fashion toward true interoperability.

“We have big things to solve around the patient, and the barriers keeping that from happening need to be addressed,” Robke says. “I think when you look at it from the patient’s eyes, things get really clear on what we need to do.”