April 27, 2016 Ask Owen

Physician Perspective: Solving EHR Integration & Interoperability

Now is the time to tackle EHR integration and interoperability in healthcare—but can these latest efforts from HHS or from the FDA achieve that? In part one of this series, we discussed how healthcare providers need to play a larger part in creating HIT solutions with Health2047’s Dr. Doug Given. In this second installment, Given provides his perspective on where we are with EHR integration and interoperability, and if these recent developments to tackle the challenge will prove effective regarding EHR interoperability and integration in healthcare:


Let’s dive into the subject matter regarding EHR interoperability: What’s your reaction to Secretary Burwell’s interoperability pledge, calling for a greater commitment to EHR interoperability by major EHR players (which provide 90 percent of EHRs used by the U.S.). That commitment has three core directives: to expand consumer access to information, to not block information, and implement nationally recognized standards.  Is this approach going to solve the issues we are seeing with EHR interoperability, why or why not?imageedit_2_3601796802

With respect to standards, full interoperability—and by that I mean not just moving data between systems, but making it easy to use the data after it has been moved—should be considered table stakes for all EHR providers. Most people think the current situation results from a technology gap, but that’s far from the whole truth. The business models and competitive strategy of the incumbents intentionally block semantic interoperability and this creates a stranglehold on innovation.

My view is that we should act collectively to dismantle such anti-competitive industry behaviors. And—for the health of our nation—we must replace excessively customized and expensive legacy businesses with next-generation EHR solutions that are connected, cloud-based, networked, secure, mobile and able to be accessed remotely—with physicians centrally positioned. We need EHRs capable of meeting both patient and physician needs, turning high-quality, accessible patient-care data into actionable information that generates better health outcomes.

Financial institutions’ networks interoperate securely and globally and they’ve found a way for everyone to benefit. The same should be true for the ready transfer of data between systems and across the care continuum. It’s just that simple.


We have seen some efforts from EHR providers to provide access points (APIs, etc.) for integration with other digital apps and tools, but those efforts have been cumbersome at best. Is this latest effort more genuine or any different than past attempts at interoperability?

EHR providers aren’t motivated to make it easy to get information out of their systems. They intentionally excessively customize every installation as a competitive strategy. It is estimated that less than 25 percent of the information gathered in EHR systems is useful in assessing and addressing health outcomes. It would be great if this effort proved to be different. We’ll have to wait and see.


The FDA has released a draft guidance for medical device developers to design interoperable devices. The criticism has been that it puts much of the weight of interoperability on the shoulders of developers. Does the pledge complete that piece of the puzzle by putting more on the part of EHR providers? Will these two calls to action complement each other, why or why not?

The draft is very much about how devices interface and interact with one another (for example, making sure that weighing scales that might be in pounds actually interface in pounds and not kilograms, or ensuring that a medical device is able to communicate over a USB port to interface with different device types and makes). In addition, there are open questions on how devices are labelled and interacted with to make sure patient safety is not at risk. So, basic common sense requires the device makers to create the interfaces that allow for consistency and the EHR providers to then be sure that they pick the baton up and link the data between systems in a secure fashion.

The FDA draft is a start in the right direction for the necessary solutions. Having devices become more accurate, be interpretable and have 100 percent fidelity every time whether digitally or physically is a must. Back in October 2015, HHS’ Office of the National Coordinator for Health Information Technology (ONC) released the final Connecting Health and Care for the Nation: A Shared Nationwide Interoperability Roadmap – Version 1.0

This was more around EHR interoperability talking about every end-to-end part of the interface that interacts with an EHR defining security, data transfer and interactions. All parts should work together to support better interaction data within and among EHRs and the surrounding technologies. Our thinking is that this is a journey that requires a lot of engagement and time.  It is also a significant lift to make changes to technology and systems. Success is defined by each party pulling its own weight. The more the standards are solidified, the better and easier it will be to deliver integration of device details, clinical context and most importantly, better patient outcomes.


Do you think both of these efforts (by the HHS and FDA) will be effective? A lot of people are saying that both are all talk and not truly enforceable action. What’s your take?

Perhaps, but only if they act more forcefully than they have in the past to reward good behaviors.


You have stated that you can offer such solutions while having the physician remain at the helm. With all this talk about interoperability, little has been said about the healthcare provider and their role. Are people missing this piece of the puzzle? What role does the healthcare provider take when we talk about easing the issues of interoperability?

It is easy to complain. Mention EHR in a primary care office at lunch and you’ll set the afternoon block of patients behind by an hour right off the bat. However, if involved appropriately, we think physicians are best equipped to define future use cases.

Today, they are saddled with poorly performing, poorly designed technology, developed with primitive usability and without their input. Data is entered by clicks into poorly designed data fields, by physicians during patient encounters. This not only grossly detracts from and interrupts the physician-patient interaction, it also reduces the time available for a quality patient and physician experience and is quite probably the most expensive data entry on the planet.  Physicians as data entry clerks? Whose bright idea was that?

As history shows, physicians are highly educated, expert multi-taskers who rapidly adopt worthy new technologies. The two key words in that sentence were “adopt” and “worthy.” The main issue to date is that much of the technology related to EHRs has been adopted by mandate not by usability (essentially technology development without user experience taken into account).  Our view is that physicians should play a critical role in designing the user stories and new solutions of the future.

Without the user defining the use cases, we won’t create useful modules that improve care. Six clicks to trend a blood pressure is unacceptable to physicians, and frankly, should be to individuals receiving care. Two hours of clicking in an 8-hour care setting is a situation our healthcare system can ill afford. We must demand a higher standard, and this requires the physician to be at the wheel—not locked in the trunk—when it comes to the design, iterative user testing and adoption of new EHR technologies.


You are a physician yourself, so you know first-hand what interoperability looks like from the provider point of view. How does that unique perspective help you frame and tackle the challenges regarding interoperability and efficient healthcare delivery? What can physicians add to the conversation that appears to be missing at the moment?

As physicians, we aim to re-architect the system through thoughtful design, attention to user experience and security; we know we can do better. The healthcare provider today is living in a new world of social and mobile technology where patients and physicians alike are trying to adapt.

Technology integration and interoperability is variable in many organizations and limited by the capabilities of the technology, data collection and the IT skills on hand. As we shift toward focusing on outcomes and measurable factors, it is important to allow patient access to personal EHRs. As physicians, we are excited by empowering patients with actionable information. We want the same thing. We all want technology to intelligently innovate itself out of the way of the doctor-patient relationship.


Out of all the evolved efforts we are witnessing here, wht do you think is going to be the most influential? What do you suspect will be the shortcomings if any of regarding these current approaches of tackling the challenge of interoperability?

Our main concern is a definition of limited scope. We don’t see the inputs, goals or technologies in place across healthcare today to be groundbreaking in the way they could be. In short, we think as a technologically advanced society in many other aspects of life (see navigation, communication), that we can do better.


Is anything missing from the interoperability equation that we have seen? One such challenge that stands in the way of interoperability is accurately matching patient records and other like data. Neither effort really explores data integrity. Will that be the next hurdle you think?

In healthcare, false information can be a life or death issue. The complex requirements of security, integrity and reliability require breakthroughs of the highest magnitude. The challenge with positively identifying patient records and the interaction with those records is a clear security, integrity and portability hurdle. New capabilities and systems that securely handle collection in a way that is designed to track, ensure validity and accuracy of each piece of data are required.

For example, as we use new methods of data collection, such as mobile devices, how the environment or medical team knows that data and device were actually with Patient A and the the data and information have not been spoofed or tampered with is a complex question to answer technologically. We see the opportunity in healthcare as an opportunity to lead in the data integrity, integration and security space related to the IoT and wearable devices.


Given all that is happening in the industry, where do you think we will be in terms of achieving interoperability and greatly improving healthcare delivery over say the next five years?

To use an analogy, the way EHRs have evolved to view and work on interoperability is similar to the way the Internet developed for a simple data reference and store and read environment, or Web 1.0.

Now, changing times beget changing needs. Web 1.0 has evolved, and Web 2.0 / 3. 0—alongside the mobile computing platform—have fundamentally changed the way we access data. Today, users interact and receive real-time responses from social and community networks, and enterprises distribute data and then reference it in real-time from anywhere. In five years, our hope is that the foundation of the ‘web of healthcare’ (or interoperable data systems in healthcare) has created the kind of stable platform upon which the brilliant and innovative solutions needed to transform healthcare can be designed and delivered to individuals and physicians at scale.


Once the issue of interoperability is hurdled, will there be anything that stands in the way for HIT?

We have so much happening in terms of big data and analytics, I would imagine we will be dealing with many finite issues for years to come.

Interoperability, at least related to EHR systems, is not the singular issue challenging HIT. Today’s HIT systems are reactive; interoperability of EHRs, as defined, is also reactive. Consequently, EHRs may serve as a functional tracking system of record, but they are in their infancy relative to connected systems and innovative solutions along the software stack. The broader issue is around how we change and adapt HIT on a stable data layer and then build ground-breaking innovations on top of it. Technology must become proactive vs. reactive; that’s when we’ll see new players and important new solutions emerge.


What is the main point you would like to get across to our readers regarding this discussion?

EHRs have taken us from analog to digital, or paper to online text within closed systems.  Interoperability of clinical data is communication within these systems at the bottom of the software stack. However, the next breakthroughs in HIT will be based on how these systems become interactive—the solutions on top of the data stack. Healthcare economy participants must move to a high-fidelity world with more responsive and real-time solutions.

This is what’s required to cause a fundamental shift in the way care is delivered and people live.

This article originally appeared here.

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