Is middleware the right medicine?

A recent Black Book survey found that 90 percent of hospitals and 94 percent of independent physicians don’t trust the business model of public health information exchanges (HIEs) and have concerns over how much of the cost payers will be fronting, causing a contraction in the HIE market.
Meanwhile, the Office of the National Coordinator for Health IT (ONC) and the medical industry are at odds on how to address the interoperability issue.

HL7 is only capable of connecting one medical facility to another and requiring specific end-point interfaces to even do that. For every additional facility, a customized interface must be built. At the end of the day, HL7 is really a point-to-point customized interface requiring extra steps, and it ties developers to specific hospitals or EHRs – and without universal access.

Meanwhile, yet another study bemoans the tragedy of a lack of interoperability. A new survey of nurses nationwide, taken by the Gary and Mary West Health Institute, finds that some 60 percent of registered nurses say medical errors could significantlydecrease if hospital medical devices were coordinated and interoperable. Seventy-four percent agreed that it is burdensome to coordinate the data collected by medical devices, and 93 percent agreed that medical devices should be able to share data with one another seamlessly and automatically.

Half of them claim they actually witness medical mistakes due to the lack of interoperability of these devices. Some 46 percent of RN respondents also noted that when it comes to manual transcription from one device to another, an error is “extremely” or “very likely” to occur.
From a cost perspective, West Health Institute officials estimate that a connected, fully interoperable health system could save a potential $30 billion each year by reducing transcription errors, manual data entry and redundant tests. Meanwhile, physicians and surgeons struggle with interoperability daily.

A patient anecdote

An obtunded, 27-year-old gentleman involved in a motor vehicle accident arrives to the trauma bay. Initial assessment reveals a closed head injury, multiple abrasions about the face, thorax and upper extremities, and an open tibial plateau fracture. From a functional standpoint, the patient is admitted to the surgical intensive care unit under the trauma service. Orthopedics, neurosurgery and an intensivist collaborate care for the patient.

With his depressed level of consciousness and a need to surgically stabilize his open tibial plateau fracture, a neurosurgeon decides to place an intracranial pressure (ICP) monitor for assessment of brain swelling, leading to intracranial hypertension following the completion of a CT scan, which revealed an axonal shear injury pattern.

In preparation for surgery, it is noted the patient has a well-healed scar suggesting a prior tracheotomy, and his coagulation panel returned with an unexpected elevation of his PT/INR. Given this finding, the trauma surgeon responsible orders fresh frozen plasma (FFP) to be prepared prior to proceeding to the operating room (OR).

Meanwhile, multiple care providers and the patient have been placed in a holding pattern as they wait for the FFP to be prepared prior to proceeding, with surgical stabilization of the patients leg fracture. Multiple quarries into the electronic health record (EHR) are required by many of the stakeholders, waiting for the laboratory to return the bold (blood plasma) products.

Not only are care providers in a holding pattern, but resources in the operating room have been placed on hold in preparation so orthopedics can proceed as soon as the blood is available. Instead of technology addressing this scenario, people and processes have been altered to deal with this recurring situation in the healthcare environment. When the FFP is available, this change in status has to be manually communicated to all of the players involved with getting the patient into the OR.

From a functional standpoint, the requirement used to develop this common clinical path is placement of an order to prepare FFP for this patient. There is an assumption that this does, in fact, take place, but often there are delays when the ordering physician is different than the one who uncovered the abnormality and prompted the decision to initiate the treatment.

In this case, the trauma surgeon ordered the blood products on the suggestion from the anesthesiologist who will be responsible for administration during the surgical procedure. Everyone on the care team has not been kept apprised of the status or even the need for this intervention unless they search through the medical record, which will not be readily available, depending on when the note was dictated or entered into the system.

Does data flow have boundaries?

The above scenario is familiar to many healthcare providers. Multiple physicians and other healthcare personnel are involved with management of a complex care delivery stream, especially for patients in critical care environments with unstable medical conditions. Although many divisions in healthcare appear functionally decomposed, many of the processes and data gathered for a patient cross demarcations, being critical to the overall care delivery and avoidance of iatrogenic complications. Communication of decisions, interpretations of data and treatment choices have become increasingly complex with the introduction of EHRs that are not interoperable.

No one can become an expert in all of the intricacies of each sub-system as well as have an understanding of the interdependency and outcomes when perturbations occur. Small changes to a single process can lead to unexpected and unintended consequences, often leading to problems, waste or possibly errors and mishaps. It becomes very difficult to uncover the root cause in highly interrelated and interdependent systems, such as healthcare and the human patients being cared for.

Operating on lack of interoperability

For patients at risk, common interoperability solutions are not solving the problem, and healthcare providers are not given the best life-saving tools. Some 2.0 healthcare vendors are turning to middleware solutions that have proven themselves in other industries. Vertical markets such as retail, banking, transportation and others have long ago solved interoperability with middleware.

More than simple system glue

Middleware, software that serves to connect previously disconnected systems, has shown value in many data-intensive sectors outside of healthcare. Middleware goes beyond the simple “gluing” of two disconnected systems together. It often serves to synergize and get more than the sum of the two systems together. And middleware allows for the spreading standard of SaaS as a mindset for software.

Employing a middleware architecture has also been shown to reduce risk as well as cost of development. With respect to EHRs, non-vendor development is not possible or scalable. Although vendors with high market penetration have introduced application program interfaces (APIs) and development platforms for their systems, development requires new strategies, code and resources for each system. This alone limits widespread implementation of solutions that sit on top of EHR systems or access health data stored in their databases.

A well-designed middleware architecture allows a user interface development to be easily standardized across EHR systems to provide visual consistency for healthcare providers, something that has been demonstrated to aid in safety and efficiency. It also solves specific needs at a fraction of the cost required for development for each EHR platform.

Middleware brings an application-agnostic approach to connect EHRs to one another while allowing for specific development to enhance the significant investment by hospitals, health systems and physicians.

Increasingly, organizations in all sectors are realizing the benefits of software, platforms and architecture as services that significantly decrease business costs. No longer does a company have to do all of the development itself, but instead it can rely on off-the-shelf applications to solve its problems while allowing for middleware to connect the various systems where data resides.

Middleware can disrupt the status quo and solve EHR interoperability challenges. Patient lives can depend on it, and in some cases their lives will depend on it. It will help bring to an end the more than 1,000 patients who die daily from preventable medical errors. Middleware should be the standard operating system for EHRs to finally bring lack of interoperability to an end without the risk of HIEs. The medical community has so far not provided a better solution to a problem that can be addressed today.

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