The quest for HIT’s holy grail

Aug. 26, 2015
Manu Varma, Vice President, Strategy, Philips Hospital to Home, Alere Analytics
Kathleen Aller, Director of Business Development for HealthShare, InterSystems
Sarah Corley, M.D., FACP, Chief Medical Officer, NextGen Healthcare
Donald Voltz, M.D., Department of Anesthesiology and Medical Director of the Main Operating Room at Aultman Hospital
Susan Niemeier, R.N., BSN, MHA, Chief Nursing Officer, CapsuleTech
Thomas Van Gilder, M.D., Chief Medical Officer and Vice President, Informatics and Analytics, Transcend Insights
Chris Hobson, M.D., Chief Medical Officer, Orion Health
Nilo Meharabian, Assistant Vice President, Product Management, McKesson Health Solutions

Some define interoperability as the real-time seamless transmission of data, regardless of device, brand, location, or even human intervention.

Ideally, a physician can input a patient’s data into an EMR/EHR at his or her clinic/office prior to a surgical procedure and have that data accessible and coherent in the hospital operating room with limited-to-no human interventions. With optimal decision support systems in place identifying trigger points, that physician can determine how best to treat their patient.

Providers, payers, and patients in the American healthcare system have yet to reach this point. Pessimists say they’re not even close, as providers and payers are not on the same page when it comes to information technology and data management. Providers and payers may be in store for a “natural collision,” noted one healthcare clinical IT executive during an off-site panel discussion at the recent HIMSS conference in Chicago. “Our [healthcare] system is dysfunctional and inefficient,” said another. “We have a once-in-a-lifetime opportunity to fix it.”

In fact, several panelists waxed on about interoperability roadblocks.

One executive amusingly painted a verbal portrait of the inherent disconnect, which drew laughter from the media crowd in attendance. “Most healthcare workers are IT ignorant, and most IT workers are healthcare ignorant,” he quipped. “They don’t really see what’s going on in either area. They’re not stupid,” he corrected. “They’re just ill-informed or uniformed. Healthcare geniuses are IT buffoons, and IT geniuses are healthcare buffoons.”

As the chuckles subsided, another panelist chimed in with some optimism that the industry may not be as interoperative as needed, but “We’re getting better.” He continued, “You can teach the IT piece to those with clinical skill sets, but then the challenge is primary caregivers will become inundated with data.”

What can be done about this? How might technology influence behavioral modification and cultural change?

“Policymakers and industry leaders have to step up to the plate on this,” Manu Varma, Vice President, Strategy, Philips Hospital to Home, tells HMT. “A big part of this is working smarter and not harder, particularly for interoperability. Healthcare organizations have to demand that their vendors support interoperability as table stakes for earning or keeping their business.”

Does interoperability matter? You be the judge. In early July, trading on the New York Stock Exchange halted for several hours due to some unspecified internal computer issues that were “not the result of a breach of its systems.”

Meanwhile, on the same day, more than 1,000 United Airlines flights were grounded for several hours due to computer problems cited as “network connectivity issues.” Unfortunately, United experienced something similar back in June when technical problems affected its flight-dispatching system. Three years earlier, United suffered a number of computer problems following its merger with Continental Airlines because it switched to using Continental’s passenger information system.

Patient accountability

While many clinicians and administrators understand what interoperability means, many more, including consumers, do not because it’s a back-end operation without overt front-end exposure.

“Patients are incredibly frustrated by all the disconnects in healthcare today,” says Kathleen Aller, Director of Business Development for HealthShare, InterSystems. “Very few would know the word ‘interoperability,’ but they know how irritating it is to fill out the same forms over and over, to struggle to remember when it was they had that surgery, and to manage what seem to be gazillions of different patient portals. Most conversations about interoperability, though, are focused on exchanging data between physician offices and hospitals. The bigger challenge is making sure communication extends to post-acute, mental health, and long-term care settings, and to social service agencies.”

Varma describes the frustration further, using a real-world example of why a “complete picture” of a patient’s health is desired. “Imagine seeing your [primary care physician] after a serious episode that took you to the hospital, but they do not have the necessary information from the hospital, or from other specialists, because they all use independent software systems,” he says. “You are forced to take paper records to them, which took you hours of work to gather. If you are successful, your [primary care physician] has to read hundreds of pages to understand your medical situation. Interoperability can fix this.”

Interoperability of health information can directly increase the quality of care, efficiency of providers, and accessibility of information, says Sarah Corley, M.D., FACP, Chief Medical Officer, NextGen Healthcare. Interoperability allows for obtaining medication formularies and also saves time by importing information from other providers.

“With data fluidity, clinical decision-making becomes more accurate, timely, and efficient, leading to fewer complications, improved patient safety, and increased patient satisfaction,” Corley says. “Again, there has to be a balance because unlimited amounts of data can hinder productivity and obscure important information in the sheer volume of data being sent. It is important to validate the accuracy of information before importing it into the medical record to prevent persistence of inaccuracies.”

Donald Voltz, M.D., Department of Anesthesiology and Medical Director of the Main Operating Room at Aultman Hospital, Canton, OH, agrees with Corley about the reliability and validity of data. He is board certified in informatics and is an Assistant Professor of Anesthesiology at Case Western Reserve University and Northeast Ohio Medical University.

“Interoperability must include how the data is used to make decisions and care for patients,” Voltz says. “The usefulness of data is the brunt of the problem. In order to realize the promised gains from widespread EHR implementation, physicians and hospitals are dependent on how information is used.

“There is no question why interoperability has become the black eye of EHRs,” Voltz continues. “If we step away from looking for a scapegoat, and look at the bigger technical landscape, we come to realize interoperability is not only about how EHR systems have been developed. Interoperability also stems from a change in the structure, model, and delivery of healthcare. Once we look at medicine from a complex, interdependent, and distributed system, we begin to realize no single EHR product will serve the needs of the many clinical and non-clinical personnel that depend on the data and documentation to care for people. When we look beyond the bounds of the hospital’s walls, we can find solutions such as middleware that have worked in other business sectors that faced similar problems.”

Clinical workflow

Interoperability extends beyond just the exchange of information to the use of information, according to Susan Niemeier, R.N., BSN, MHA, Chief Nursing Officer, CapsuleTech.

“While the efficient exchange of information can bring numerous benefits to the healthcare environment and improve patient care, it can be impractical, even dangerous, if the data is not accurate, timely, and complete,” Niemeier says. “So much data entered and exchanged is on the shoulders of the clinician.”

To enable interoperability, providers must focus on implementing medical device integration, which automates the delivery of device data and information to the EHR, alarm management systems, and clinical decision support systems, she says.

“When the record is up to date and accessible to other care providers, the patient can optimally continue through the care continuum,” Niemeier says. “When the clinician has meaningful information to use at the bedside, both clinical workflow and care are enhanced. Better data means better care. And better care means happier, more satisfied patients.”

Thomas Van Gilder, M.D., Chief Medical Officer and Vice President, Informatics and Analytics, Transcend Insights, reinforces the accessibility of information as a key outcome of interoperability, even more than the exchange of it.

“Interoperability is not just an exchange of information; it’s a method of taking information wherever it’s stored and presenting it in a usable way at the point of care,” he says. “It allows [clinical decision support], for example, to be fully populated within a clinical workflow so clinicians can utilize it in a way that’s helpful, rather than distracting. Done correctly, interoperability will enable CDS and improve clinical workflow, leading to better patient and physician satisfaction.” Transcend Insights is a wholly owned subsidiary of Humana, formed by the March 2015 mergers of Certify Data Systems, Anvita Health, and nliven systems. At press time, Humana was entertaining an acquisition offer by larger rival insurer Aetna Inc.

“High-quality interoperability improves clinician workflow tremendously, because they no longer have to struggle to find all the relevant information about a patient that they need,” says Chris Hobson, M.D., Chief Medical Officer, Orion Health. “Without high-quality interoperability, clinicians and their staff have to spend considerable time phoning and faxing multiple hospitals and clinics to track down a key piece of information. However, there is a caveat to this: In the desire for more data, it is important that clinicians are not overwhelmed by too much poorly displayed or low-quality data. The need is to provide clinicians with rapid access to the data that’s of most value to them. Clinician workflow is negatively impacted when clinicians struggle to understand or use their health IT systems, if their user interfaces are complex, non-intuitive, or poorly usable.”

There’s a practical aspect, too, according to Nilo Meharabian, Assistant Vice President, Product Management, McKesson Health Solutions.

“The goal of using decision support and automating processes is to create a collaborative environment for payers and providers alike – one which can help eliminate administrative work and speed confident decision-making,” she says. “It helps providers ensure the care they deliver is medically necessary and will be reimbursed in a timely manner. And it helps ensure the patient doesn’t get stuck with unnecessary out-of-pocket costs. Equally important, it helps the industry continue its transformation from volume- to value-based care.”

Is true interoperability even achievable?

Christine Kao

“Interoperability is required to streamline clinical workflow, but current IT ecosystems do not deliver interoperability across all departments. Healthcare providers today are dealing with two challenges – proprietary IT systems and legacy departmental systems such as endoscopy, dermatology, and others – that were never designed to share information outside the department. Radiology has an advantage because the DICOM standard was implemented years ago, and it enables sharing of data across multiple platforms and users. To achieve interoperability among other “ologies,” healthcare providers’ best option is to implement a data-gathering platform that can identify and collect patient and exam information from departmental systems and make it accessible across the enterprise.”
– Cristine Kao, Global Marketing Director,  Healthcare Information Solutions, Carestream

“I’m not convinced we will ever solve all the integration issues. There is always something new you don’t control coming into the mix. Strategic interoperability should provide a foundational infrastructure that lets you connect together everything that matters to you and provide a platform to create new solutions.”
– Kathleen Aller, Director of Business Development for HealthShare, InterSystems

Jason Williams

“First, recognize that these are not entirely related issues. Interoperability must be focused on only the data required to facilitate a set of interactions between systems. This is a narrower problem than an organization’s system integration issues. That said, it also has its own unique set of complexities. Whether reckoning with interoperability or integration, it is important that the organization prioritize. Not every system needs to integrate, and not every piece of data needs to interoperate to achieve substantial gains in data liquidity and business improvements.”
– Jason Williams, Vice President, Business Analytics, Financial Solutions, RelayHealth Financial

“Interoperability and integration are two sides of the same coin. This question is a variation of a well-understood issue frequently stated as ‘perfect is the enemy of good enough.’ In this case, we are saying that it is possible to achieve a level of interoperability that delivers real value to clinicians even while not achieving true interoperability. Organizations should definitely work to solve their own internal integration issues. However, there are many ways they can still interoperate with and gain benefits from linkages to outside organizations while they are also working on their internal integration challenges. We typically take an incremental approach to integration, acknowledging that it will take some time to solve every last issue, and in the meantime building each connection in turn using our extensive toolkit and experience.”
– Chris Hobson, M.D., Chief Medical Officer,  Orion Health

“In order for organizations to achieve interoperability without integration, teams within the organizations who are responsible for the different systems must be able to talk to one another. On top of that, each of the IT systems within a healthcare system must have a built-to-serve purpose. If the teams don’t understand the purpose of connection among the silos, then it’s difficult to take the step toward integration. Step 1 is getting the existing IT teams to talk, but they also need to share a strategic vision for integrating data across the systems. Step 2 is to identify tools that can achieve interoperability and integration. These tools must be able to normalize data and present it back in a way that is helpful for care teams and patients.”
– Thomas Van Gilder, M.D., Chief Medical Officer and Vice President, Informatics and Analytics, Transcend Insights

“I am a firm believer that if we try to achieve interoperability just through effort, we will fail. We need to not just work harder; we need to work smarter. A great way of doing this is through API-based interoperability solutions such as FHIR. The good news is that API-based tools can accelerate cross-system interoperability and intra-system integration. Organizations that are behind on integration should care even more about API-based interoperability because this can help with their integration efforts too.
– Manu Varma, Vice President, Strategy, Philips Hospital to Home

Eyal Ephrat

“The new generation of decision support solutions coming must have the capability of capturing, understanding, and advising based on the most relevant data from different sources (e.g., EMRs and ancillary sources like labs, radiology, pharmacy, physician dictations, nurses’ and providers’ notes, and discharge summaries) without requiring true interoperability between data sources and without requiring cumbersome integration efforts. Decision support solutions have to be nimble, easy to install, powerful, and accurate in order for them to have an impact.”

– Eyal Ephrat, M.D., CEO, medCPU

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