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Saturday, February 16, 2013

"Interoperability" - soon to be the #1 cliche of the 2010's HIT decade?

Below a Word Cloud I ran using the ONC blog RSS feed as grist.

"Interoperability" looks, informally, to be about #6.
1. data
2. health
3. information
4. standards (3 and 4 may be pretty much a tie)
6. interoperability
Rounding out the Top Ten, hmmm...
 7. use
 8. may
 9. EHR
10. exchange
I have a bit of a pedantic streak that surely elicits a bit of eye-rolling here and there. Nonetheless, I beg to pick a nit or two here.

I will commence by citing an interesting TCHB article:
Is Interoperability Possible in HIT? And if it Is, Do We Even Want it?

Anyone who understands the importance of continuity of care knows that health information exchange is essential. How are we supposed to cut waste and duplication from the healthcare system and truly focus on patient welfare if doctor B has no idea what tests doctor A conducted, or what the results were?

The predominant proprietary HIT vendors know this, yet have engaged in prolonged foot-dragging on interoperability and even basic data interfacing. Yes healthcare IT is their business, but interoperability is not in their nature.

As we’ve seen before, the problem is with the business model.

The proprietary business model makes the vendor the single source of HIT for hospital clients. Complexity and dependence are baked into both solutions and client relationships, creating a “vendor lock” scenario in which changing systems seems almost inconceivable...

[W]hile the commitment to data exchange is progress, we are still just talking about exchanging data, not true interoperability. Let’s look at a couple of definitions.

From the Institute of Electrical and Electronics Engineers (IEEE) Glossary definition on Wikipedia:

The ability of two or more systems or components to exchange information and to use the information that has been exchanged.
So narrowly tailored, this concept might be better defined as “interface-ability” or simply data exchange. And it completely lacks context, which matters a lot to those of us in health IT. There is no mention of the technical challenge and costs. There is no concept of separate systems operating together, which is requisite. And there is no mention of the alternatives.

Compare that with another interoperability definition found on Wikipedia:

Interoperability is a property of a product or system, whose interfaces are completely understood, to work with other products or systems, present or future, without any restricted access or implementation.
This definition, much closer to genuine interoperability, is arguably what Kenneth Mandl and Isaac Kohane of Harvard Medical School had in mind in 2011 when they published “Escaping the EHR Trap – The Future of Health IT” in the New England Journal of Medicine:
“We believe that EHR vendors propagate the myth that health IT is qualitatively different from industrial and consumer products in order to protect their prices and market share and block new entrants…”
None of which is exactly news (if just a tad inaqequate). Margin is, after all, significantly a function of opacity. How could it be otherwise? "Efficient Markets Hypothesis" and all that -- otherwise revered in the irony-free zone of Free Marketistan.

Just getting started here. More to come in the morning. For now, how about a little swig of Kleinke?
If health care’s IT problems are a reflection of its broader economic problems, then the strategic conflicts within the health insurance and hospital industries themselves—the two most obvious beachheads for HIT development—are sufficient explanation for why we have no interoperable health care infrastructure. Notwithstanding the happy talk of their advertising, health insurers aim to attract and lock in healthy people and drive away sick ones. The less masqueraded goal of the hospital is to attract and lock in sick people and market to those who are not sick yet. Having an interoperable HIT system that allows patients to shop around, with their fully portable EMRs, for a higher-quality or lower-cost health insurer or hospital works directly against these goals.

For insurers in particular, this strategic conundrum over HIT is a redux of the broader managed care conundrum about prevention,which is essentially the prisoners’ dilemma at the heart of game theory. The prisoners’ dilemma always results in an unfortunate ending: All actors in the game would be rewarded if they cooperated and did the right thing by each other. But none will do the right thing without assurance that the other players will all follow, and so they each do exactly the wrong thing, limiting their own downside and thus creating a suboptimal outcome for all. The best way for a health insurer to use HIT to cope with the prisoners’ dilemma is to design a proprietary system that makes it easy for healthy members to sign up; difficult for sick members who need good information to find it and thus remain satisfied with their plan; and even more difficult for everyone outside the insurer’s own organization (that is, everyone looking to get paid) to navigate it. The worst way to cope with the prisoners’ dilemma is to provide an open, interoperable system that works equally well for all members and can exchange data with all other health insurers.
Dot-Gov: Market Failure And The Creation Of A National Health Information Technology System, JD Kleinke, Health Affairs, 2005 (pdf)
 As  spot-on and timely today as it was seven years ago.


Emphasis on the second part. What's so difficult to understand? Dr. Billings has it right in his foregoing observation "...narrowly tailored, this concept might be better defined as “interface-ability” or simply data exchange."

Indeed, and for that all you need are reciprocal "data maps" -- aligned bi-directional data dictionaries that enable data to find unaltered repose and subsequent use in the mutually push-pull source-recipient HIT systems (and, here, to be sure, I assume a transport standard such as HL7) .

That is a far cry from that which the term "interoperability" infers, i.e., where Dr. Bobby here in Vegas, running Amazing Charts could "operate" Dr. Kirsten's eClinicalWorks EHR in Boston -- and vice versa -- via our respective GUI interfaces.

In other words, "integration" versus "interface."

What would be the point of such "integration"? What would be the point of having two or more such functionally commoditized systems were that to be the case? Product differentiation, after all, is the entire point of a commercial for-profit market, through which the "best" products arguably emerge out of the fires of competition, giving the customers the best deals.

What would we be left with? Merely differences in cosmetics (GUI presentation)? Nominal workflow "usability"? What would be the drivers of "sustainability" for the respective vendors?

Dr. Billing summarizes his take:
Mandle and Kohane describe an interoperability that goes beyond mere interfaces and data exchange. Indeed, the fulcrum of this advanced interoperability is open application programming interfaces (APIs), which enable applications to quickly, easily and affordably integrate with the core EHR. Think of all those iPhone apps in the iTunes store and then recall that Apple doesn’t even make open systems.
Right now open APIs are most frequently associated with the Web and work being done by companies like Facebook, Google, Salesforce and LinkedIn, which might seem irrelevant but is anything but. True interoperability in healthcare will result from tightly secured Web-based applications that enable a circle of accountable clinicians to work together with optimal patient health—not a billable test or procedure—as the ultimate goal. Does that sound like something simple data exchange can accomplish?
Policy and industry dynamics are moving toward data exchange, which is merely a precursor to a new healthcare business model and a safer health system with lower costs and better quality. As the paradigm shifts, we will follow other industries and move from interfaces to interoperability and real collaborative care. And we’ll recognize that open APIs eliminate the obstacles to interoperability that stifle competition and innovation.
Well, that's interesting. I've long been one advocating "Change The Payment Paradigm," but I don't underestimate the difficulty of doing so, shiny new nascent ACOs notwithstanding.

For example, the FFS "payment paradigm" is ostensibly not an issue in Single Payer UK. Nonetheless, check out a couple of very recent articles from across the Pond.
The first recounts a dust-up regarding Medicity.
15 February 2013

The Rotherham NHS Foundation Trust has been found in significant breach of its terms of authorisation by Monitor, with its electronic patient record implementation identified as a key issue.

The trust this month admitted it was facing "persistant serious issues" with the deployment of its Meditech EPR including "clinician and staff acceptance and usability".

It has stopped all go-lives of the system and has hired an external consultant, Larry Blevins, to conduct an immediate review of the system.

A statement from Monitor said The Rotherham had significantly underperformed on its financial plans leading to concerns about the way it was governed.

Key concerns included the trust’s failure to successfully implement a new EPR which led to problems booking patient appointments and loss of income.

A letter from Monitor to The Rotherham says: “The trust has not managed EPR implementation in an effective way and significant operational and financial risks will remain until the trust has a robust and operationally effective EPR system."...
The second goes to travails with Cerner Millenium.
12 February 2013

Eight months on from its go-live with Cerner Millennium, Royal Berkshire NHS Foundation Trust is still struggling to reach a “full business as usual model.”

The trust continues to experience problems with appointment booking and reporting and expects to spend a further £6.2m this year on implementing the system; against a budget of £2.5m.

Not what was hoped five years ago

The situation is a far cry from what the trust hoped to achieve when it quit the National Programme for IT in the NHS in 2008.

In mid-2009, it signed with the University of Pittsburgh Medical Centre, which had done a deal to implement Millennium across Newcastle, to implement the US system in Reading.

The plan was to get theelectronic patient recordsystem live between July and September 2011. But the trust did not go-live until June last year, more than 1,000 days after project start-up.

By this time, UMPC was nowhere in sight, and there were reports that the project had been dogged by problems with poor project management and an over-reliance on contractors...
Read the comments too. They're as good as the articles.Very cool publication. I will add them to my ongoing "must-read" list.


The late CBS News commentator Edwin Newman wrote some delightful books on language and its misuse back in the mid-1970s. I have them. They are treasures to me.

Short take? Sloppy use of language leads to sloppy thinking (and, of course, surely the converse).

Which leads to all manner of sloppy policy, IMO.

Which, I guess, was the notion which begat this rant.

When I read stuff like "Numerous Interoperability Strategies Accommodating The Breadth of Standards Deployment..." my BS detector goes loudly and irritatingly off.
  • As we have seen, HIT "interoperability" is a chimera. Settle for "exchange";
  • "Strategies"? You mean "tactics," really;
  • "The Breadth of Standards"? At some point, the proliferation of "standards" means that none effectively exist. For Health IT data exchange, you really only need one. Not that it will be perfect out of the box. Not that it will encompass every stray, tangential data item of perceived utility to someone. Not that it will mollify everyone. Not that it will be static. But, you don't need a "proliferation." It just becomes a busywork industry.
NEMA 5-15 std outlet
Imagine a nation standardized to 120 VAC power but with 3,965 "Certified" sizes and shapes of electricity "interoperability" portals.

Just Google "data types." There aren't that many. Is it any more difficult than "code sets"?

If the state of U.S. medical technology is one of our great national treasures, then the state of U.S. HIT is one of our great national disgraces. We spend $1.6 trillion a year on health care—far more than we do on personal financial services—and yet we have a twenty-first-century financial information infrastructure and a nineteenth-century health information infrastructure. Given what is at stake, health care should be the most IT-enabled of all our industries, not one of the least. Nonetheless, the “technologies” used to collect, manage, and distribute most of our medical information remain the pen, paper, telephone,fax, and Post-It note. Meanwhile, thousands of small organizations chew around the edges of the problem, spending hundreds of millions of dollars per year on proprietary clinical IT products that barely work and do not talk to each other. Health care organizations do not relish the problem, most vilify it, many are spending vast sums on proprietary products that do not coalesce into a systemwide solution, and the investment community has poured nearly a half-trillion dollars into failed HIT ventures that once claimed to be that solution. Nonetheless, no single health care organization or HIT venture has attained anything close to the critical mass necessary to effect such a fix. This is the textbook definition of a market failure...
All but the most zealous free-market ideologues recognize that some markets simply do not work. Indeed, reasoned free-market champions often deconstruct specific market failures to elucidate normal market functioning. The most obvious examples of such failures (such as public transit and the arts) are subsidized by society at large because such subsidies yield benefits to the public that outweigh their costs. Economists refer to these net benefits as “positive externalities,” defined as effects that cannot be captured through the economic equation of direct cost and benefit. The positive externalities of an HIT system approaching the functionality of our consumer finance IT system include reduction of medical errors like the one that killed Joe Wilson; elimination of tens of thousands of redundant and expensive tests, procedures, and medications, many of which are not only wasteful but harmful; and the coordination and consistency of medical care in ways only promised by the theoretical version of managed care. These public health benefits are well beyond the reach of a health care system characterized by the complexities of medicine and conflicts of multiple parties working at economic cross-purposes. They are trapped outside the economic equation, positive externalities of a stubbornly fee-for-service health care system that inadvertently rewards inefficiency, redundancy, excessive treatment, and rework.
Again: Dot-Gov: Market Failure And The Creation Of A National Health Information Technology System, JD Kleinke, Health Affairs, 2005 (pdf)


My friend the uber-blogger John Lynn has some worthy thoughts.

Interoperability Needs Action, Not Talk – #HIMSS13 Blog Carnival

When you talk to people outside of healthcare about the value of healthcare IT, you will often get a response that healthcare IT is fantastic because it makes it so easy for medical data to be shared with who needs the data when they need it. Those of us in healthcare IT know that this is far from the reality of what’s possible with healthcare data today. This is really unfortunate, because the promise of technology in healthcare is to make the movement of data possible. We’re currently missing out on the benefits of this promise.

I don’t know about the rest of you, but I’m sick and tired of hearing the excuses for why healthcare data can’t be shared. We’ve heard them all: privacy, security, data governance, payment model, etc etc etc. Yet we go to the HIMSS Interoperability Showcase and see that the technology to start sharing data is there, but what seems to be missing is the willpower to push the data sharing through despite the challenges and naysayers...
See you in NOLA, John.

Fast could lead to furious over EHR meaningful use
CMS’ schedule for physicians to show electronic health record proficiency is too ambitious given system limitations and issues that haven’t been addressed from stage 1.
Editorial. Posted Feb. 18, 2013.
The first stage of the federal meaningful use program, covering physician adoption of electronic health records, has not been completed. Yet already the Centers for Medicare & Medicaid Services not only is rolling out proposals for the second stage but also is talking about what is going to be in the third and final stage of the program.
While meaningful use certainly has encouraged physicians to adopt EHRs, to some extent stage 2 and most definitely stage 3 demand physicians to reach standards that are nearly impossible to meet in full. And yet, at stage 3, doctors will have to be at 100% compliance in some measures to meet the standards. The program requires doctors to buy potentially expensive technology that they then must configure and adapt to meaningful use requirements. This is even though those systems might not be right for their practice and aren’t capable of doing the things that CMS requires of doctors. On top of that, all of this must be done in the next three years.
That is an ambitious schedule not required by law but by regulators at CMS. The agency would do well to take a breather. Outside help should be enlisted to review how the meaningful use program has gone so far. Then, substantive change can be made to requirements so meaningful use of EHRs really does mean better and more efficient care, and not just lots of meaningless data entry and technological frustration...
Before CMS talks further about stage 3, whose requirements are in a preliminary phase, it should address these concerns to make sure that physicians have access to systems that truly are meaningful to improving care. Physicians shouldn’t be required to meet mandates on exchanging information when systems aren’t capable of doing it. Doctors should be able to opt out of meaningful use measures that don’t apply to what they do. Additional measures for meaningful use should be held off so vendors can fix the problems current systems have.Before implementing stage 2 (which starts in 2014) and stage 3, CMS should have an independent evaluation conducted of stage 1 and share those results with the public so everyone can learn what went wrong, what went right and what is the best course going forward.
That all takes time, but the meaningful use schedule would be better for it. It would help to ensure that EHRs reach their best potential, not become one more rightfully resented bureaucratic hassle.


More to come...

1 comment:

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